Treatments for Anxiety, Panic & Phobias

Treatments for anxiety, panic and phobias generally consist of

medications, counseling, or a combination of both.  Treatments

may be delivered by physicians such as internists, general practitioners,

family practitioners or psychiatrists, or therapists such as psychologists

(see Panic Doctor) and social workers. There are many different types

of treatment available, however for many, panic continues to be an

misunderstood and undertreated condition.  I've compiled descriptions

of the most common forms of treatment for you to use as a reference in

understanding your condition and seeking treatments appropriate for you.

For more detailed information and a jumpstart to effective treatment, visit

Panic Free, my state-of-the-art guide to overcoming panic.

 How effective is treatment? 

This is the most important question, yet hardest to answer. Good outcome studies are very difficult to do, and then they are hard to find and evaluate. Researchers defend their positions passionately. Clinicians sometimes disagree with researchers. The treatment scene is changing actively. And so on, yet the news is good. The American Psychological Association reports that Panic Disorder is "highly treatable", and that "treatments are extremely effective" (providing you obtain appropriate treatments from qualified, experienced professionals).

Who gives treatment?

In one large NIMH study, as many sought a physician or nurse (43%) for help as a mental health professional (40%).. Another 20% sought the clergy; 28% sought self-help networks. Yet only 24% with phobias or obsessive-compulsive disorders actually found help - the least of any disorder! Panic is little known, much hidden, and undertreated.

   Effective Medications  

In this medication summary, assume effectivness rates are for individuals who have completed treatment. Dropout rates are high, from 20-35% of those who start, because of side effects, oversensitivity, allergies, non-compliance, and many other reasons. Some estimate the 15% of phobics are ultrasensitive to medications and require very small doses for effect. Interestingly, when given a placebo (sugar pill),  some 20-30% react as if they had taken the actual medication, including having withdrawal symptoms and side effects.

There are three general classes of anxiety/panic medications: the benzodiazapines, the tricylclic antidepressants, and the MAO inhibitors.  None are truely addictive, but most can lead to psychological dependence.  The benzodiapines require a careful, slow withdrawal under a physician's supervision to avoid excessive side effects.

Generally, the benzodiazapines (BZD's) have a range of improvement from none to complete remission of panic.  Usually, about 70-80% of these treated have moderate to complete remission,  while about 30% have no relief from symptoms. The effectiveness for each BZD is very different from one person to another and is hard to predict.  When medication is discontinued, about half relapse.

The tricyclics have effectiveness rates as good or better than the benzodiazapines. Using the older tricyclics, about 35% are improved, and another 35% improved markedly.  The newer tricyclics , called SSRI's (Prozac, Zoloft, Paxil, etc.) have comparable improvement rates but have far fewer side effects, so that dropout rates are not as high. Relapse after medication is discontinued is less common than relapse with the BZD's, but still  higher than relapse after counseling.

The MAO inhibitors have not been researched as much as the two above, but they have comparable or even better effectiveness.  However, there are major drawbacks  in the inconvenience of the special diet needed and the added health risk if the wrong food is eaten. MAO inhibitors are usually prescribed only when the BZD's and the tricyclics have not worked well.

 Effective Counseling

This summary of counseling assumes that everyone has completed counseling. It also assumes that "effective" means that most or all of the panic has gone and stayed away for at least a month. About 15-30% drop out of counseling before treatment is completed, and less is known of what is effective for them.

The results of psychoanalysis for panic disorders are not reliably known, since most reports are of individual cases and are highly selective.  Even large studies have been inconclusive.  There is more to report of the outcomes of psychodynamic therapies. Non-directive dynamic therapies are fairly ineffective for panic. More directive therapists who encourage facing the feared situations, using the standards methods of understanding, insight,  and emotional release, report about 30-40% effectiveness.

Usually, attempts to self-help are unsuccessful.  Attempts to tough out the panic situations usually bring on more panic, and then even more tendency to panic, worry and avoid these situations. Self-help groups with an active leader are more effective than mutual support groups, whose members can make each other more anxious with "horror" stories.  The effectiveness of these groups has not been well measured.

Flooding methods, which coach the panicky person to stay in the fearful place for hours, were the first to show promise, particularly for simple phobias (of animals, insects, etc.). These cure rates were fairly high, about 50-60%, but lower for complex situations (crowds, public speaking, etc.). Other methods evolved, such as systematic desensitization, in which the panicky person vividly imagines the fearful situation while being coached to relax. Recovery rates climbed to 50-70% effectiveness for complex situations.

Cognitive approaches to panic disorder correct catastrophic beliefs about panic by giving corrective information, interpreting sensations realistically, and learning positive attitudes. In combination with desensitization or other methods, it has always improved results. While less is known about its effectiveness alone, still it is the only psychological treatment to meet NIH (1991) approval for panic disorder. 

The latest treatments have evolved around desensitization, often called exposure therapy or behavior therapy.  In it, a person learns to stay long enough and calm enough in the anxious situation until, seeing that his worst fears do not come true, most anxiety and panic disappear. This method reaches 65-80% effectiveness and up to 85-90% effectiveness when used wth anxiety medications.  The most recent development, introceptive conditioning, enables one to get desensitized to the symptoms of panic itself: the alarming sensations of heart racing, nausea, dizziness, faintness, lightheadedness, and so on. Relapse rates are low.  Combining these counseling methods has led to effectiveness rates of 75-85% without medication and now represent the state of the art for mainstream psychotherapy.

