What lies within: Understanding and addressing panic disorder

One of the scariest issues some clients have to deal with is panic disorder. The scariness comes from experiencing intense anxiety in the form of panic attacks which appear to hit them from ‘out of the blue’. Add to this the ongoing fear after having one panic attack of knowing that another one may be on the horizon but not knowing when it will happen can result in a person with panic disorder being in an ongoing state of elevated anxiety.  Fortunately, this issue can be treated in therapy. I will discuss how this is done in the following sections.

The ‘triggers’ for intense anxiety in panic disorder

In any anxiety disorder there are ‘triggers’ for the person’s experience of intense anxiety. In social anxiety disorder, the triggers are situations in which the person interacts with others. In phobias, it is a particular situation such as heights, driving or closed-in spaces. In post-traumatic stress disorder, it is stimuli which remind the person of a traumatic event which they experienced or witnessed.

In panic disorder, the triggers are internal sensations which the person experiences. These are often physical sensations such as minor fluctuations in one’s heart rate.

Negative interpretations of the triggers lead to intense anxiety

Just as with the other anxiety disorders I mentioned, the intense anxiety which the person experiences as a result of these triggers is caused by the person’s overly negative interpretations of the meaning of the triggers. These interpretations, sometimes referred to as ‘fortune telling’ or ‘catastrophizing’, typically involve overestimating the danger indicated by the presence of the triggers or underestimating one’s ability to cope with the consequences of the triggers. Each of these kinds of negative interpretations can result in the experiences of uncomfortable to intense levels of anxiety.

In panic disorder, the negative interpretations are of one’s internal sensations. In the case of physical sensations such as minor fluctuations in one’s heart rate, the negative interpretations happen very quickly and initially may be outside of a person’s awareness.

For example, consider that a person gets up from being seated and consequently experiences a slight increase in heart rate. For most people, this would not be a trigger for intense anxiety. But for people with panic disorder, the slight increase in heart rate is interpreted negatively with thinking like, ‘My heart rate increased. There must be something wrong with my heart’.

This negative interpretation then results in a further increase in heart rate. This in then followed by an even more negative interpretation of one’s physical state which is then followed by even stronger heart activity. The negative cycle escalates into intense anxiety accompanied by catastrophic interpretations of it like ‘I’m having a heart attack’. This example illustrates how panic attacks occur in panic disorder.

Treating anxiety disorders: Exposure facilitates desensitization and inhibitory learning

In any anxiety disorder, treatment involves exposing the person deliberately to the triggers. Exposure overcomes the natural avoidance of these triggers which occurs as a result of the strong anxiety people experience in the presence of such triggers.

Consistent exposure, done in the right way under the direction of a skilled therapist, leads to the anxiety disorder being addressed through two mechanisms. One of these is desensitization. This refers to a lasting reduction in the intensity of the anxiety which occurs with consistent exposure over time. The second mechanism which accompanies and facilitates desensitization, is inhibitory learning. This refers to the person changing their thinking from believing they cannot cope and function effectively with the anxiety to the view that they can cope and perform effectively while experiencing the anxiety.

Treating panic disorder: Exposure through sensation inductions

Treating panic disorder involves exposure through ‘sensation inductions’. This involves having the client deliberately and consistently expose themselves to the internal sensations they experience which are the triggers for their strong anxiety and panic attacks.

For the example of strong anxiety being triggered by slight heart rate increases and the panic disorder characterized by thoughts of having a heart attack, sensation inductions would involve having the person deliberately engage in activities to increase their heart rate. This procedure would, in turn, help the client to overcome their avoidance of such activities which commonly occurs in this form of panic disorder.

Sensation inductions for panic disorder typically begin in therapy sessions and are done in the context of ‘behavioural experiments’ in which the client is able to gather data relating to the primary elements of catastrophic thinking which fuel their strong anxiety—the belief that the sensations will put them in physical danger (such as ‘I’m having a heart attack’) and the belief that they cannot cope with the anxiety they experience.

Consistent exposure through sensation inductions allows the client to gather data demonstrating to them that the danger they fear will not come to pass and that they can cope with the anxiety they experience. Gathering this data through consistent exposure with sensation inductions promotes desensitization and inhibitory learning, the two main indicators of successful exposure treatment for anxiety disorders.

Please note that sensation induction treatment is preceded by the client having received clearance by their physician that they do not have a physical health issue which will lead them to be endangered by this treatment.

May you address whatever anxiety issues you are facing,

-Dr. Pat