Comments on
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.

57 thoughts on “Panic Disorder: Therapy That DOESN’T Work

  • January 14, 2013 at 4:52 am

    Ive been taking Paroxetine for 4 years ans several other times since the age of 17…. during this time Ive taken several other ssri’ This drug paraxatine, does NOT stop my anxiety or depression. The dose has been increased to 30mg 2 years ago. I tell the doctor each time i have a review, they just offer to increase the dose. My last GP needed another opinion and I am still on a waiting list, 6 months later

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    • April 20, 2013 at 7:15 am

      Jellyjuice you need to find another GP that deals with patients that suffer with mental health issues like depression, ask the reception when ringing they will let you know what the doctors specialise in, it is critical to find that doctor that listens to you and get a referal to a physciatrist that you feel comfortable with to talk too, all the best xx

      Reply
  • January 14, 2013 at 9:34 am

    I took benzo’s for about 5 years…I found that your description of what works and doesn’t works resonates on a deep level for me. What little relief I gained was at a trade off of not moving forward. I found that I took benzo’s to prevent any form of stress even the good kind. I have been off benzo’s for 2 years now and have learned many CBT approaches to handle anxiety far superiorly

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  • January 14, 2013 at 10:02 am

    Thank you for this article. I’ve had very sporadic panic attacks since puberty-nothing debilitating usually 20 minutes of pretty bad discomfort, some fresh air and I was fine. I had two within a week so I went to the doctor. He prescribed a “benzo” within three months I was dependent and anxious all the time. I was having panic attacks daily. I finally read a lot about what I was taking and believed it to be the culprit. It was the roughest 6 weeks of my life slowly weening off of it. I’m back to my very sporadic panic attacks that “will not hurt me, will not kill me. I will be okay and people will understand” (my mantra).

    Thank you, again, for spreading awareness about the hazards of these drugs.

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  • January 14, 2013 at 10:48 am

    So true! I was on Klonopin for 9 years and have started the process of micro-tapering off. I had all those symptoms for years but was too scared to face life without my pills, and even more scared of the nightmarish withdrawal of tapering. I can say it hasn’t been as bad as all the war stories on the internet and I STRONGLY ADVISE anyone taking this poison to get educated and wean VERY SLOWLY off. This is coming from a mental health counselor with anxiety himself. Don’t use any supplements, get plenty of sleep, exercise, and be patient with the process. Mine will take 10 months to get off 1 mg/day. I’m not down to .48 with very little side effects. I work, go to grad school,am writing a memoir, mentor teens, and am planning an engagement while moving. All of this while tapering. God really has answered my prayers since I came to believe in and follow him. Thank you for the truth of this article.

    Reply
    • January 15, 2013 at 8:28 pm

      Pete

      It took my daughter a year and a half to get off of 5 drugs.

      Reply
  • January 14, 2013 at 11:38 am

    There’s something to be said about benzos hampering an exposure response to CBT, but there’s also something to be said about the effectiveness of benzos.

    I’ve been on a benzo/SSRI combination for 10 years (yes, years.) My dosage has remained steady over that time, and I am happy with the outcome. There are only mild “breakthrough” attacks from time to time, and I can almost always predict them.

    With that said, I also had CBT therapy which was ineffective. I know the cognitive portion, and the exposure/behavioral portion didn’t do much for my response.

    I know everyone’s mileage may vary, but for some, Ithink that benzos are truly the answer. For others, SSRIs will do the trick. And for some, CBT is the ticket.

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    • January 14, 2013 at 2:43 pm

      Improvement is improvement and that is good. There is, of course, something to be said for individual variation in treatment response as well as in the factors contributing to and maintaining anxiety. I would wonder whether you were on a benzodiazepine while engaging in cognitive behavioral therapy and if that challenged your ability to benefit from treatment. Also, there is certainly a great range in the quality of therapy provided. I would still wonder if you could further improve, eliminating those breakthrough attacks altogether with quality therapy.

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    • January 16, 2013 at 4:39 pm

      …I have to agree with you…I have been on ativan for well over 10 years for anxiety and panic attacks… I am well aware of the addictive nature of them but this does not concern me..I take a very low dose and it has not changed in many years.. Yes I am probably psychologically dependant on them but I chose not to think like that. Instead I am pleased for the little bit of help they allow me in living a normal full working / social life. It works for me and I refuse to feel ‘bad’ about taking them. I think there are a lot worse things I could be using….sometimes I feel we are told what is good or bad for us, and yet I feel the individuals makeup and personality needs to be considered… Good on those that can function without any medication and by therapy only.. Thats great…. This works for me….!!!

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      • January 16, 2013 at 5:51 pm

        I agree with you, brains are individual. Yet, doctors seem to paint us with a broad brush and prescribe the “latest best thing” for your symptoms, which does a disservice to so many. I’m bipolar, but was originally diagnosed with clinical depression and cycled through several drugs myself before concluding that the treatment was worse than the disorder. The side effects alone were horrible and cost me personal relationships and a job.

