The following sections review psychosocial interventions that
have been formally evaluated for treatment of panic disorder, as
well as some treatments that have not been tested but are occasionally
utilized by patients with panic disorder. Psychosocial treatments
for panic disorder should be conducted by professionals with an
appropriate level of training and experience in the relevant approach.
Based on the current available evidence, CBT is the psychosocial
treatment that would be indicated most often for patients presenting
with panic disorder. The efficacy of CBT (including exposure therapy
alone) for panic disorder has been documented in numerous controlled
trials. CBT is effective when delivered individually or in a group
format. Individually administered PFPP also has demonstrated efficacy
for panic disorder, although research on this treatment is in earlier
stages and its evidence base is more limited. Panic-focused psychodynamic
psychotherapy may be indicated as an initial psychosocial treatment
for panic disorder in some circumstances (e.g., with a patient who
is motivated for and able to engage in this approach). Other psychosocial treatments
either have not been formally tested for panic disorder (e.g., certain
forms of psychodynamic psychotherapy) or have proven ineffective
or inferior to standard treatments (e.g., EMDR, emotion-focused
The use of CBT for panic disorder is based on the assumption that
maladaptive patterns of cognition and behavior maintain panic disorder.
Cognitive-behavioral therapy generally targets these maintaining
factors and places less emphasis on determining the origins of panic
disorder for a particular patient. Cognitions hypothesized to maintain
panic disorder include catastrophic misinterpretations of physical
symptoms (e.g., the belief that palpitations signal an impending
heart attack) (for example, see references 167 and 168).
Therefore, many versions of CBT seek to identify and change mistaken beliefs
about physical symptoms and their consequences. The symptoms of
panic disorder and agoraphobia also have been conceptualized as
resulting from conditioning processes (for example, see references 169–171).
Consequently, many versions of CBT include techniques aimed at 1) weakening
or extinguishing learned associations between stimuli (both internal
and external) and panic and 2) creating opportunities for learning
and strengthening nonanxious responses. All forms of CBT conceptualize
avoidance behavior as a maintaining factor in panic disorder, either
because it prevents patients from disconfirming their anxious beliefs
or because it prevents habituation of fear responses. Thus, confronting feared
stimuli and situations is an essential part of CBT for panic disorder.
Most forms of panic-focused
CBT employ the following treatment components: psychoeducation,
self-monitoring, cognitive restructuring, exposure to fear cues,
modification of anxiety-maintaining behaviors, and relapse prevention.
In providing CBT, the clinician may opt to focus more on certain
treatment components than on others, depending on the patient's
symptom profile and response to different CBT techniques.
Panic-focused CBT is generally administered in 10–15 weekly
sessions (172). Therapy usually begins with one or more
psychoeducation sessions that serve to identify the patient's
symptoms and areas of impairment, provide accurate information about
the nature and purpose of anxiety and fear, conceptualize the patient's
experiences in terms of the CBT model, and outline a rationale and
plan for treatment. Information gathering and education are done
in an interactive manner, with a continual focus on applying the
CBT model to a patient's particular symptoms and situations.
The CBT therapist adopts a collaborative stance, and the educational material
sets the stage for the therapist and patient to develop a shared
understanding of the patient's problems. A major goal of
psychoeducation for panic disorder is conveying that panic symptoms
result from the body's natural fear response and are not
dangerous. Reading material that reinforces the concepts introduced
in the psychoeducation sessions is usually assigned for homework
(see the Appendix for titles of patient workbooks that include these
Self-monitoring is another core component of CBT. Patients
monitor their panic attacks using techniques such as keeping a daily
diary. They are asked to record the date, time, location, and any
perceived triggers of the panic attack. They also may be asked to
record the physical symptoms, anxious thoughts, and behavioral responses
that occurred during the attack. Patients are informed that this
will help to assess the frequency and nature of their panic attacks
and to provide data regarding the relationship of panic symptoms
to potential triggers.
