07/20/2025
Panic Disorder: the role of therapy vs the role of medication.
Panic Symptoms: A False Alarm
While panic symptoms can feel terrifying, they are ultimately temporary and harmless. They come from the body’s natural alarm system, meant to protect us from danger. When we face a real threat, the body activates the "fight, flight or freeze" response, causing a racing heart, rapid breathing, tense muscles, and other changes that help us react quickly.
However, in panic disorder, the brain misreads harmless sensations as a threat, setting off a false alarm. It’s like a fire alarm going off when someone burns toast; the body reacts the same way whether there’s real danger or not. Over time, this cycle of misinterpreting normal sensations as dangerous can heighten anxiety and reinforce the fear of having another panic attack.
Impairment
As a result of these false alarms, individuals with panic disorder often avoid situations that they fear might trigger panic symptoms. For example, they may avoid exercise due to fear of a racing heart, tight spaces like elevators or crowded places like malls and concerts, or driving out of concern that they might have a panic attack and be unable to get help.
They may also rely on safety behaviors – such as always carrying water, staying near exits, or only going out with a “safe” person – to try to manage their panic symptoms. While these strategies may offer short-term relief, they keep individuals from learning that they can handle these situations without relying on safety behaviors, reinforcing the belief that panic symptoms are dangerous and intolerable. Over time, avoidance and safety behaviors can disrupt school, work and social life, leading to isolation and reduced quality of life.
Treatment Approach
Fortunately, panic disorder is highly treatable. The gold-standard treatment approach is cognitive behavioral therapy (CBT), with an emphasis on exposure therapy. This treatment involves systematically confronting, rather than avoiding, feared physical sensations and situations.
A key component is interoceptive exposure, or deliberately triggering panic-like sensations to help the individual learn to tolerate these false alarms. For example:
Spinning in a chair to provoke dizziness
Running in place to increase heart rate and breathing
Breathing through a straw to mimic shortness of breath
Individuals also work up to entering feared situations and gradually removing safety behaviors. Eventually, combining interoceptive exposures with situational exposures (like going to feared places and purposefully inducing panic symptoms) can help patients re-engage with their life and tolerate uncomfortable body sensations.
The Role of Medication
For panic disorder, fast-acting medications like benzodiazepines (e.g., Xanax) or beta blockers (e.g., propranolol) are sometimes prescribed to help immediately suppress panic symptoms. In addition, SSRIs (selective serotonin reuptake inhibitors) have been shown to reduce panic symptoms. This is the mainstay of medication treatment for panic disorder when it is very impairing.
While these medications can provide immediate relief, they can sometimes become a safety behavior, where a person might feel they need the medication to face certain situations (e.g., "I can only handle being at school if I take my medication"). If medication is used as part of a treatment plan, it is typically recommended for short-term use in cases of acute panic symptoms that are interfering with the individual’s ability to engage in exposure therapy. When clinically appropriate, support individuals in gradually facing feared situations without relying on medication.
