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Panic Disorder: Therapy That DOESN’T Work

Approximately 6 million individuals experience panic disorder each year. Panic disorder is characterized by recurrent, intense periods of anxiety/panic, which are often unprovoked, or, “out-of-the blue,” and are accompanied by anticipatory anxiety regarding the possibility of future attacks. Panic disorder can be quite debilitating, sometimes accompanied by agoraphobia, or avoidance of pubic places due to fear of being in a setting or situation from which escape or finding help may be difficult.

Before we get to what DOES NOT work, let’s discuss what DOES work. Evidence for effective treatment of panic disorder is very well documented. The data show with great robust that cognitive behavioral therapy (CBT) is effective and is superior to a number of other treatment strategies.

Cognitive behavioral therapy for panic disorder often includes:

1) Psychoeducation – Education regarding the nature and course of the disorder; the autonomic nervous system and the fight-or-flight response; conceptualization of panic as the magnification and misinterpretation of somatic experiences which result in further physiological arousal and panic symptoms; treatment rationale; and, course of treatment.

2) Relaxation training – Learning to engage the relaxation response via training in diaphragmatic breathing; paced breathing; progressive muscle relaxation; or biofeedback.

3) Cognitive restructuring – Identifying the individual’s cognitive structure/sequence during panic; learning to identify cognitive distortions; challenging cognitive distortions; and restructuring these thoughts to be more realistic, accurate, and helpful.

4) Exposure – Eliciting panic symptoms and utilizing coping skills to reduce symptoms; creating a hierarchy (least anxiety-provoking to most anxiety-provoking) of avoided or distressing situations and exposing the individual to these experiences in a structured, systematic manner, allowing them to utilize their coping skills to minimize anxiety.

The KEY TO EFFECTIVE TREATMENT is creating mastery experiences, “I did it” experiences, in which the individual has a new emotional experience in these previously distressing situations, one of newly perceived control over anxiety.

You may have noticed that I have not mentioned medication yet.  While this is a blog about effective psychotherapy, psychotropic medication is an effective treatment option for many psychiatric disorders.

In the case of panic disorder, CBT has been shown to be as effective, and, in some studies, superior to psychotropic medication. Common medications approved for the treatment of panic disorder include: selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and benzodiadepines, which brings me to what DOES NOT work… actually, more of a caution and highlight of potential for unintentional maintenance of the problem…

(I step onto my “soap box.” ) Benzodiazepines (e.g., Xanax, Ativan, Klonopin) are frequently prescribed by physicians for patients who present with anxiety (and panic).  Often, when primary care physicians or psychiatrists prescribe these medications, these patients are at my door several months later, anxious, overwhelmed, and relying on their benzodiazepine for a small amount of temporary relief.  They cling to it, yet they report that it is not very helpful. Although it may “take the edge off,” the anxiety quickly returns to which they can only respond by taking another pill.

Thus, herein lies what DOES NOT work.  I truly enjoy treating panic disorder; I do. It is why I became a psychologist. But, time and time again, I see patients who present as prescribed benzodiazepines who are not likely to improve until they are no longer relying on benzodiazepines.  Here’s why:

1) There is a risk of physiological dependence. Yes, that’s right; it’s habit forming.

2) There is a risk of psychological dependence. So frequently, I see patients who are fearful of leaving benzodiazepines behind, as benzodiazepines have been their only source of potential relief, albeit minimal. Benzodiazepines can undermine CBT treatment, in this way, as it unintentionally validates their belief that they cannot control the anxiety and must rely on external forces to do so.

3) It can create a dysfunctional treatment response. As noted above, although it may “take the edge off,” the anxiety quickly returns to which they can only respond by taking another pill, as they have learned.

4) Most importantly, benzodiazepines can be counterproductive to CBT. The aforementioned problems notwithstanding, benzodiazepines, which enhance the action of the neurotransmitter, GABBA (Gamma Amino Butyric Acid), resulting in a “calming” or dulled excitatory response.  In essence, it dulls the emotional experience, thereby reducing the potential for anxiety/panic intensity.

Ay, here’s the rub, as a cognitive behavioral therapist, I WANT you to experience anxiety (in our planned, systematic manner) in order to have mastery experiences, experiences in which you are able to learn that you can, indeed, effectively use your newly acquired coping skills to control and minimize your anxiety.  If your ability to experience anxiety is blunted by benzodiazepines, you may be less likely to benefit from CBT and may have a higher potential for relapse.

I’ll step down off my “soap box” now.

What are your experiences?


Dr. Deibler

Lead photo available at 123rf

Panic Disorder: Therapy That DOESN’T Work

Marla W. Deibler, PsyD

Marla W. Deibler, Psy.D., is a clinical psychologist and nationally-recognized expert in anxiety disorders and the obsessive-compulsive spectrum, including trichotillomania and other body-focused repetitive behaviors, obsessive-compulsive disorder, hoarding, and tic disorders. She is the Founder and Executive Director of The Center for Emotional Health of Greater Philadelphia in New Jersey, an outpatient facility specialized in providing evaluation and evidence-based, cognitive-behavioral therapies for these and other difficulties. She currently serves on the Board of Directors of OCD-NJ, the New Jersey affiliate of the International OCD Foundation (IOCDF). Dr. Deibler gained her formative clinical experiences at the National Institute of Mental Health (NIMH) at the National Institutes of Health (NIH), Children’s National Medical Center, and the Kennedy Krieger Institute at Johns Hopkins University Medical Center. She gained specialized behavior therapy experience in the treatment of obsessive-compulsive spectrum disorders at the nationally-recognized Behavior Therapy Center of Greater Washington. Dr. Deibler served as a clinician at the National Center for Phobias, Anxiety, and Depression. She also served as Director of Behavioral Sciences at the Temple University School of Dentistry and served on the clinical faculty at Temple University Schools of Medicine and Allied Health as well as Temple University Children’s Medical Center. Dr. Deibler has published scientific research in peer-reviewed journals and has presented clinical training seminars and research findings at national and international meetings. She has appeared on the Dr. Oz Show, A&E’s “Hoarders”, TLC’s “Hoarding: Buried Alive”, CBS News, ABC News, FOX News, It’s Your Call with Lynn Doyle (CN8, Retirement TV), and CBS’s “Swift Justice with Nancy Grace”. She has been quoted by media outlets, including the Wall Street Journal, CNN, Philadelphia Inquirer, Philadelphia Daily News, and the Connecticut Post, among others. Dr. Deibler holds licenses to practice psychology in New Jersey (Lic. No. 35S100438000) and Pennsylvania (Lic. No. PS0157790). She is an active member of the American Psychological Association, Trichotillomania Learning Center, International OCD Foundation, OCD-New Jersey, Association for Behavioral and Cognitive Therapies, and Anxiety Disorders Association of America. Dr. Deibler resides in suburban Philadelphia with her husband (who is also a psychologist) and three children.

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APA Reference
Deibler, M. (2013). Panic Disorder: Therapy That DOESN’T Work. Psych Central. Retrieved on July 5, 2020, from


Last updated: 15 Jan 2013
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