Another component of CBT is exposure to fear cues. Patients
with panic disorder can experience panic attacks in response to
internal and external cues (169). The most common internal
fear cues are bodily sensations (e.g., heart racing, dizziness,
shortness of breath). Common external fear cues include situations
in which having a panic attack would be embarrassing or in which
escape would be difficult (e.g., public places, enclosed spaces).
For most patients, exposure to both internal and external fear
cues is necessary for remission of panic symptoms to occur. Exposure
proves to be the most challenging and often the most potent component
of CBT. Additional effort on the part of the clinician is often
required to motivate the patient to initiate and persevere with
increasingly difficult exposure practices. Internal fear cues are
addressed through interoceptive exposure. Interoceptive exposure
involves exposing the patient to feared bodily sensations in a systematic
way, until he or she no longer responds fearfully to those sensations.
Feared bodily sensations are provoked using a series of exercises
such as running in place (to induce heart pounding), spinning in
a chair or while standing up (to induce dizziness), and hyperventilation
or breathing through a straw (to induce light-headedness or shortness
of breath). The CBT therapist first assesses which of these exercises
produce symptoms that are anxiety provoking for the patient, and
then instructs the patient to perform those exercises repeatedly
until the patient is no longer afraid of the exercises or the symptoms
that result. External fear cues are targeted through situational
exposure, which involves confronting situations or activities that
commonly provoke fear. Situational exposure can include a wide variety
of exercises such as driving on a highway, riding in an elevator,
or visiting a grocery store or shopping mall.
The process of conducting exposures to internal and external
fear cues is systematic. The therapist first works with the patient
to identify a hierarchy of fear-evoking situations. The degree of
anxiety elicited in each of these situations is graded on a 0–10
scale, and several situations that evoke anxiety at each level are
documented. The patient is then asked to confront the symptom or
situation, usually beginning at the low end of the hierarchy on
a regular (usually daily) basis until the fear has attenuated. The
symptom or situation that arouses the next level of anxiety is then
targeted. Interoceptive exposures are usually conducted in the therapist's
office and at home in naturalistic situations. Situational exposures
are best carried out in the actual situation(s). Patients typically
conduct situational exposures on their own for homework; however,
some CBT therapists will accompany patients to locations for situational
exposures. Whereas the usual practice is to start with the least
anxiety-provoking exercises and move up in intensity, patients who
are motivated to treat their panic disorder more aggressively can
begin exposure treatment with exercises that are more challenging
(i.e., those near the top of their hierarchy) with the notion that
this approach may help them achieve their treatment goals more quickly
(54). Patients also are encouraged to combine interoceptive
and situational exposure as they progress through treatment (e.g.,
deliberately hyperventilating while driving) in order to learn that
they can enter feared situations and cope with them even while experiencing
intense physical sensations.
Most CBT practitioners include cognitive restructuring techniques
as one element of treatment, although some CBT therapists and some
studies (for example, see reference 140) have questioned
whether cognitive restructuring provides benefits beyond those obtained
with exposure. When used as a CBT component, cognitive restructuring
focuses on identifying and countering erroneous beliefs that contribute
to panic disorder. Patients with panic disorder commonly interpret
panic symptoms in a catastrophic manner (e.g., as signs of an impending
heart attack or fainting spell). They also typically underestimate
their ability to cope with panic attacks (42). In CBT,
the therapist encourages the patient to recognize the thoughts that
occur during panic attacks and to consider the evidence for and
against these thoughts. When erroneous or exaggerated beliefs are
identified, the CBT therapist and patient work together to review
the evidence and generate a more realistic appraisal of the situation.
The skill of countering anxious thoughts and generating more evidence-based thoughts
is reinforced throughout treatment with in-session practice and
homework assignments. Many CBT therapists integrate cognitive and
exposure procedures. This integration focuses on using the exposure
to fear cues as a vehicle for helping the patient acquire corrective
threat-disconfirming information (e.g., "even though I
felt anxious and dizzy while at the grocery store, I did not faint").
