(revised format 12/2014)
When you have repeated panic attacks, you have a choice:
- medications work; and
- a short-term, simple therapy may be even better!
How research has shown therapy is better than medications
This essay is designed to help you choose between these two approaches. You can find some general information on panic disorder here.
High quality research has shown that a 10-12 session therapy can work as well as medications for panic.Barlow, Hendriks This approach is more like getting some coaching on anxiety management techniques than “therapy” as you might usually think of it. And it seems to work better than medications if you look at how people are doing 6 months after treatment. Indeed, a 2007 study recently showed that people on medications need to stay on them in order to maintain the benefits. That makes a one-time psychotherapy, even if it takes 10-12 sessions, pretty attractive — versus years of taking a medication.
Above all, you should select a treatment that has been shown with good research to actually work! Since there are two such approaches, you should be getting one of them, especially if your symptoms are severe. If your panic attacks are not so bad, or are infrequent, you could try treating yourself using some of the books or websites on self-treatment. But just be aware: these have not been proven to work. They probably help a lot of people. But in any case you should be “panic-free” by the end of treatment, since that’s possible for at least 50% of people getting the proven treatments. If you’re not “panic-free” after trying another method, it’s time for:
- Medications; or
- Cognitive-Behavioral Therapy.
We know these work, for a large number of patients. Let’s compare their advantages and disadvantages.
|Type of Treatment||Advantages||Disadvantages|
|Cognitive Behavioral Therapy||
I have highlighted in red a difference which you may not hear about elsewhere. If you use a medication approach, you are more likely to see your panic return after you stop the pills. Compare this “therapy”, which is really more like getting coaching on some anxiety management techniques. You may have to pay more money and invest more time to do the therapy, at first. But if you are one of the large number of people who remain free of panic after treatment — for years, maybe forever — then in the long run you could easily pay less and suffer less. Just think how it would feel, to walk around panic-free, knowing that you were the one who did that, not a pill.
Update 11/14: This approach is still being advocated. Nothing has changed since I wrote this page several years ago. As an example, a review of treatment for panic attacks recommended that this therapy as “first line” — in other words, to be offered as one of the first things to try, not just after medication approaches have been tried.Otto
A 10-12 session therapy for Panic Attacks
Cognitive-Behavioral Therapy, or CBT for short, was actually fun for most of the more than 100 people I’ve treated that way. Really. “Fun”. Well, not at first — but after about 5 of the 10-12 weekly sessions, people see a lot of improvement and start doing things they have not been able to do for a long time, like going to a movie or going for a walk. They are able to do things that really mean a lot, and it does indeed become fun at that point, as they get better.
What is CBT? This is very different kind of treatment from what most people think of as “psychotherapy”. You do almost all the work. Your tasks are all explained in a treatment workbook you receive when you start. You have weekly homework, although it usually takes less than 30 minutes per day even at the peak of the demand on your time. The therapist is there as an experienced guide, and a sort of “coach”. She or he emphasizes the parts of the treatment that you need the most, and encourages you to stay on schedule with the homework. She can help build your confidence where necessary, or point out to you where more work is needed. He can help you learn some of the specific techniques if you are having difficulty mastering them.
But from the beginning you understand that this therapist is not the key to getting better. She or he will help you grow steadily more confident that “you can do it!” She can help you keep going when panic comes back after were were making great progress, which definitely can happen. As you go, you do more and more of the work on your own. In fact, the evidence shows that it’s those who really do the homework that get better! The therapist is there to make sure you are one of those people. If you’re ready, you might ask “How do I find a therapist who does this kind of treatment?” But if you want to know more about the therapy, read on.
What are the steps in this therapy?
Cognitive Behavioral Therapy (CBT) is a 4-step process:
- learning what causes panic attacks
- learning to breath differently so as to reduce anxiety and panic
- learning how to handle panic thoughts
- testing your new abilities in low-anxiety situations, then higher-anxiety situations
This treatment uses your body’s natural “anxiety-ending” capacity. Panic attacks don’t go on forever, as you have seen. What makes them stop?
To understand that, we need a ruler to measure your anxiety. On our ruler, we’ll say that 0 is no anxiety at all, and 10 is the worst it ever gets, ok?
Now, imagine a situation that makes you moderately anxious, perhaps a 4 on our scale. For example, let’s say you’re one of those people that doesn’t like going to a big grocery store. That might be a 6 or 7 on your 0-10 scale. But going into a small neighborhood store might be a 4 for you. Now imagine staying in that store for 15 minutes, buying a few small items you need. By the end of that stay, you might be down to a 2 or even a 1 on this anxiety scale.
If you had some tools to use to cope with your anxiety while you’re in the store, the process would be easier. For example:
- something to make you feel less tense, more able to breath, less intensely aware of your heart beating; and
- something to do with your thinking besides “what if I have a heart attack in here where no one knows me?!”
If you went into the store like this every day for a week, do you believe that on the 7th day you would be less anxious in there? What if you did it every few days, for a month? Almost everyone sees improvement doing this: they get 3-level anxiety, but not 4. And if they keep doing it, over and over, they can even get to 1-level anxiety. They might notice a little tenseness, a little sweating in their palms, but otherwise there’s not much difference between in-the-store and outside.
Ah, but you’re saying: “I couldn’t go in a store like that, I couldn’t even get started! I’d have a panic attack just trying to walk in there!” Fair enough, you might be right. So the therapy won’t make you go in a store, or wherever tends to make you have anxiety, until you’re clearly having less panic attacks overall. And if by that time going into a small grocery still seems to big a leap, your therapist would work with you to find something smaller to try first. You might start with a situation that only raises your anxiety from a 1 to a 2. The therapy will help you get to “1” as a starting place for these exercises.
