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Several researchers have attempted to use biofeedback to uncover the etiology of panic disorder and help individuals reattribute those bodily sensations. Lynch, Bakal, Whitelaw, and Fung (1991) found that highly anxious participants with panic disorder exhibited significantly higher electromyography (EMG) activity than low anxious or controls. Beck and Scott (1988) found frequent panickers to have significantly higher elevations in trapezious EMG and muscle tension. Increased heart rate and EMG during the onset of panic attacks was a common finding in a number of studies (Beck & Scott, 1987; Cohen, Barlow, & Blanchard, 1985; Ehlers et al., 1988). No research was found that explored the efficacy of biofeedback in the treatment of panic disorder.
Cognitive restructuring. Cognitive restructuring is designed to assist these individuals in modifying specific aspects of their thinking by questioning the logical basis of their fears and by encouraging them to consider alternative ways of thinking (Clark, 1986). Research results indicate that this form of treatment is equal to or superior to interoceptive exposure, in which exposure to somatic cues occurs through visualization or symptom induction, relaxation training, or the use of imipramine.
Margraf and Schneider (1991) found cognitive restructuring to be as successful as interoceptive exposure alone, or a combination of cognitive and interoceptive exposure, with up to 93% of their participants panic-free at 3-month follow-up. The short interval of the follow-up may explain why no differences were found between experimental groups. Margraf et al. (1993) reported in their meta-analysis of panic disorder treatment that the cognitive component of assisting clients to reattribute their bodily sensations was found to be more important to recovery than simply habituating participants through exposure.
In a study by Clark et al. (1991), cognitive restructuring was found to be more effective in reducing panic and panic-related conditions then applied relaxation or imipramine. At a 12-month follow-up, the same pattern of results emerged. Waddell, Barlow, and O'Brien (1984) investigated the effectiveness of self-coping statements and progressive relaxation on panic symptoms. They found that significant decreases in panic attacks occurred with self-coping statements. The relaxation component did not add significantly to the participants' progress, although the gains made during the cognitive treatment were not reversed. This study suffers from a very small number of participants and no controls, but it is generally supportive of the results of the previous research on this technique.
Focused cognitive therapy. Focused cognitive therapy is a specific technique designed for use in the treatment of panic disorder that has received recent attention in the literature. Using this technique, specific panic-related symptoms are reproduced in the therapy session through verbal means, hyperventilation, imagery, or brief rigorous exercise. Individuals are encouraged to test the validity of their pathological misattributions and consider noncatastrophic interpretations instead (Salkovskis, Clark, & Hackmann, 1991). Overall, preliminary studies with focused therapy have been promising.
Sokol et al. (1989) also found focused cognitive therapy to be successful. Individual weekly meetings, ranging from 10 to 40 sessions, were able to bring the number of panic attacks to zero in all participants. These gains were maintained at 1-year follow-up, but this study suffers from a lack of control and experimental comparison groups, and the results must be interpreted with caution.
Similar results with focused cognitive therapy were found by Beck et al. (1992) when compared with brief supportive therapy. Nearly half of all participants were on benzodiazepines. After 8 weeks, the cognitive therapy participants improved significantly more on all measures of panic and anxiety. Furthermore, these therapeutic gains were stable at the 1-year follow-up, when the majority of those on benzodiazepines had either reduced or eliminated their medication.
A study by Black et al. (1993) reported the use of fluvoxamine to be more effective than focused cognitive therapy. They found that at the 8-week endpoint of their study, 81% of the fluvoxamine participants were panic-free, compared with 53% of the cognitive participants. They concluded that cognitive therapy showed some promise, but was not superior to fluvoxamine in treating panic disorder. Nonetheless, no follow-up data was reported, and studies have demonstrated that gains made in psychological interventions with panic are longer lasting than those made with pharmacological interventions (Beck et al., 1992; Clum, 1989; Shear et al., 1991; Sokol et al., 1989). Because of the lack of follow-up data, it is unclear whether the fluvoxamine remained a superior treatment.
Current Diagnosis and Treatment of Anxiety Disorders
- Bystritsky, A., MD, PhD, Khalsa, S. S., MD, PhD, Cameron, M. E., PhD, & Schiffman, J., MD, MA, MBA. (january 2013). Current Diagnosis and Treatment of Anxiety Disorders. P&T, 38(1), 32-57.
Reflection Exercise #12