        Plus, I strongly feel they changed my brain forever because I never fully came back to myself after using wellbutrin, prozac, ativan, etc. Depressions seem longer and deeper now. Again, individual brain, individual case, not saying that others would conclude the same.

        Even “the experts” (see Charlie Rose “Brain Series”) will tell you that, for bipolar disorder, even the latest medications are a partial solution AT BEST. Now I exercise, sleep when I need to, meditate, monitor everything I consume for artificial chems, and smoke pot with very few side effects.

        Point is, as an individual you must decide what’s best for you and NOT hand that over to a doctor who’s prescribing basically the same regimen to everyone they see with similar symptoms. It’s “trial and error” for those guys, with your brain as the test subject.

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  • January 14, 2013 at 5:32 pm

    I beg to differ. I’ve dealt with severe anxiety for as long as I can remember. I’d reached the point where my body actually did not know how to relax. I couldn’t turn off the panic. I TRIED CBT. I TRIED various relaxation techniques. I tried mindfulness. What I really needed was a way to lower my body’s constant anxiety reaction enough that any approach would be effective. Until that happened, nothing worked. Finally, after 3 years with an awesome therapist (preceded by 4 years with 2 not so awesome therapists), I was convinced to talk to a psychiatrist and consider medication. My psychologist and I had made amazing progress, but it wasn’t enough…I was down from daily to weekly panic attacks, but we both agreed that I deserved more relief than that. I had tried medication once before – an SSRI – and did not have a good reaction to it. After some trial and error, I’ve found that a very low dose of Xanax is enough to help my body relax just enough that I am able to work through panic when it occurs. Because my body is not constantly primed for anxiety, I am able to recognize when panic sets in and employ the skills I learned.

    I have not experienced physical or psychological dependency from taking a benzo. If I skip a pill, or am late with taking a dose for some reason, I don’t crave it or feel like I need it. I don’t feel like it’s the only way that I can deal with situations that produce panic. I just know that starting from a point of less anxiety in general makes it much easier to deal with panic when it crops up. My psychiatrist and I have an end point in mind and a plan for me to come off the benzos when I feel like I’m ready. My psychologist and I continue to work on skills for dealing with panic, and I continue to use those skills. Being on a very low dose of a benzo allows the panic to come through on occasion, which allows me to continue to learn that I can deal with panic inducing situations.

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    • January 14, 2013 at 6:12 pm

      You raise an excellent point. There is certainly no “one-size-fits-all” approach to any kind of treatment. And, you raise a good example of how one may benefit from a benzodiazepine as a supplement to CBT when CBT alone has not been sufficient. Unfortunately, they are not always used in this way. Best of luck to you in eliminating the Xanax as well as the remaining anxiety.

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      • January 17, 2013 at 10:22 pm

        I have been taking Xanax since 1985, for a severe panic disorder that would not respond to other treatment or medications.I had my first panic attack when I was in the third grade…but at that time, no one knew what caused panic disorders.I believe that is still the case. By the time I was 44, I had seen so many physicians and psychiatrists, and been through so many treatments that had no effect on my condition, that I literally became housebound, and was planning my own suicide!One physician told me to “get religion”…and proceeded to inform me that what I needed was a “frontal lobotomy”!
        Interesting that my father also suffered from the same disorder and took barbiturates for 33 years. Prior to takin barbiturates, he could do nothing…but while taking barbituates, he created and invented the Frost Free Refrigerator for Westinghoooouse Corp., and had many other patents and certificates for product design and developement. He is listed in “Who’s Who of American Scientists and Inventors”, however, after having had a heart attack at age 66, he was removed from barbiturates…cold turkey. After suffering thrugh the withdrawal symptoms, he became, as he had been prior to taking barbiturates…unable to function mentally! What is interesting is that his brother, my paternal uncle, was afflicted with epilepsy, and had been hospitalized since the age of 16. My father stated that “epilepsy had destroyed the mind of a genius”. In as much as I have never been given a truthful answer by the many physicans and psychiatrists that I have had to endure during my lifetime, I decided to do some research on my own. At this time I would like to refer your attention to two articles, among the multiple articles regarding panic attacks, seizures, and medications. I found these articles most helpful: “Sudden Onset Panic: Epileptic Aura or Panic Disorder?” The Journal of Neuropsychiatry and Clinical Neurosciences, May 5,2012, and “Benzodiazepine Dependency And Withdrawal” Benzo.org.uk, October 24, 2011. At this point in my life, I can honestly say that Xanax saved my life, and that “severe panic diorder” and “epilepsy” are most likely more closely related than anyone realizes. Thank you.

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  • January 15, 2013 at 2:10 am

    Respectfully disagree with some of what you say… CBT didn”t work that well for me. Mindfulness did, though! Took 3 years of Satir training, and I conquered habits/patterns that I had tried to overcome for years. Use my Satir training–working from the inside out–with my clients with MUCH success.

    And, medication…depends on the person and his/her system.