Others of you might be saying “I don’t need therapy to do this”. And if you think you can do it on your own, you could just go ahead and try it. The self-help resources can give you a good start on some of the “tools” that make it easier. This process is called “desensitization”, because it makes you less “sensitive” to the anxiety-producing situation. You desensitize yourself by leaving yourself “exposed” to the situation. Once you learn how to do this “desensitizing”, you can definitely get better on your own, if you want to try that. But many people seem to need the help of the therapist/guide.
You can see where this is going. The process is repeated with something that causes you a 5-level anxiety. But wait, now — don’t run away yet, you don’t have to take on any 5’s, or even 4’s, until you have seen this “exposure” trick work and are absolutely convinced it will help you. Instead, you can start with the tiniest anxiety level you can find — something that causes 2-level fear, say. Even 1-level fear would be ok, if you want — it’s just harder to tell if your sensitivity is really going down when you start that low.
The therapist works to make sure you are really learning the process. The goal is not simply to be free of panic attacks – it is to know how to handle panic attacks, so well that you don’t really worry about them much. You become a professional at handling your own anxiety. And that’s what makes this treatment so valuable: once you know how to do this, you can do it again if your panic ever returns. That’s why this therapy “wins” over medications, in the long run.
What about using the medications with the therapy?
“If medications are a little quicker, how about giving me something now while I learn the first steps, ok doc’?” Well, that can work all right. We might save you three weeks, maybe four, of your current symptoms. I’ll bet you’ve had them many times longer than that, though. Is it worth it to take the medications for a short while?
Here are two big reasons why not. First, it won’t save you much time and there are always some risks if you use medications. You can read more about the options and their risks below. But more importantly, the key in this CBT approach is that you learn how to handle your symptoms. In an odd way of thinking, you “need” your symptoms now to help you in this learning process. The first few weeks involve some really intense note-taking about the symptoms you experience — learning exactly the parts of your panic experience, because each part has a treatment angle that you must “match up” to the symptom. It’s easy, but it depends on the specific symptoms that you have. Every person’s panic experience is a little different.
Finally, there is actually some evidence that the medications can interfere with the learning you need to do. This makes sense, actually: if the key in the therapy is to realize that “you alone can do this”, then having the medication around works directly against that, right? Instead of coming to recognize that you are making the difference with your learning, you can always wonder “will I be able to do this — stay panic free — after I stop the medication?” Many people have to “do it over again” to some extent as they stop their medication. However, even if that is necessary, it is usually no more difficult than learning the therapy method in the first place.
What are my medication options, and their risks?
There are two main classes of medications to choose from. Antidepressant medications treat panic disorder, for sure, and often very effectively: no panic, few or no side effects. They’re a little slow to get going. You have to start more slowly than is routine for the treatment of depression. There’s a good chance that by the time you’re really up to the dose that “works”, you could have started the therapy described here and be seeing a decrease in panic attacks just from your own efforts.
There’s a quicker medication option: the Valium group. The official group name is “benzodiazepines“, and there are quite a few of them. We don’t use Valium much anymore because some newer ones don’t hang around for quite so long after each dose. But all of them have the same advantage: they act fast, within an hour of the first dose. However, (you knew this was coming, didn’t you?) they all have the same “addictive potential” that Valium does. That means they all cause your body to get used to the medication, so that a higher dose is required to get the same benefit you got at first. This “tolerance” develops after 2-3 weeks.
So, you could take a “benzo” for a few weeks while you’re finding your CBT therapist. Many doctors will offer you that option, or have you take the benzo’ while you’re working your way up on the antidepressant dose. Of course, then you’re on two medications. On the other hand, as long as you taper off these med’s, you should be no worse when you stop than when you started. If you’ve been doing CBT during that time, you might be much better than when you started, even as you stop the medication.
Many people can take the medications for a few months, then stop, and remain “panic-free”. In the big study comparing medications and CBT, patients took an antidepressant for 9 months then tapered off; 6 months later, 1 person in 5 (20%) who started the study was still panic free . Remember the point of this whole website though: of those who got the CBT one person in 3 (32%) was panic-free by 6 months after treatment. Not a great rate, I’ll grant you, 1 in 3. If you only have panic problems (not depression or a traumatic childhood or sexual abuse also), and if you work hard at the therapy, you are probably even more likely than these numbers indicate to be panic free, months after treatment. Obviously you can see my bias: both are good, but one may be better.
Finally, there are some side effects to consider. All of the antidepressants can cause weight gain if taken for months: this includes all the serotonin antidepressants: fluoxetine/Prozac, citalpram/Celexa, and the rest. Paroxetine/Paxil is the worst among these.Blumenthal All are equally effective against panic. And all the antidepressants are known to frequently cause problems with sexual function. (Ok, ok, not bupropion/Wellbutrin, but it is not as good for panic).
I’m ready, how do I find a CBT therapist
There are some basic principles for finding a therapist I’ve summarized and linked. Before I send you there, let me add some specifics about finding cognitive behavioral therapy (CBT).
Make sure a therapist you might see knows about CBT — ask “do you have experience doing cognitive behavioral therapy for panic disorder?”. If the answer is yes, ask if she/he uses a treatment manual in the process. If the answer is yes, ask if it’s the Barlow manual called Mastery of Your Anxiety and Panic. If you get a yes there, which will be rare, see that person.
If they use another manual, or none, ask them if they’d be willing to use the Barlow manual. You can order the manual online ( I’m not making any money on this, no connection!) (you want the Client Workbook (MAP-III), Order Code: 104; $29.00. ) However, remember that the research on this method was done with trained therapists using this manual, not patients reading the manual on their own. I strongly recommend that you do this with a therapist who knows the general principles of CBT.
Click for some general guidelines about finding a therapist.