Panic disorder and agoraphobia can significantly disrupt daily life, leaving individuals trapped in cycles of fear and avoidance. Behavioural interventions, such as exposure therapy and panic induction, are powerful tools that help individuals confront and manage their fears head-on. These evidence-based strategies empower patients to face the physical sensations of panic and challenging situations, gradually reducing anxiety and restoring a sense of control over their lives.
Panic Induction
Panic induction is a key part of treating panic disorder, with or without agoraphobia, as it targets the physical symptoms that patients fear. Studies show that panic induction can effectively reduce these symptoms on its own (Clark, 1996; Craske & Barlow, 2008). During therapy, the physical symptoms of panic are intentionally triggered to help patients become less afraid of these sensations over time. This process starts with an assessment to identify which symptoms cause the most fear. The identified symptoms are then repeatedly induced until the fear naturally diminishes.
Patients are encouraged to let their fear build naturally without using safety behaviours, like sitting down to prevent fainting. Safety behaviours can reinforce the belief that the symptoms are dangerous, so avoiding them helps patients learn that they can handle the symptoms without these crutches. For example, a patient who always sits down during a panic attack may never realize they won't faint without sitting, so facing the panic standing up helps break this belief.
Panic induction exercises vary but commonly include hyperventilation, which can cause symptoms like dizziness, blurred vision, and tingling. Other methods involve spinning in a chair to induce dizziness, tightening chest muscles to create chest tension, or staring at a bright light to trigger depersonalization. Hyperventilation is frequently used because it can replicate multiple panic symptoms, although it's not suitable for patients with conditions like asthma or heart issues.
Different therapeutic models use panic induction slightly differently. Clark's model emphasizes changing catastrophic beliefs (e.g., "I'm having a heart attack") through cognitive reappraisal. Here, patients are guided to hyperventilate to trigger symptoms and then use techniques like breathing into a bag to restore CO2 balance, showing that panic attacks can be controlled by adjusting breathing. This helps patients reframe their symptoms as non-threatening.
Barlow's panic control therapy uses panic induction as a form of exposure therapy. Patients repeatedly engage in exercises that trigger panic symptoms during and between sessions, continuing until the anxiety decreases. Unlike Clark’s approach, which focuses on cognitive change, Barlow’s method emphasizes extinction, where repeated exposure to feared sensations reduces their emotional impact over time.
Overall, panic induction helps patients face their fears of physical sensations and learn that these symptoms are uncomfortable but not dangerous.
Constructing a Fear Hierarchy
Patients with panic disorder often avoid certain situations or feel extreme anxiety in various scenarios. To help manage this, therapists work with patients to create a fear hierarchy—a list of feared or avoided situations ranked from least to most anxiety-provoking. The patient identifies these situations, ranks them, and assigns each a distress rating from 0 to 10, called Subjective Units of Distress (SUDs).
Ideally, the fear hierarchy should include situations the patient can face without using safety behaviours (like "going to a movie theatre alone"). However, if a patient struggles to confront any situation without safety behaviors, these can be included initially (e.g., "going to a theater with my spouse") but should be gradually phased out. Creating a list of safety behaviours in order of difficulty helps the therapist understand which behaviours will be easier or harder for the patient to give up and guides the process of helping the patient gradually stop using them (response prevention).
Safety behaviours are actions or items that patients use to feel safer, such as the presence of another person, taking medication, or keeping food and drinks on hand (Craske & Barlow, 2008). However, patients may also have unique safety behaviours, like leaning on objects to prevent fainting or using a visual anchor to feel grounded. Some feel safer in the presence of others, thinking they'll receive help if needed, while those afraid of embarrassment may prefer to be alone to avoid judgment.
The fear hierarchy should be customized to each patient's needs, ensuring it reflects their specific fears and safety behaviours while providing a structured way to gradually face and overcome their anxieties.
Exposure to the Fear Hierarchy
Exposure therapy targets the fear and avoidance behaviours associated with agoraphobia by having patients confront their fears gradually. After creating a fear hierarchy, the therapist helps the patient tackle these fears step-by-step, starting with the least feared situation (e.g., driving around the block) and progressing to the most feared (e.g., driving on a highway).
If patients are too anxious to start with real-life (in vivo) exposure, they may begin with imaginal exposure, where they vividly imagine the feared situation and its potential consequences (e.g., losing control of the car). The patient stays with the image until their fear naturally subsides, repeating the exercise until anxiety decreases. This approach helps the patient face their fears when direct exposure isn’t initially possible.
Patients are encouraged to discontinue all safety behaviours (e.g., driving only with a spouse) during exposure, as these behaviours prevent them from learning that their fears are unfounded. For example, a patient who only drives when accompanied might think they avoid accidents because of their companion, not realizing they can safely drive alone. Exposure therapy works best when patients confront feared situations without these safety crutches.
The goal of exposure is not necessarily to eliminate fear but to help patients learn that they can tolerate and cope with anxiety without avoiding the situation. In the past, exposure sessions were often ended when fear subsided, but recent research suggests that the key is for patients to experience self-efficacy and see that their catastrophic beliefs don’t come true, rather than completely eliminating anxiety (Craske & Mystkowski, 2006).
Patients practice exposure both during and between therapy sessions to reinforce their learning. To further help disconfirm their fears, patients may write down their anxiety levels, predictions, and outcomes before and after exposure. For example, a patient afraid of losing control on a bridge might record her fear before crossing and her actual experience afterward. Repeated exposure in various contexts and documenting outcomes helps reduce anxiety and change misappraisals over time, allowing patients to reclaim previously avoided activities.
This structured approach ensures that patients can gradually face their fears, reduce avoidance, and gain confidence in their ability to handle anxiety-provoking situations.
Conclusion
Behavioural interventions offer a structured and effective path to overcoming panic disorder and agoraphobia. By systematically confronting feared situations and sensations, patients can dismantle their anxiety responses and rebuild their confidence. With commitment and guidance, these approaches enable individuals to break free from the limitations of their fears, reclaim their independence, and live more fulfilling lives.
References:
Leahy, R. L., & Holland, S. J. (2000). Treatment plans and interventions for depression and anxiety disorders (pp. 128-132). New York: The Guilford Press.
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