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    • January 15, 2013 at 7:58 am

      Good for you! That’s great. Yes, mindfulness-based and other acceptance-based strategies, considered a “third wave” cognitive behavioral therapy, can be quite helpful. When I talk about what is effective and not effective, I am, not talking about a case by case basis. Of course, there is individual variation. I am talking about a trend reflected in the empirical literature. Mindfulness-based strategies can be quite helpful. They simply have been studied less frequently.

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      • January 16, 2013 at 8:47 pm

        Agree, Marla. Thanks.

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  • January 15, 2013 at 7:22 am

    I think that a one-size-fits all (or one-size-doesn’t-fit anyone) approach doesn’t make sense. My panic attacks (mercifully only a few per year, so I’m quite lucky) tend to wake me up in the middle of the night. I wake up to an electrical sensation running down my spine, and my autonomic nervous system does its crazy thing. So there are no particular thoughts or specific situations that trigger them since I’m usually asleep. I don’t have any panicked thoughts during them other than how unpleasant the attack is and I wish it would hurry up and be over. CBT, for example, just doesn’t apply here. They tend to occur when life is stressful, so general stress management is more appropriate. When they do happen, I use Xanax. It is very effective in shortening the duration. I know full well that the attack will eventually settle down; I just don’t see any reason not to use Xanax to stop it sooner, especially since I tolerate the drug well and never have rebound anxiety when it wears off.

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    • January 15, 2013 at 8:22 am

      If you found what works for you and are happy with your current status, good. My question would be, are you satisfied with having residual nocturnal attacks for which you require psychotropic medication, when you likely have the potential to eliminate them? One could also ask, why not empower yourself with strategies to control your baseline anxiety as well as reduce the symptoms when they occur at night? Yes, benzodiazepines can absolutely settle you down quickly and help you fall back asleep. However, it also has the potential to make one feel groggy and cause sleep disturbance, rendering it difficult to wake up and get going in the morning. Of course, this is not necessarily true, and varies by individual. If this is a good strategy for you and you are happy with your current symptom status, that’s good, but there is likely potential to eliminate the symptoms altogether and the need to take the mediciaton. Again, individuals can becomme reliant on taking a pill, rather than harnessing one’s own ability to gain freedom of the problem, thereby, maintaining the problem. Just because they’re nocturnal, does not mean that you cannot have control over them. You certainly could. Great comments. Thanks for the discussion.

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  • January 15, 2013 at 8:26 pm

    When my daughter was 15 she started getting depressed. She social anxiety among other things.
    The 1st therapist she saw gave full dose paxil.
    By the time she was 21 she had already been on at least 10 pills including benzos. nothing worked
    and she went on disabilty. After 5 or more therapists things were worse and she was totally addicted. Every pill she took had a negative effect. By the time she was 25 she decided on her own to get off all the drugs. Sge read a plan by a therapist in England. She discussed it with her Psychiatrist and they agreed to try it using Ambien as the counter drug. It took over a year but she got off eveything. As a father I can tell
    you that unless your child has a strong biological
    illness do no under any circumstance put them on Benzos.

    Reply
  • January 16, 2013 at 10:36 am

    My mother will be 88 years old next week and suffers from panic/anxiety attacks. She also has Parkinson’s Syndrome with its attendant dementia. How does the CBT approach work for someone like her? Drs. have her on Xanax for anxiety and recently put her on Zoloft for depression and she’s like a flipping zombie. Without the Xanax for two days and she’s a crying, hyperventilating hot mess. When she is on the Xanax, she seems to be a little bit better, I can reason with her sometimes but if she gets on a tangent, the only thing that works is if I “send her to bed”. The Zoloft is new and she just seems chronically sad, to the point of tears.

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    • January 16, 2013 at 5:23 pm

      Good question. This is outside of my area of expertise. I suggest consulting with a geriatric psychologist with a background in CBT.

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    • January 16, 2013 at 8:56 pm

      My mom was on the same meds as I was; she was doing well; and then she decided to go off them! No other medication was as successful. She was in her 70’s at the time. Newer meds like Cipralex (sp?) was the next best for her…very few side effects.

      Also, I don’t find Clonazepam addictive…I can go off it for a few days every month.

      Panic attacks seem to affect people so differently. If I had a child experiencing them now, I’d go the “mindful” way–proper food, less sugar, water, enough sleep, exercise, meditation, etc. And family of origin work helped me rid myself of unhealthy coping patterns.

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      • January 16, 2013 at 9:21 pm

        Certainly, individuals are unique and assessment and individual treatment planning is appropriate. Wouldn’t it be nice though to not need a benzodiazepine almost every day of the month? That’s the point of the blog. It maintains its own use and inhibits habituation and does not allow for consistent successful mastery experiences that could lead to habituation and extinction. As for an elderly individual, treatment planning as well as therapy and medication response can be different than for younger individual.

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  • January 16, 2013 at 11:17 am

    I have to agree and disagree, but only to a point.

    I had to get my anxiety and panic attacks under control, and I was so far gone I was having severe, physically painful manifestations of anxiety. The pain was real, my back muscle tied in knots and spasm, along with my entire torso. No analgesic med touched the pain, because it was all mind driven. Ativan had an effect on both my central nervous system and on the contorted muscles.

