Cognitive behavioural therapy (CBT), which is a multimodal psychotherapy. Specific techniques used in CBT for panic disorder include:
- psychoeducation
- breathing retraining
- progressive muscle relaxation
- cognitive restructuring
- behavioural experiments
- interoceptive exposure and in vivo exposure.
Panic disorder affects approximately 10% of general practice patients.
CBT is recommended as first-line therapy for panic disorder. It can be used alone or in conjunction with pharmacotherapy.
Training
Accredited mental health training is available from The General Practice Mental Health Standards Collaboration (GPMHSC).
Intervention
The cognitive component of CBT helps patients to understand how the way they think about their symptoms affects their experience. For example, being fearful of the symptoms can create a feedback loop, increasing the length and intensity of the ‘fight or flight’ response and continuing the length and severity of the panic attack. Conversely, challenging these thoughts can lead to control of panic and agoraphobia.
The behavioural component may involve exercises to induce symptoms as a teaching and mastery tool. An example is getting a patient to hyperventilate (a form of interoceptive exposure) to induce symptoms. This can be undertaken during a consultation, or the patient may undertake this as part of their ‘homework’.
The behavioural component often also involves patients gradually challenging themselves within triggering situations while giving them skills to manage their panic in vivo exposure.
Face-to-face therapy is generally limited to 5–10 sessions of 1 hour, often weekly, over a maximum of 4 months. Sessions may be delivered individually or within a group.
Patients can expect to be asked to undertake homework and to monitor their symptoms. Weekly sessions provide a chance to review the progress of homework exercises. The frequency and severity of panic attacks are monitored by the patient and are a guide to progress.
CBT may be provided by GPs or other mental health professionals (e.g. mental health nurses, psychologists, occupational therapists, accredited mental health social workers). Ideally, GPs should be familiar with the areas of expertise of their local network to ensure an appropriate referral.
GPs can provide the appropriate psychoeducation even if they do not use all of the CBT techniques recommended for management of attacks including agoraphobic avoidance. This involves describing the symptoms related to the adrenaline fuelled ‘fight or flight’ response, and how this can be misinterpreted if a person does not flee or fight.
CBT is increasingly becoming available online (mindspot.org.au). This option is more effective if supported by a ‘coach’ such as a GP or another mental health professional.
NHMRC Level 1 evidence.
References
- Cuijpers P, Cristea IA, Karyotaki E, Reijnders M, Huibers MJH. How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry 2016;15(3):245–58.
- Pompoli A, Furukawa TA, Imai H, Tajika A, Efthimiou O, Salanti G. Psychological therapies for panic disorder with or without agoraphobia in adults: A network meta-analysis. Cochrane Database Syst Rev 2016. doi: 10.1002/14651858.CD011004.pub2.
