Patients in treatment for panic disorder (with or without phobic avoidance behaviors) always ask, “Will the panic come back in the future?” This is an important question, and although my office does not contain a crystal ball, 18 years experience working with anxious, panicked and phobic people has taught me to identify some variables that contribute to relapse prevention.
Panic disorder is defined as the cycle of “fear of fear.” The patient is afraid of severe anxiety symptoms and what they might mean – that one might die, go crazy, lose control, feel embarrassed. He or she may have had one or more of these attacks and lives in fear of the next one, which increases the likelihood that it will occur again. Overcoming this vicious cycle and no longer fearing the panic symptoms is the crux of treatment.
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Effective treatment involves several components of the following: panic and anxiety-reduction techniques, lifestyle changes to maximize stress-management, medication, modifying anxiety-producing thoughts and attitudes, awareness of one’s areas of psychological vulnerability, and how to cope effectively with current-day stressors.
Understanding “Why Me”
Patients need to understand the biopsychosocial nature of this disorder. Understanding the interplay of these factors helps explain to the patient why and hoe he or she developed a panic disorder. This helps lessen the sense of victimization often felt by patients. Learning to appreciate how a sensitive nervous system plus psychological backgrounds factors plus an overload of stress interacts to produce massive anxiety answers the question, “Why did this happen to me?” Not knowing leaves people feeling forever vulnerable and afraid the anxiety will recur.
Panic and Anxiety-Reduction Techniques
While patients may use medication to control their anxiety and panic, it is crucial they learn that they have control over their anxiety. Relaxation techniques may include breath retraining, progressive muscle relaxation, meditation, biofeedback, hypnosis and various exercises such as yoga. These teach a person how to lower the body’s arousal level and quiet the mind. For people with severe anxiety conditions, it must be emphasized that they practice some combination of these techniques on a daily consistent basis, even when the panic ceases to be problematic.
Panic management includes ways of thinking and coping with a panic attack when it occurs. Since beliefs about the meaning of these attacks vary, it is important that every patient understand and modify his or her dysfunctional beliefs. Daily relaxation periods also reduce the frequency and severity of these attacks. Other lifestyle changes also may include eliminating caffeine getting adequate rest and eating a balanced diet.
Not adhering to these stress-management strategies, or relying solely on medication, means patients have not learned they have control over their anxiety nor have they overcome the “fear of the fear.”
Unfortunately, short-term behavioral-cognitive treatment sometimes ignores psychological background factors. Areas of vulnerability to anxiety may have their roots in one’s childhood or adolescence. If, for example, a patient lost a parent in childhood, he or she may have more anxiety at the loss of a relationship in adulthood. Or, rejection or humiliation by peers during adolescence may lead to the development of anxiety around other people.
Understanding our histories gives us important clues about why we find it difficult to cope with certain present-day stressors. Patients feel more integrated when they can pinpoint the origin of some of their fearful reactions. Also, this prepares them for the future. Having compassionate self-awareness goes a long way toward feeling more prepared to cope with life’s difficult challenges without undue anxiety.
It is important to help patients understand that thoughts, not situations, cause anxiety. Effective coping skills may include problem-solving, assertiveness training, communication skills, conflict resolution skills, anger management and parent-effectiveness training, to name a few. Learning these skills creates a sense of self-efficacy that reduces anxiety about dealing with people and the world. This is important in order to avoid feeling overwhelmed, avoidance or anxious in stressful situations.
Occasionally, marital or family therapy sessions may help. Unhealthy marital or family dynamics may undermine the patient’s treatment. Sometimes the family may receive secondary gains from a patient’s illness. For progress to continue, the counselor may need to involve the whole family in treatment.
This comprehensive treatment approach minimizes relapse because it also prepares the patient for the future. For best results, the patient should augment therapy with adjunctive reading, support groups, or workshops. Should a relapse occur, patients should review the old patterns of thinking, behaving and coping they feel have returned. In this way, a relapse becomes a learning experience on the road to successful recovery.