    It calmed me enough to do the CBT work, which, sad to say, most therapists are not good at, do not have the time for, and are, for most, even with insurance, unaffordable after awhile.

    I got more understanding from John Sarno MD, Claire Weekes MD, Abraham Low MD and from Steven C. Hayes than I got from a therapist.

    The psychiatrist gave me pills and told me it was “all in my head” and the pain would go away. The various therapists actually watched the clocks on their walls and desk more than they watched my reactions.

    Not to say all have received this kind of neglect from all therapists, but, in talking to many and reading many forum experiences, it is all too common.

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    • January 16, 2013 at 7:11 pm

      Steven C. Hays is an excellent psychologist who is the “father” of Acceptance and Commitment Therapy (ACT), an evidence-based, “third wave” cognitive behavioral therapy. I’m so sorry to hear you’ve had such unhelpful experiences from other “therapists” and that you’ve read similar experiences from others. Empathy, acceptance, and validation are so very important to a therapeutic relationship. There are good therapists out there. If you are in need of a good referral, please do send me a message and I will send you a few who practice in your area.

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      • March 21, 2013 at 11:45 am

        Hi Marla
        Can you help recommend someone in the Phila Pa area? I have reading your blog. I recently started to have panic attacks and anxiety issues probably revolving around getting older and absence of perceived opportunities. First time for it and it scares me to lose ability to function. I need to find someone in CBT therapy or realted. I would like to avaid medication.

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      • March 21, 2013 at 1:23 pm

        I am in the Philadelphia area. We are located in Cherry Hill, New Jersey, specifically. Please feel free to call our office. If our location is not convenient, I would be happy to recommend another facility that is more convenient for you. Our office number is 856-220-9672. You can read more about our practice at http://www.theCenterforemotionalhealth.com.

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  • January 16, 2013 at 11:20 am

    I don’t think it’s productive to pit one forms of treatment against another. There is already a lot of stigma against those of who do take medication for anxiety, writing us off as weak and unable to cope. I was treated with a combination of CBT, relaxation (learning techniques and also scheduling regular exercise), structuring my day to lower stress, and benzodiazepines. I still employ all of these techniques. I frequently go weeks without benzodiazepines, but I am glad to have them in my toolkit.

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    • January 16, 2013 at 12:39 pm

      The intention was to at all to “pit” treatments against one another, but rather to bring to light a caution that may challenge successful treatment. Excellent points. Glad to hear you’ve found a good combination for you.

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  • January 16, 2013 at 11:39 am

    Underneath the comments I’m reading is the very important fact that every client needs to get a good and thorough evaluation, which integrates your unique set of symptoms, co-occuring problems, strengths, history, genetics, etc. into a comprehensive understanding of what’s going on.
    So get a well-trained professional to do a good intake/evaluation (requires you to be completely forthcoming though!) before they offer up suggestions for treatment. It is a complex issue to address for many people so therapists tend (and should) design a treatment plan for the individual.

    One other note: Use of thc (pot), especially heavy use, is often accompanied by panic/anxiety and sensitizes some people to anxiety, even small amounts seem big, and it cannot be treated effectively until the individual cuts down to very little use or none, just like with the Benzos. Other mood altering drugs, especially anxiolytic drugs, actually can make things worse over time, but getting people to let go of them is very difficult. As mentioned, physiological and psychological addictions grow so unintentionally, sometimes a persons immendiate “solution” becomes our biggest long-term problem.

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  • January 16, 2013 at 11:43 am

    I have been very sick with chronic fatigue syndrome since 1995. The onset included low grade fevers, confusion, swollen lymph nodes. In spite of this a neurologist gave me Paxil in case I had clinical depression. That night I was up all night feeling like I had to push the air out of my lungs or I would stop breathing. A couple of years earlier my husband had mono, again misdiagnosed as depression. He was given Prozac and hallucinated all night. Seven years ago I again got very sick with what seemed to be meningitis. I have not fully recovered and routinely wake around 3 am feeling like I want to slam my head against a wall or kill myself. I do not act on this, nor do I take SSRIs or other medication. I focus, meditate, pray and continue to search for the CAUSE of my constant head pressure. Does my case apply to others? Possibly, yes. When someone becomes ill and then has what we think are psychological problems I believe we must look for other causes such as infections found in Lyme disease or new emerging viruses.

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  • January 16, 2013 at 11:54 am

    I am curious as to whether or not you have had to endure a panic attack. If you have and the above works for you, then congratulations, but I don’t believe that you truly understand the horror of feeling like you are dying and knowing you are not. I have fought them for 30 years now. I spent the first 20 without the benefit of xanax. I have also spent a significant time in therapy. While many of the techniques listed are often helpful, there are times when the only thing that can end the attack is the medication. I have two small children, so I don’t take the use of any mind altering medication lightly. I always try to “talk myself down” before medicating. For me (and many others I know), breathing exercises only make things worse. Believing one should be able to control these feelings, then failing at doing so, only exacerbates the problem. People need to know that it is not their fault that they have these issues. There are both biological and psychological triggers. Your essay is too simplistic in discussing the treatments of panic disorder. However, I would like to note that these medications should be prescribed and monitored by a mental healthcare professional, not a GP.