Modification of anxiety-maintaining "safety behaviors" is
another common goal of CBT. Common safety behaviors include carrying
medication bottles, establishing exit routes, and checking the locations
of hospitals (173). Safety behaviors often provide
the patient with an immediate feeling of security; however, within
CBT they are conceptualized as maintaining anxiety in the longer
term. Safety behaviors may reinforce the notion that everyday situations
are inherently dangerous, prevent patients from disconfirming their
threat-laden beliefs, and interfere with deriving maximum benefit from
exposure practices (174). Fading and eventual elimination
of safety behaviors is therefore a goal of most CBT protocols.
Some CBT protocols also teach slow, diaphragmatic breathing
as a skill that patients can use to decrease anxiety and interrupt
the cycle of panic (for example, see reference 111). Although
the evidence suggests that breathing retraining is likely not a
necessary component of treatment (175), it is still often
included in CBT for panic disorder and may be a useful anxiety-reduction
tool for some patients.
Cognitive-behavioral therapy for panic disorder is often provided
individually, but there is evidence that group treatments may be
equally effective (137, 142, 176–179).
Exposure treatments for patients with agoraphobia also are efficacious
when conducted in a group format (178). The inclusion
of the spouse or significant other in treatment can be helpful,
especially if the significant other is educated about the CBT model
of panic disorder and can provide support and encouragement when
the patient confronts feared situations (180, 181).
Because CBT is not widely available in some communities, some
patients may have to travel a great distance to see a clinician
who is proficient in CBT, or they may not have access to CBT at
all. Some evidence suggests that high-density therapy (i.e., several
hours of therapy within a few days) can be effective (182, 183),
and this approach may be useful for patients who cannot attend a
standard course of weekly sessions. One small waiting-list-controlled
study showed that telephone-based CBT was effective for patients
with severe agoraphobia who lived in rural areas (184).
Self-directed forms of CBT and exposure therapy that are guided
by a computer (often with minimal therapist contact via email or phone)
also have been shown to be effective in several controlled studies
(185, 186). Studies that directly compare
live CBT to largely computer-guided formats have generally shown
both to be effective, but in some studies live CBT produced larger
effects and was associated with lower dropout rates (139, 186–189).
When available, computer-guided CBT may be a useful option for patients
with panic disorder who do not have ready access to a specialist.
The available data suggest that the benefits of a short-term course
of CBT are long-lasting (for example, see reference 160).
However, once patients have achieved a satisfactory reduction in
symptoms and impairment, the focus of CBT shifts, and development
of a specific relapse prevention plan becomes an integral part of
treatment. The therapist normalizes fluctuations in anxiety and
anticipates that the patient may experience periods of increased
anxiety (including occasional panic attacks) in the future. The
therapist and patient collaborate to anticipate potential triggers
for these periods of increased anxiety (e.g., work stress, moving
to an unfamiliar place) and to develop an individualized relapse
prevention plan that the patient can follow if symptoms recur. This plan
typically involves a return to more intensive practice of CBT skills
that were previously helpful such as exposure and cognitive restructuring.
If symptoms do not improve with the implementation of the practice
plan, the therapist and patient can consider the option of "booster
sessions" (i.e., a short course of CBT to help the patient
reinstitute skills that were previously helpful). If efforts to
boost response are unsuccessful, the psychiatrist should consider
trying a different treatment modality or referring the patient to
another qualified professional.
There is little evidence to suggest that CBT and commonly
prescribed medications for panic disorder either enhance or counteract
one another in the acute term. One randomized controlled trial found
that fluvoxamine plus exposure therapy was superior to either alone
in treatment of panic disorder with moderate to severe agoraphobia
(68); however, this result has not been replicated.
In contrast, another study found that, 6 months after treatments
were withdrawn, patients who responded to a combination of imipramine
and CBT for panic disorder displayed poorer maintenance of response
than those who received CBT alone or CBT plus placebo (111).
