Dr Robert London

Treating Panic Disorder and Agoraphobia

Clinical Psychiatry News - Volume 33, Issue 8, Page 22 (August 2005)

Thousands of people are seen in emergency departments nationwide for chest tightness, shortness of breath, dizziness, and perfuse sweating accompanied by shaking, tingling in the extremities, and an imminent sense of doom. These patients are routinely evaluated for heart attacks, GI disorders, and possibly thyroid disease.

As it turns out, many of these patients are experiencing psychiatric symptoms. Some emergency department physicians estimate that up to 50% of those acutely ill people have some form of stress or anxiety.

A literature review in the Canadian Journal of Psychiatry found that 30% of emergency department patients who presented with chest pain and had a medical work-up for coronary artery disease were diagnosed with a panic disorder. Furthermore, 98% of those panic disorder patients went undiagnosed when first evaluated (Can. J. Psychiatry 2003;48:361–6).

This was not always the case. In the mid-1970s, for example, the short-term psychotherapy program at New York University Medical Center/Bellevue Hospital in New York began to see its first panic disorder patients. At that time, most outpatient therapy was analytic, analytically oriented, or driven by some analytic model. Results-oriented, short-term treatments were not as valued as they are today. Cases in which patients recovered because of transference were considered successful—a concept that was invalid then and remains so today.

With the new short-term approaches, we began treating motivated, results-oriented patients. These patients had either traditional or nontraditional psychotherapy—both of which were unsuccessful. In 1980, panic disorder and panic disorder with agoraphobia were defined in the DSM-III.

Both at the NYU/Bellevue program and in the private sector during the 1980s, the number of people wanting to try behavior modification therapy for panic/agoraphobia disorders increased markedly. Successful advances in treating panic disorder/agoraphobia also were made by using antidepressants and, at times, by judiciously prescribing benzodiazepines.

While directing the short-term psychotherapy program at the NYU Medical Center/Bellevue Hospital, I developed the learning, philosophizing, and action (LPA) treatment model. The three distinct phases of LPA were important, because patients could find success in any or all of these.

The learning phase enables the patient to use cognitive skills about the panic or panic/agoraphobic responses. For example, in patients experiencing panic attacks, it is useful to learn the concept of “possibilities vs. probabilities.” Essentially, almost anything is possible, but what are the probabilities of one of these dreaded events occurring?

Systematic thinking can be developed using the possibilities and probabilities concept. The patient can be told: “You've had these attacks before, and you are alive and well. It is possible but not probable that you could be having a heart attack. You've been examined several times by doctors and nurses, and you've been given a clean bill of health. But you do have a disorder; it's known as a panic disorder.”

It's so important for the patient to begin to think differently. Over several visits, this new kind of thinking begins to take a permanent place in the patient's thought process, and cognitive changes start to occur. A printout of the DSM description of panic and agoraphobic disorders is valuable during the learning phase.

As we treat the panic disorder, the patient begins to identify and understand cognitive changes. When the patient incorporates this new therapeutic perspective, a lasting cognitive change can take place. Many patients are able to substitute new beliefs that are more reality based.

During the philosophizing phase, a patient often will ask: “Why do I have this disorder? Will it ever go away?” This is a chance to discuss the reasons that a panic disorder develops. The patient should be assured that, yes, the disorder is indeed treatable, and often, the disorder goes away or can be brought under control.

The causes for a panic disorder can range from a genetic or family predisposition to a biochemical imbalance. In some cases, we must try to determine whether life experiences—real or imagined—predisposed the patient to this disorder. Such discussions have great value.

Agoraphobia, also in this spectrum of disorders, can also be addressed. One could use the same LPA techniques that were part of the panic disorder treatment program to produce cognitive changes to help the patient to deal better with the phobic response and resolve it. In the action phase, I continue to believe that systematic desensitization, guided imagery, and reciprocal inhibition are very effective when used in vitro [CLINICAL PSYCHIATRY NEWS, “Conquering Phobias,” May 2004, p. 43].

During this procedure, the patient is taught general relaxation techniques. From there, guided imagery allows the patient to project scenes of the dreaded panic or agoraphobic experiences onto the screen and then replace those images with pleasant ones.

I like the split-screen technique, which I've discussed before in my column. The patient visualizes a large screen, with the anxiety projected on the left side and pleasant experiences of the patient's choosing projected on the right side.

The patient then shifts back and forth from the left to the right side of the screen. In effect, the pleasant side of the visualization overwhelms all or part of the anxiety-producing side. If these techniques are taught effectively and the patient is given good training in how to practice, the result is often a great reduction in anticipatory anxiety, anxiety, and agoraphobia. When used before the panic sets in or even during the panic or agoraphobic reaction, this action phase technique is very helpful. In vivo techniques are effective, though they are time consuming and not cost effective. In the future, I believe that virtual reality will hold great promise as a desensitization technique.

According to S. Timothy Stroupe, M.D., an expert in treating many types of anxiety disorder, the combination of medication with a short-term cognitive therapy program or of behavior modification with medication management often produces excellent treatment outcomes.

“My staff and I are in the profession to care for people,” said Dr. Stroupe, chief of inpatient services, which includes the psychiatric emergency department at Lutheran Medical Center, New York. “When combining psychopharmacology with CBT or [when] behavior modification is best for the patient, we use those techniques and interventions.” Furthermore, Dr. Stroupe points out, failing to make the proper diagnosis at the onset is very costly—both in expensive medical work-ups and in long-term disability for patients.

Getting psychiatrists to teach emergency physicians and cardiologists to recognize this disorder early in the evaluation would be a positive first step to treatment.

A pilot study of emergency physicians and cardiologists, divided into two groups—those who know and understand panic disorders and those who have not been formally instructed in panic disorders—might be useful, Dr. Stroupe said in an interview. It would be helpful to compare the results 1 year later, Dr. Stroupe suggests.

Developing CBT strategies and other behavior modification techniques to treat these disorders successfully is hard work. But learning these procedures and offering them to our patients is well worth it.

Let me know how you treated panic disorder/agoraphobia. I'll try to pass your ideas along to my readers.

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