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    • January 16, 2013 at 5:22 pm

      I understand on a deep level the impact of panic disorder, yes. I also know on a personal level that long-term symptom abatement is possible. You are correct that the post simplifies CBT and conceptualization as each individual is unique. It is a summary of the evidence-based standard of care. You mentioned a sense of blame and shame. This is not your fault and there is no shame in this struggle. Relaxation or paced breathing practice can sometimes initially lead to an increase in anxiety because the feeling of the relaxation response is unfamiliar and can be alarming (e.g., lightheaded, fuzzy, dizzy). Your mind and body will adjust – calm this faulty interpretation of alarm (habituate), given the practice. I’d suggest a different approach such as biofeedback or progressive muscle relaxation which can divert the attention to focus on the sensations in order to gain control over them.

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  • January 16, 2013 at 12:35 pm

    Oh, I love this post and think it is so important to get the word out, especially via therapists, as to when and when not to use these drugs. I’ve been planning to write a post about the use of benzos and how they can affect the success of ERP Therapy for those with OCD….I will likely link to this post.

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  • January 16, 2013 at 1:38 pm

    I think paradoxical intention and a behavioral approach can help. You may be right, benzo’s may interfere with some of the learning that takes place in ‘mastery experiences’.

    On the other hand, my severe anxiety started when I was 16. I begged my mom to see a Doctor or Psychiatrist, but she said “No!” So I was left to cope. I had dissociative symptoms with my panic attacks that lasted for a day and left me shaken for much longer.

    I limped through life in my 20’s, I had to learn some coping skills in order to eek out an existence. I did not know there were social programs/welfare or the like, so I had to get part time jobs in order to survive. I was afraid of being seen by a mental health professional, because I thought I might be locked up in a mental institution.

    When I was 29, I sought treatment for the first time and Xanax was a miracle drug for me. My diagnosis at the time was OCD, Panic Disorder, Depression. (later they added BPD and Schiztotypal PD to the list).

    Articles like this scare me. Because I like my Xanax, and I am surely psychologically, maybe physically dependent on it. It helps me to function day to day, and I honestly believe it has kept me off of disability. It helps me to be able to function at work …and that is a pretty big reinforcer.

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    • January 16, 2013 at 4:31 pm

      Co-occurring psychopathology can certainly complicate the clinical picture and require a multimodal approach to treatment. Benzodiazepines certainly have their place in psychiatric treatment. They should however be used with caution. Glad to hear you have found some help.

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  • January 16, 2013 at 1:56 pm

    I was taking klonopin to help me calm down enough to sleep every night for years. Then one day the doctor told me about some of the side effects. Now I take it one or two times a month depending on life circumstances. For me it helps in the moment but the anxiety seems to come back, sometimes worse. I am working hard on trying other coping mechanisms, especially mindfulness, and not believeing my thoughts. this has helped me to stop being anxious about being anxious.
    Still, Sometimes the medication gets me through a especially difficult time but I realize I use it as a crutch and honestly sometimes I take it to avoid really intense feelings of anger as well. I know that is not healthy.
    I think I will get off it completely one day as I practice the other things I am learning.

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    • January 16, 2013 at 3:47 pm

      As a psychologist, I have found a surprisingly large number of clients who have intermittent panic attacks have a lot of pent up anger (unexpressed and internalized anger). Again, a professional can help with this too.

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  • January 16, 2013 at 5:55 pm

    My 20 year old daughter who is in college suffers panic attacks. Because I’ve been dealing with my own mental illness (Bi Polar) for 27 years I recognized it right away. The scariest incident was when she called me at night going back to college at night on a 20 mile bridge with no exits. As a mother it was terrifying to hear her shallow breathe over the phone. She was too scared to pull over so she kept driving. I kept telling her she was going to be alright and she wasn’t going to die. I stay on the phone until she got to her dorm. We have her on Zoloft, she is 98% better. Because our insurance doesn’t cover counseling, I have to help her myself with tools I’ve learned over the years.

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  • January 16, 2013 at 6:40 pm

    A tranquiliser might control the reaction of panic, but it doesn’t do anything about the reason BEHIND the panic, and it doesn’t help you learn how to cope with it without the pills. I blessed whoever invented twilight sedation when I had major dental surgery – but all it taught me was ‘you don’t need to be afraid, the tranquilisers will knock you out cold’. It didn’t do anything to help me cope when I had to have a root canal a few years later. My immediate reaction was to say ‘knock me out cold and pull it out because I can’t do it and I don’t care how my mouth looks!’ but the very wise dentist persuaded me to let her do the root canal and save the tooth. She was ready to give me valium and/or nitrous if I needed them, but I found out that it wasn’t nearly as terrible as I’d anticipated and I could do it without the pills! And now I have much more confidence in my own ability to survive one of my phobias if I ever have another dental emergency. The main reason I could get through it was because I know from experience that exposure therapy WORKS, and that no matter how anxious I feel, it’s not going to kill me. I can get through it. Taking a pill just teaches you that the pill can do it for you.