This finding raises some concern that simultaneously initiating
medication and CBT may negatively affect the durability of the effects
of CBT after treatments are withdrawn. This topic requires further
study before firm conclusions can be drawn. Concern also exists
about possible decreases in the efficacy of CBT if combined with benzodiazepines,
although there is a dearth of systematic empirical data on this
topic (190). One large randomized controlled trial
showed that although adding alprazolam to exposure therapy marginally
enhanced gains during acute treatment, patients who received the
combination relapsed more after treatment withdrawal compared to
those who received exposure plus placebo (149). Another
small study showed that patients taking benzodiazepines had poorer memory
for the educational material presented in CBT than patients who
were taking no medications (161). Clinical experience
suggests that p.r.n. ("as needed") use of benzodiazepines
to block anxiety symptoms can be difficult to reconcile with certain
components of CBT, and many CBT therapists discourage p.r.n. benzodiazepine
use as soon as the patient has developed other anxiety management
Cognitive-behavioral therapy for panic disorder has been shown
to be effective in treating not only the targeted panic disorder
but also in reducing the rates and severity of some co-occurring
The goal of psychodynamic psychotherapy is to achieve remission
of panic disorder symptoms through a therapeutic process that encourages
exploration of feelings and past and present traumatic experiences.
The core principles of psychodynamic psychotherapy are 1) the appreciation
that much of mental life is unconscious, 2) childhood experiences
in concert with genetic and constitutional factors shape adult personality,
and 3) individual symptoms and behaviors may serve multiple functions
Many studies suggest that acute stressors, or "life
events," occur just prior to panic disorder onset (196–198).
According to psychodynamic theory, the psychological meaning of
these events as well as symptoms, behaviors, and coping styles are determined
by complex forces that may be unavailable to the patient's
conscious awareness (199–201).
In patients with panic disorder, one of the goals of psychodynamic
psychotherapy is to uncover and understand the thoughts and feelings
associated with panic symptoms as well as the unconscious psychological
meanings of these panic symptoms, issues that are theorized to be
related to separation, autonomy, self-esteem, anger, or aggression.
Understanding of transference and interpretation are used to elucidate
these issues as well as related interpersonal conflicts. In addition,
the therapist attempts to identify and alter core conflicts in order to
reduce vulnerability to future panic symptoms (145).
Given the highly individualized nature of these thoughts, feelings, and
conflicts, the length and intensity of most psychodynamic psychotherapy
also tends to be individualized.
In psychodynamic psychotherapy, symptom relief or resolution
is theorized to result from emotional growth and understanding of
the various developmental and psychological issues that relate to
the patient's symptoms. Examples include both conscious
and unconscious problems of self-esteem and self-cohesion, unresolved
developmental trauma, and psychic conflict (e.g., unacceptable impulses,
unrealistic or harsh issues of self-esteem and conscience, unadaptive
psychological defenses). The therapist places the current symptoms
in the context of the patient's life history and current
realities. The therapist-patient relationship is often used as a
vehicle to achieve insightful awareness by bringing the unconscious
into consciousness, as well as to facilitate intrapsychic growth.
Because psychodynamic therapies are rooted in various psychoanalytic
and/or psychodynamic theoretical models, there are a variety
of methods for conducting psychodynamic psychotherapy.
Panic-focused psychodynamic psychotherapy is a twice weekly,
12-week manualized treatment program developed by Milrod and associates
(145) that has been tested in a randomized controlled
trial (146). It focuses on the underlying psychological
meaning of panic symptoms and on current social and emotional functioning.
Panic-focused psychodynamic psychotherapy is based on the postulate
that panic symptoms carry a specific emotional significance that
the patient must confront before remission of the panic symptoms
can occur. According to this theoretical model, patients with panic
disorder are conceptualized as having difficulty separating from
important attachment figures and perceiving themselves as autonomous,
which is thought to motivate agoraphobic avoidance. The combination
of perceiving their environment and relationships as overly dangerous
and themselves as inadequate and lacking autonomy triggers high
levels of anxiety that perpetuate panic and agoraphobic avoidance.
