____________________________________________________________________________ Anxiety Disorders
Education and Support Psychoeducation states that providing information to patients with anxiety about their anxiety symptoms and theories of psychologic therapy may help reduce these symptoms. By increasing the patient’s sense of control, psychoeducation may reduce catastrophic thoughts and emotions. This is especially relevant to patients with panic disorder, whose cognitive cop- ing mechanisms are disrupted and whose anticipatory anxiety may cause additional attacks [151]. Supportive psychotherapy uses encouragement, rationalizing/ reframing, and anticipatory guidance to reduce symptoms and maintain, restore, or improve self-esteem, ego function, and adaptive skills. This approach views the therapeutic alliance as the most important element. The archetype of supportive psychotherapy is the Rogerian client-centered approach; a warm, empathic, and non-directive therapeutic relationship helps clients become aware of their true feelings and achieve full self-acceptance. This approach may benefit patients with agoraphobia, but efficacy in panic disorder is unclear [151]. Physiologic Therapy Physiologic therapies involve physical training (e.g., breathing retraining, relaxation techniques, biofeedback) to help patients control physiologic anxiety symptoms. Hyperventilation and hypocapnia are identified factors in panic disorder develop- ment and maintenance; panic attacks can be caused by acute hypocapnia states in a positive feedback loop between hyper- ventilation and anxiety. Breathing training is used to ameliorate panic symptoms, but it shows mixed efficacy in panic disorder [162]. Progressive muscle relaxation teaches patients with panic to reduce general tension and achieve a body state that lowers the risk for panic-inducing stressors. Applied relaxation teaches patients to observe the first signs of a panic attack and apply a rapid and effective relaxation technique to cope with and abort panic symptoms before escalation into a panic attack. Applied relaxation is comparable to progressive muscle relaxation in reducing panic attacks [151]. Psychodynamic Approaches Psychodynamic therapies differ in length and depth, influenced by Freudian psychoanalysis and later refinements. Psychody- namic psychotherapy views mental symptoms as manifestations of intrapsychic and unconscious conflicts; treatment involves uncovering, interpreting, and resolving such conflicts using analysis of unconscious contents, dreams, past experiences, parental relationships, transference, and/or resistances [151]. A brief panic-focused psychodynamic psychotherapy, derived from psychodynamic theories, utilizes emotion-focused ther- apy, whereby the therapist is viewed as an “emotion coach” who works to enhance emotion-focused coping by helping patients become aware of, accept, and make sense of their emotional experience [163].
One psychodynamic psychotherapy approach is derived from the proposition that fearful parental dependency in childhood may lead to anger toward the parent. A vicious cycle is created; anger threatens the needed tie to the parent and increases fearful dependency, which promotes further frustration and rage at the parent. This cycle may recur in adulthood when threats to attachment trigger intense feelings of abandonment, anger, and anxiety, promoting the development of pathologic anxiety. The goal is to address such underlying psychologic factors to decrease panic symptoms. Some evidence suggests this approach is a valid therapeutic option, especially when SEPAD is present [98; 151]. Exposure Therapies Exposure therapy is defined as any treatment that encour- ages patients to systematically confront feared stimuli, which can be external (e.g., feared objects, activities, situations) or internal (e.g., feared thoughts, physical sensations) [136]. Expo- sure therapy is an effective, empirically supported treatment modality for anxiety disorders and a core component of CBT. Variants of exposure therapy include: • In vivo exposure: Exposure that involves real-world confrontation of feared stimuli • Imaginal exposure: Vividly imagining and describing the feared stimulus, including details about external (sights, sounds) and internal (thoughts, emotions) cues • Virtual reality exposure: Patient immersion into a software-generated virtual world that allows them to confront their fears The success of exposure therapy occurs by targeting maladaptive learning and fear conditioning, core mechanisms implicated in anxiety disorder etiology and maintenance. Standard exposure therapy involves exposure to feared objects or situations and gradual elimination of safety behaviors—the subtle avoidance behaviors that temporarily diminish distress in feared situa- tions but interfere with long-term anxiety reduction. Patients are encouraged to continue confronting the feared situations through exposure until substantive reductions in fear occur. Exposure therapies facilitate extinction learning by diminish- ing the association between the avoided situation and fear and promoting new learning of the true nonthreatening nature of the situation [164; 165]. Exposures are graded in intensity, with the same process used for weaning safety signals. For instance, a patient with panic disorder and agoraphobia can initially practice walking through a congested shopping mall with a family member; on the next exposure, he or she may practice walking separately through the shopping mall and eventually walk through the congested mall alone. Patients are taught that treatment setbacks are common and to distinguish between expected treatment lapses and relapses. Symptom flare-ups do not mean treatment failure, but instead are opportunities to revisit psychoeduca- tion, cognitive restructuring, or exposure, and work toward regaining progress [166].
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