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  • January 16, 2013 at 10:15 pm

    Anything, whether its drugs, alcohol or blocking kinds of psychotherapy, can contribute to enabling the phobias, anxieties, PTSD etc. So many Therapists and Psychiatrists are either too much in a hurry, capitated with number of sessions, or are afraid of sitting in the room with someone who is re-experiencing gruesome traumas. Most of the short term “Evidence Based” therapies are just that, short term relief and little or no integration of the experience and mastery.

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    • January 16, 2013 at 10:29 pm

      That depends upon how it is done. Exposure based therapies should provide patients with mastery experiences and long-term relief of distress.

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      • January 17, 2013 at 7:46 am

        Thanks for your post. I will definitely blog about EMDR at some point, it’s evidence base and its controversy regarding its mechanism of action and exposure processing.

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  • January 17, 2013 at 7:07 am

    I’m a therapist who uses EMDR as my primary method and I’ve also personally had EMDR therapy for anxiety, panic, grief, and “small t” trauma. As a client, EMDR worked extremely well and also really fast. As an EMDR therapist, and in my role as a facilitator who trains other therapists in EMDR (certified by the EMDR International Assoc. and trained by the EMDR Inst, both of which I strongly recommend in an EMDR therapist) I have used EMDR successfully with panic disorders, PTSD, anxiety, depression, grief, body image, phobias, distressing memories, and bad dreams.

    One of the initial phases (Phase 2) in EMDR involves preparing for memory processing or desensitization (memory processing or desensitization – phases 3-6 – is often referred to as “EMDR” which is actually an 8-phase method of psychotherapy). In this phase resources are “front-loaded” so that you have a “floor” or “container” to help with processing the really hard stuff. In Phase 2 you learn a lot of great coping strategies and self-soothing techniques which you can use during EMDR processing or anytime you feel the need.

    Grounding exercises are terrifically helpful. You can also use some of the techniques in Dr. Shapiro’s new book “Getting Past Your Past: Take Control of Your Life with Self-Help Techniques from EMDR.” Dr. Shapiro is the founder/creator of EMDR but all the proceeds from the book go to two charities: the EMDR Humanitarian Assistance Program and the EMDR Research Foundation). Anyway, the book is terrific. It’s an easy read, helps you understand what’s “pushing” your feelings and behavior, helps you connect the dots from past experiences to current life. Also gives lots of really helpful ways that are used during EMDR therapy to calm disturbing thoughts

    As I’ve mentioned about Phase 2, during EMDR therapy you learn a lot of great coping strategies and self-soothing techniques which you can use during EMDR processing or anytime you feel the need. You learn how to access a “Safe or Calm Place” which you can use at ANY TIME during EMDR processing (or on your own) if it feels scary, or too emotional, too intense. One of the key assets of EMDR is that YOU, the client, are in control NOW, even though you certainly haven’t felt in control during a PA. You NEVER need re-live an experience or go into great detail, ever! You NEVER need to go through the entire memory. YOU can decide to keep the lights (or the alternating sounds and/or tactile pulsars, or the waving hand) going, or stop them, whichever helps titrate – measure and adjust the balance or “dose“ of the processing. During EMDR processing there are regular “breaks” and you can control when and how many but the therapist should be stopping the bilateral stimulation every 25-50 passes of the lights to ask you to take a deep breath and ask you to say just a bit of what you’re noticing. (The stimulation should not be kept on continuously, because there are specific procedures that need to be followed to process the memory). The breaks help keep a “foot in the present” while you’re processing the past. Again, and I can’t say this enough, YOU ARE IN CHARGE so YOU can make the process tolerable. And your therapist should be experienced in the EMDR techniques that help make it the gentlest and safest way to detoxify bad life experiences and build resources.

    Pacing and dosing are extremely important! So if you ever feel that EMDR processing is too intense then it might be time to go back over all the resources that should be used both IN session and BETWEEN sessions. Your therapist should be using a variety of techniques to make painful processing less painful, like suggesting you turn the scene in your mind to black and white, lower the volume, or, erect a bullet-proof glass wall between you and the painful scene, or, imagine the abuser speaking in a Donald Duck voice… and so forth. There are a lot of these kinds of “interventions” that ease the processing! Bringing your adult self into the memory is a great strategy. Your therapist can use what we call “cognitive interweaves” to help bring your adult self’s perspective into the work as well. Such interweaves are based around issues of Safety, Responsibility, and Choice. So therapist questions like “are you safe now?” or “who was responsible? and “do you have more choices now?” are all very helpful in moving the processing along.

    In addition to my therapy practice, I roam the web looking for EMDR discussions, try to answer questions about it posted by clients/patients, and respond to the critics out there. It’s not a cure-all therapy, however, it really is an extraordinary method and its results last. Check out the research: emdr dot com/general-information/research- overview dot html>. In the hands of a really experienced EMDR therapist, it’s the most gentle way of detoxifying really horrid experiences.