Panic symptoms in turn are thought to reinforce conflicted interpersonal
relationships in which the patient feels excessively dependent on
significant others and frightened of losing them. Panic-focused psychodynamic
psychotherapy focuses on the transference as a mutative therapeutic
agent and does not require behavioral exposure to agoraphobic situations.
It helps patients to confront the emotional significance of their
physical symptoms and recognize that their fears of upcoming catastrophe
reflect an internal emotional state rather than reality. Through
these techniques, PFPP encourages patients to function more autonomously
and may help patients with panic disorder to achieve a greater sense
of personal efficacy, yielding improved function and symptomatic
Compared to PFPP, other approaches to psychodynamic psychotherapy
often have a wider focus on other psychological and interpersonal
issues in the patient's life. These alternative approaches
have not been the subject of rigorous research studies. Consequently,
evidence for the use of other psychodynamic psychotherapy approaches
in panic disorder is limited to case reports and opinions of psychodynamic psychotherapy
experts. No studies have compared the efficacy of the different
psychodynamic psychotherapy approaches or have compared psychodynamic
psychotherapy with other psychosocial treatments in patients with
As with all psychiatric treatments, psychodynamic psychotherapy
(including PFPP) should be conducted by appropriately trained therapists,
and patients need to understand the rationale, goals, and potential
risks and benefits of the treatment. The exploration of memories
and important conflicted relationships and the surfacing of unconscious
material may sometimes be associated with powerful affects and transient
upsets in the therapeutic and other relationships. These occurrences
tend to decline in both frequency and intensity as the patient experiences
how they relate to and help resolve the symptoms and problems that
brought the patient to treatment.
Many patients with panic disorder have complicating co-occurring
Axis I and/or Axis II conditions. The broad focus of some
forms of psychodynamic psychotherapy may be useful in reducing symptoms
or maladaptive behaviors in these associated conditions. For example,
some preliminary data showed that PFPP demonstrated superiority
to applied relaxation therapy for patients with Cluster C personality
disorders, compared to patients without Cluster C personality disorders
Although evidence is limited, psychodynamic techniques have
been used in combination with pharmacotherapies or with elements
of CBT (145, 203, 204). For
example, patients with agoraphobic avoidance may be encouraged to
expose themselves to frightening situations and explore the feelings that
the exposure aroused to gain a deeper understanding of the conflicts
surrounding feared situations. In practice, psychodynamic therapies
are often used adjunctively with medication to assist in the resolution
of the panic symptoms (204, 205).
3. Supportive psychotherapy
The available evidence suggests that supportive psychotherapy
is inferior to standard treatments for panic disorder. One controlled
study compared the efficacy of emotion-focused therapy, CBT, imipramine,
and pill placebo in patients with panic disorder (147).
Emotion-focused therapy was described as a short-term psychotherapy
that involved empathic listening and supportive strategies. Emotion-focused
psychotherapy was based on the theory that unrecognized emotions
(typically triggered by interpersonal situations) trigger panic
attacks; therefore, patients were encouraged to explore and process
their emotional reactions with the aim of resolving panic symptoms.
Results suggested that emotion-focused psychotherapy was less effective
than CBT and imipramine in treatment of panic disorder and that its
effect was approximately equivalent to that of placebo. Therefore,
emotion-focused therapy and other supportive psychotherapies that
resemble it cannot be recommended as treatments for panic disorder.
4. Eye movement desensitization
Eye movement desensitization and reprocessing was originally
developed as a treatment for posttraumatic stress disorder (206),
but it has been studied as a possible treatment for panic disorder.
Eye movement desensitization and reprocessing involves reprocessing
distressing memories while engaging in guided eye movement. When
applied to panic disorder, EMDR targets distressing memories such
as the memory of the first panic attack and life events that the
patient associates with panic disorder (207).
