Panic Disorder: Building Skills to Tolerate Symptoms and Fear

Panic attacks can be profoundly unsettling, especially when individuals are unaware of their origins or triggers. The experience of having recurrent panic attacks, coupled with the anxiety of anticipating another episode, is classified as panic disorder. This condition can be overwhelming, debilitating, and significantly disrupt daily activities. Simon Rego, PsyD, ABPP, A-CBT, a member of the ADAA, empathizes with those grappling with panic disorder, acknowledging the intense feelings of dread they endure.

At Montefiore Medical Center and the Albert Einstein College of Medicine in New York City, Dr. Rego remains acutely aware of his patients’ fears. He emphasizes that it is often their “fear of fear” that perpetuates the cycle of panic attacks. Through therapeutic interventions, he equips his patients with essential skills to respond differently when panic strikes. A crucial aspect of effectively managing panic disorder involves helping patients reduce their fear of panic symptoms. But how does Dr. Rego achieve this? In a recent discussion with ADAA, he revealed that it requires significant effort, can be exhausting, and at times, dizzying, yet the results are undeniably effective.

Understanding the Distinction Between Panic Attacks and Panic Disorder

Grasping the distinction between a panic attack and panic disorder is essential for effective treatment. Statistically, approximately 20-25% of individuals will experience a panic attack at some point in their lives. Compounding the situation, Dr. Rego notes that many may encounter the symptoms of a panic attack—such as sweating, heart palpitations, chills, difficulty breathing, chest discomfort, tingling sensations, and the overwhelming fear of fainting or dying—without any identifiable cause.

Dr. Rego refers to these as “out-of-the-blue” or unexpected panic attacks, indicating that they occur without any apparent trigger or connection to the person’s activities at that moment. However, only about 3% of adults in the U.S. receive a diagnosis of panic disorder in any given year. Panic disorder is characterized by the recurrence of panic attacks and the subsequent anxiety about experiencing future episodes.

Panic attacks may also manifest in other anxiety disorders, such as social anxiety, generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and depression, or even in relation to substance use disorders. However, this does not necessarily indicate the presence of panic disorder. In such cases, the panic attacks typically stem from the heightened anxiety associated with the primary disorder (for example, a person with social anxiety disorder may experience a panic attack while speaking in front of a large audience), rather than occurring independently.

“Panic disorder fundamentally involves individuals experiencing recurrent panic attacks and the fear of those attacks,” Dr. Rego explains. “To meet the criteria for a disorder, the fear and presence of these attacks must be severe enough to cause significant disruption in one or more areas of life—such as academic performance, professional responsibilities, relationships, or social interactions.”

Many individuals who experience an unexpected panic attack do not require treatment because they do not develop a fear of the attack’s consequences, do not worry about having another episode, and do not modify their lifestyles as a result. Conversely, individuals with panic disorder often develop “catastrophic” beliefs regarding their panic attacks (for instance, believing that each panic attack signifies a heart attack). This distorted thinking can lead to lifestyle changes that impair their ability to function and promote avoidant behaviors.

As outlined in ADAA’s Patient Guide to Mood and Anxiety Disorders, panic disorder is recognized as one of the most prevalent “physical” psychiatric disorders, with symptoms that can prompt visits to emergency rooms or consultations with cardiologists, neurologists, pulmonologists, and other specialists. The guide refers to the cycle of panic attacks as the “march of panic” and offers valuable insights into the disorder and its treatment. Dr. Rego is dedicated to helping his patients halt, or at least slow down, this march.

Effective Strategies for Treating and Preventing Panic Disorder

Dr. Rego expresses a preference for receiving patients directly from the emergency room during their initial visit, as they have typically undergone a thorough evaluation and have been medically cleared. This allows for earlier intervention regarding distorted thoughts, which can be addressed before the onset of problematic (i.e., avoidant) behaviors.

Panic disorder is highly treatable, supported by extensive research and established methodologies. The treatment process is well-defined, enabling practitioners to assist individuals, irrespective of the duration or severity of their condition.

A cornerstone of treatment is Cognitive Behavioral Therapy (CBT), which is the most recognized psychological intervention for panic disorder. Medication can also be beneficial, and a combination of therapy and medication may be utilized, especially in cases where co-occurring issues like depression are present. While exposure therapy is a primary component of CBT for panic disorder, comprehensive treatment encompasses symptom monitoring, education about panic disorder, and skill development to manage attacks and confront avoidance behaviors.

“To prevent future panic attacks or at least diminish the associated fear, it is essential for individuals with panic disorder to reframe their thinking,” he asserts. Dr. Rego notes that the majority of those who experience panic attacks do not develop panic disorder, which suggests a difference in cognitive processing and behavioral adjustments following an attack between those who do and do not develop the disorder.

Essential Skills for Managing Panic Disorder and Their Functionality

Patients seeking help for panic disorder from Dr. Rego face a challenging journey ahead. While attending CBT is crucial, Dr. Rego emphasizes the importance of translating theory into practical skills for everyday life. He has identified three fundamental skills that he imparts to his patients with panic disorder:

1. Enhancing Cognitive Flexibility: Catastrophic thinking often exacerbates symptoms, leading to heightened panic. By learning to identify, scrutinize, and reformulate their thoughts, patients can transform their emotional responses. This involves recognizing harmful thoughts, analyzing their validity, and altering or distancing themselves from them, thereby fostering a more balanced perspective.
2. Developing Tolerance for Physiological Symptoms: Utilizing a method he terms “interoceptive exposure,” which he calls his “Decathlon” day, Dr. Rego creates controlled scenarios where patients intentionally provoke physical sensations associated with panic attacks. This may involve exercises such as running up and down stairs, spinning in a chair, voluntary hyperventilation, and using breathing modalities like tiny straws. These activities are designed to demystify the symptoms, allowing patients to understand they are not life-threatening. Familiarity with these sensations can reduce fear and empower individuals to confront rather than avoid them when they arise later.
3. Engaging in In Vivo Exposure: Primarily targeting agoraphobia, this strategy also assists those who have altered their lifestyles because of panic. Dr. Rego collaborates with patients to gradually face avoided situations, providing an opportunity to acclimate to any initial anxiety. By confronting these scenarios, patients can challenge their beliefs about what might happen during a panic attack, such as heights, by eventually ascending to the top of iconic structures like the Empire State Building.

Building Trust Through Empathy and Honesty in Treatment

Dr. Rego recognizes the profound fear his patients endure, and his empathetic approach is evident in his treatment methodology.

“For my patients, taking the steps I recommend requires immense trust and a leap of faith,” Dr. Rego shares. “I strive to earn their confidence through respect, support, validation, and compassion, while also maintaining honesty. Our journey begins by uncovering the factors that brought them to my office, followed by developing a tailored plan for change.”

Dr. Rego acknowledges that the process can be complicated or “muddy,” as he describes it, yet he reassures his patients—and anyone else grappling with panic disorder—that they are not alone. This condition is common, and effective treatments are available.

“Navigating this journey requires someone willing to walk alongside you through the difficulties. I often say, let’s tackle this challenge together. The process demands confronting deeply rooted fears, which can be daunting. I understand this is a significant request, and together, we will devise a strategy to help you emerge from this challenging situation,” he asserts.

While this is a metaphor, Dr. Rego embodies the kind of mental health professional who would genuinely immerse himself in the struggle if it meant supporting his patients in overcoming their panic disorder.