    I can’t say enough good things about EMDR. It’s changed my life both as a person/consumer, and as a therapist. It’s so satisfying to have someone come in for help and then to witness them get through their issues and finish therapy relatively quickly (compared to regular talk therapy, it’s like night and day). I am both humbled by and grateful for this wonderful method that heals suffering.

    Reply
  • January 18, 2013 at 6:33 pm

    I didn’t read the last several posts; however, after many responses indicated that they’d been crippled with severe anxiety and have been on meds for years, I think one could surmise that the panic is related to another mental disorder (bipolar, depression)that, when successfully medicated alleviates some or much of the anxiety. Those folks are often supplied with benzos, as needed. It’s easy to misuse them, though, so meds abuse always remains a possibility. CBT is appropriate for ANY and ALL mental illness/discomfort, big or small. Never give it up. If one trick doesn’t help, keep trying.

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  • January 19, 2013 at 12:26 am

    Let me start by saying I have a Ph.D. in Psychology from a top school and have been a psychologist working with anxiety/ panic disorders for over 20 years. MOST IMPORTANT, I suffer from panic disorder. I had my first panic attack in college during my B.A. program, I did all the therapies doctors, professors and friends suggested and nothing worked very well. After 10 years of struggling and feeling like a failure because nothing was working I finally went on meds. My world was so small, although I functioned and worked and went to school and got great grades, I always had to be close to an ER and my car in order to get to help when I had a panic attack. I could not vacation, fly or go places that left me too far from an E.R. I now take 30 mg of celexa, 1 mg. of Ativan and 30 mg. or Inderol. I have been doing this since 2000 with no increase in doses. My life is 100% different, I now travel the world for a consulting job with the military that takes me to Germany, Korea, England etc. several times a year. I have no fear to be anywhere including some very remote regions in Turkey with no medical help anywhere. Last year I climbed Germany’s highest mountain in Garmisch with my husband. All of this would have been nothing but a dream before the medications. They completely saved my life and now I work with others to help them. I hate when I see CBT fixes all, EMDR fixes all, meds fix all. NO you have it all wrong, it is different for each and every one of us. People come to me in their 40’s having suffered for 20 years and afraid to go on meds. When they do and their life changes it is so rewarding to me (however I still think meds is a LAST resort). So many of what people call panic attacks are NOT. In my years of suffering from them and the 1000 of people I have worked with, true panic disorder is often misdiagnosed. To me real panic disorder is a physiologically based and can only truly be helped by some form of medication management (although I agree benzos only in the most severe cases) I do think SSRI’s are the first line. At this point the only issue I have was being so stubborn and spending 10 years of my life in hell because I was sure it was “all in my head”. Now I know its a physical condition irregardless of what anyone else says. I am glad I have the experience to now help so many others after shifting through those who truly suffer from panic disorder and those whose panic is something separate and not biological. If I could only tell you how great the last 12 years of my life have been… and how much I changed with out ONE relapse you probably would not believe me, but my friends and family are living testimonies to what medication did for me.

    Reply
    • January 19, 2013 at 1:10 am

      Thank you for your comments. I do agree that treatment varies by individual and I am glad to hear what works for you. However, what you’ve said is somewhat illustrative of one of my points; you are on a benzodiazepine on which you will indefinitely rely for symptom relief or, perhaps, just avoidance of the anticipatory anxiety associated with being without it at the risk of experiencing panic symptoms. Although you have found relief in maintaining on the medication, you still rely on the medication to maintain. Wouldn’t it be nice if you were able to maintain without it?

      This point aside, the main point of the post was that benzodiazepines can interfere with successful cognitive behavioral treatment by preventing habituation. There is substantial research demonstrating this.

      I hear some anger and resentment toward cognitive behavioral therapy in your response. I have never asserted that it is a “fix all” therapy. In fact, I consider myself to be an integrative psychotherapist and was trained as such, focused on evidence-based treatments. There are numerous orientations and approaches to conceptualizing and treating problems. My only bias is toward those that have been demonstrated through scientific investigation to be effective. As you know as a fellow psychologist, individual experiences (case reports, essentially) are interesting and foster thought for further hypothesis and investigation, but empirical study is much more robust and generalizable.

      I do agree that panic is sometimes misdiagnosed, as are many other psychiatric problems. However, I am not aware of any literature supporting your distinction between a biologically-based panic disorder and something else that may resemble it. In fact, it is characteristic of those who have panic disorder to feel that they experience panic as much more intense and distinctive from others. From a cognitive perspective, we may hypothesize that this is a misinterpretation of one’s own bodily experience and the emotional and cognitive reaction to that physiological arousal. Further, CBT is considered first line treatment for panic, and has been shown to be more effective than medication for the long term. In fact, a recent study demonstrated that those who have benzodiazepines and/or other medications alone as well as those who have medications in addition to CBT have a significantly higher relapse rate than those who have CBT alone.

      I will refrain from significant public self-disclosure, but will say that I do understand panic disorder on a more personal level as well and also know that it can be effectively treated for the long-term without medication, as demonstrated in the scientific literature.