Empirical data on the use of EMDR in treating panic disorder
are limited. In one trial, six sessions of EMDR were superior to
a waiting-list control at posttreatment; however, the investigators
questioned the clinical significance of the treatment's
effect because very few patients who received EMDR showed substantial
functional recovery at 3-month follow-up (207). Another
study found EMDR to be equivalent in its effects to a credible attention-placebo
control (208). Eye movement desensitization and reprocessing
therefore cannot be recommended as a treatment for panic disorder
at this time.
Clinical experience suggests that possible benefits of a group format
for treating panic disorder include 1) decreasing shame and stigma
by providing experiences with others who have similar symptoms and
difficulties; 2) providing opportunities for modeling, inspiration,
and reinforcement by other group members; and 3) providing a naturally
occurring exposure environment for patients who fear having panic
symptoms in social situations. Most approaches to group therapy
have not been empirically tested for panic disorder. However, group CBT
for panic disorder has been shown to be effective in controlled
studies and therefore can be recommended with confidence as a treatment
for panic disorder (137, 176–179).
When considering a patient for inclusion in a CBT group, the therapist
should consider the severity of the patient's panic disorder, co-occurring
disorders, level of insight, interpersonal skills, and the patient's
preference for a group versus individual format.
There is limited evidence from a small uncontrolled trial for
the effectiveness of group mindfulness-based stress reduction for
patients with panic disorder (209, 210).
This modality includes training in meditation and relaxation strategies.
Other types of groups, such as medication support groups, may provide
useful adjunctive experiences for patients with panic disorder but
have not been tested empirically.
6. Couples and family
Patients with panic disorder have symptoms that can disrupt day-to-day
patterns of relationships and may place a family member in a caretaker
or rescuer role. Increased dependency needs of patients with panic
disorder may lead to frustration in family members, and relationships
may be jeopardized. Results are mixed with regard to whether panic
disorder is associated with increased incidence of relationship
dysfunction or whether relationship dysfunction affects outcome
of standard treatments for panic disorder (180).
The scant available literature
suggests that marital therapy alone is less effective than established
treatments in relieving panic symptoms (211). Based
on the available data, couples or family therapy alone cannot be
recommended as a treatment for panic disorder. In contrast, partner-assisted
exposure therapy for panic disorder has been shown to reduce symptoms
of panic disorder in several studies (180). Other studies have
documented benefits of including patients' significant others
in group-based CBT (177, 212, 213)
and of adding couples-based communication training to exposure treatment (214).
Therefore, including a significant other in CBT or exposure-based
treatment may be a useful approach for some patients.
When pursuing other treatments for panic disorder (e.g., pharmacotherapy),
educating significant others about the nature of the disorder and
enlisting them to improve treatment adherence may also be helpful.
However, no empirical studies of involving partners or family members
in other types of treatment have been published.
7. Patient support
Patient support groups may be helpful for some patients with panic
disorder. Patients who participate in support groups have the opportunity
to learn that they are not unique in experiencing panic attacks
and to share ways of coping with the illness. Family members of
patients with panic disorder also may benefit from the educational
aspects of patient support groups. In deciding to refer a patient
or family member to a support group, it is important that the psychiatrist
obtain information about the nature of the group and the credentials
of its leader(s). Support groups are not a substitute for effective treatment;
rather, they are complementary.
and alternative treatments
A review of research on a variety of self-help and alternative treatments
for anxiety disorders concluded that there was no evidence for efficacy
of most of these treatments for panic disorder (215).
Treatments evaluated included natural products (e.g., kava, St.
John's wort, inositol), other physical treatments (e.g.,
acupuncture, massage), and lifestyle treatments (e.g., yoga, relaxation).
Most of the treatments had never been formally tested in patients
with panic disorder. Very preliminary support is available for the
efficacy of the glucose isomer inositol in treatment of panic disorder;
however, inositol is rarely used clinically, and more extensive clinical
research is necessary to establish its efficacy (216, 217).
Evidence of efficacy has also been found for relaxation training
(215). Although one controlled study found applied relaxation
to be as effective as CBT and exposure therapy (218),
a recent meta-analysis suggested that relaxation training is less
effective than CBT for patients with panic disorder (219).