      I specialize in treating anxiety disorders and I often see patients who are able to put their panic behind them as well for the long-term, without meds. More importantly, I see many people who are unable to effectively use cognitive behavioral therapy until they discontinue their benzodiazepines. They simply do not have the ability to become anxious enough to have mastery experiences and habituate while on them. Once they are discontinued, they do very well and the panic is effectively treated. This problem with benzodiazepines and habituation has also been discussed in the literature. See aforementioned reference.

      Reply
    • February 23, 2013 at 11:56 pm

      I agree with you that severe panic disorder is a physiological malfunction that is most successfully treated by medication, and that many who claim to have a panic disorder are actually suffering from anxiety, a psychological disorder. I found that SSRIs, tri-cyclic antidepressants and Elavil actually provoked panic attacks, however…surprisingly, Dexadrine did not! But I am not willing to risk a heart attack by taking “super-speed”. After all of the agony and misery that I experienced, plus the embarrassemnt to me as well as the loss of patience from those who tried to treat my condition, just one 1mg. tab of Xanax, followed by a two hour nap completely changed my life. My phychiatrist was totally astounded at the difference! I told him “Well, it looks like you found the right medication, after all.” I might also add that, of all the physicians, helth consultants and psychiatrists that I had suffered through, he was the only M.D. to ever admit that he DID NOT KNOW WHAT WAS WRONG WITH ME…but he was going to find out…I owe that man my sanity…and my life!

      Reply
      • February 24, 2013 at 12:06 am

        Please allow me to clarify. Panic disorder is an anxiety disorder. It is a psychological disorder. I was not at all saying that severe panic is best treated with medication. to the contrary, scientific literature demonstrates that CBT is superior to medication in the long-term treatment outcome of those with panic disorder. That being said, I am glad to hear you have found something that works for you. Your situation, as you described, does not sound like panic disorder alone.

        Reply
  • January 25, 2013 at 12:23 am

    Thanks for this thought-provoking article! I was started on a benzo because I didn’t have a therapist at the time, and I pretty much had no other choice. After going on the benzo, I’ve gone through about 8 different therapists and psychologists that have not seemed to help me much. Alas, I haven’t been able to find someone who really advocates CBT, especially with homework. After almost two years on the benzo, I wonder if I’m going through withdrawal symptoms because I have mostly been taking the original dosage I was prescribed, and I have a lot of fear that it will be almost impossible to get off of the medication, mostly from what I’ve read about dependance and addiction to benzos. Any advice for or steps to take to get the right help would be appreciated. Thanks again.

    Reply
    • January 27, 2013 at 11:04 pm

      Jeff,

      Thanks for sharing your experience. Everyone is different in how they respond to medication and how easily they are weaned. As I am a psychologist and not a physician, I cannot give you specific advice about the medication. However, I will say that most individual who have been on benzodiazepines for an extended period of time find that weaning slowly under the direction and care of a physician is the most effective strategy, in conjunction with support of a good therapist who is working with you to change your perception of panic symptoms as well as cognitive and behavioral coping strategies. Conquering panic attacks is possible. Keep at it.

      Reply
  • January 28, 2013 at 10:15 am

    I’ve been diagnosed with Panic Disorder and have had an extremely hard time with it. I’ve become slightly agorophobic because of it and can hardly control my obsessive thoughts. I am in CBT but I also take meds. My PCP gave me Xanax to take at the onset of an attack to, as you said, take the edge off. But she also prescribed my Zoloft for everyday use. I hardly touch the Xanax because I know so many people who are addicted to it and the Zoloft seems to be working somewhat. My CBT is even better but I’m still scared to go off the Zoloft. But I hope one day I can and not live in fear all day everyday.

    Reply
  • February 23, 2013 at 2:03 pm

    I understand that “benzos” blunt anxiety, which is why they are usually prescribed. What if panic is an artifact of childhood trauma, i.e., violent, physical abuse? Do you want the patient to relive those terrifying traumas until they don’t hurt anymore? What if you can’t extinguish the terror within the response? Terror is part of response. Can you carve that out to make it more endurable?

    Reply
    • February 23, 2013 at 7:06 pm

      I was addressing panic, not PTSD. That being said, there is an appropriate use of benzodiazepines for short term relief. For PTSD, evidence based treatment does involve a cognitive behavioral exposure based approach.

      Reply
  • April 20, 2013 at 7:11 am

    I have really BAD Anxiety and Depression long story cut short I was sent to mental heath and he said i didnt have Depression (for which i have been seeing a physciatrst for over a 18months) he gave me a script for Benzodiazepines and i ended up in hospital that night after mt hubby walked in on me in the shower cutting my leg, i have NO memory of that day or most of the next day 🙁 my physchiatrist was horrified they didnt listen to his recomendations to have me put into hospital that first day and have ECT treatment for which i have had in the past twice with GREAT results, i will never take those medications again, and it worries the life out of me that if i feel i need help again in the future i will not ask for it because of my experience of haveing to go to that mental health centre because of prodicole of where one lives. 🙁

    Reply
 

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