   Finding A Doctor for Medication

Your search for a good medication doc is like threading a needle.  You want to find a doctor with experience prescribing psychotropic medication, and with panic in particular.  Surveys show that many doctors undermedicate with anxiety medications and don't give much information on side effects.  Be savvy in choosing your doctor.

Doctor types

Primary care doctors are in a good position to review your overall health and emotional problems.   Yet many feel uncomfortable and beyond their competance in prescribing   anxiety and panic medications.  Still, he or she is in a good position to refer you to other health providers.  Sometimes a family practitioner or gynecologist may afford overall integration of your physical and emotional difficulties.

Psychiatrist choice

You may feel more confident with a psychiatrist that knows about panic conditions and the in's and out's of various treatments.  He/she will certainly know more about the newer anxiety medications and how they are used, as well as being much more alert to the wide range of emotional problems.  He/she also can sort out the medical vs emotional problems and work closely with your primary care doctor.  Psychopharmacologists are physicians who specialize in mind medications.

Where to look

Look for a doctor who has had at least three to five years of practice.  A doctor in his middle years has the most likelihood of having training and experience with anxiety medications. The Directory of Medical Specialists in your library will show you board certification (a standard of competance) and recertification in their speciality (a sign of committment and knowledge). Another place to inquire is at the administrative offices of the best hospital near you for the names of two to three doctors.  Charge nurses who work in hospitals don't miss much that goes on and can give a first-hand recommendation. Some states list malpractice claims.  Of course, your HMO or managed care plan may put limits on your choices.

Questions to ask referrers

• How have you got to know the doctor's work?

• How highly would you recommend him/her?

• Do you have any reservations about him/her?

• Does the doctor prescribe anxiety medications?

Questions to ask the doctor

Now that your search is down to two or three doctors,  phone each and leave a message that you are looking for a new doctor. See how soon he/she replies and ask these questions:

• What is his area of competance or speciality?

• Are anxious or panicked persons a regular part of his/her practice?

• Is he/she comfortable prescribing anxiety medications?

• Does he/she consult or refer to others about panic patients?

Your doctor's appointment

Make the appointment before you experience panic.  Bring your medical records with you, as best you can.  Expect a brief physical and lab work - all before medications are prescribed.  Some medications require three to six weeks before you will notice much change. Ask you doctor for reassurance about these items:

• Handling a severe reaction to a medication

• Explaining something you don't understand

• Checking out medical conditions that mimic panic

• Advising about dosage, side effects, and as-needed doses

• How to try different med's to find the most effective one

• How to reach him/her in case of adverse reactions

• How he will work with your counselor

Now you have an experienced doctor who knows about panic disorder and their medications and has agreed to ground rules and reassurances you need.

Finding a Therapist for Counseling

The work of a counselor or psychotherapist is quite private compared to the scrutiny that doctors receive.  One therapist is not likely to have much direct consulting room experience of another therapist, even one that shares  the same worksite.  There is no all-seeing charge nurse to recommend one counselor or another. Yet, there is wide variation in training, experience and speciality of counselors, and these are important to know. It is especially so in states that allow anyone to call themselves a psychotherapist, or wherever standards of professional practice are not well publicized.

Credentials

You can get basic credentials, such as licensing or registration, from your state Board of Licensing or from a  professional association's referral service in the Yellow Pages. Psychologists,  social workers,  psychiatric nurses,  and marriage counselors have boardlike exams. Unlike physicians, therapists have few formal specialty exams even though they may have had much specialty training and postgraduate work. Many therapists specializing in anxiety and panic maintain membership in speciality professional groups such as the Anxiety Disorders Association of America or the OCD Foundation. You'll find my own credentials here on this site.

Specialty

Because panic disorder is a true specialty, ask for the specialty area right away in your search - an anxiety and panic specialist. Friends who know a therapist with a panic specialty have had time to observe their therapist in action and can answer essential questions. The professional referral organization of psychologists, social workers, or marriage counselors can be phoned to get a short list of specialists. The reference librarian of your local library have current reference books of membership in professional groups such as the National Registry of Health Providers in Psychology. Your regional Mental Health Association or Yellow Pages can help you start your search as well.  The internet provides an abundance of sources for specialists, and you can find Links on this site which can help get you started. My own specialty and methods used can be found right here on this site.

Questions to ask

Psychotherapists set aside time to answer inquiries, but vary a lot in ease of access.  A good idea is to phone and ask for the best time to talk by phone. Therapists expect some description of the problem over the phone and a discussion of  the kind and terms of therapy. So be sure to ask:

        How long have you been in practice?
        How long have you specialized in anxiety and panic?
        Do you use exposure therapy and homebased practice?
        Do you consult with doctors about medication?
        Have you ever panicked yourself?

Your first visit

On your first visit to your counselor, he should help you state your problem and whatever bears upon it. You may be asked to take short scales or tests afterwards. For your part, you should feel that you fundamentally like and trust your therapist early on. You should feel he/she has listened well and has offered at least an overview of treatment and what it entails for you. Satisfy these questions:

        Have you treated a panic condition like mine before?
        Can you give me reassurance about my condition?
        Can you explain your therapy and how it works?
        Will you set specific goals with me?
        Can you narrow down how long it will take?
        Will you consult with my doctor?

Now you have a licensed, trained therapist with specialized experience in your panic disorder.  You have greatly improved your chances of recovery.

 The PanicDoctor option

You can ask me all of these questions and more to qualify me as your therapist for your panic condition.

My practice is first to listen with feeling, exploring my client's concerns and life satisfactions. In clarifying the problem, we discuss different treatment methods. While I lean towards the cognitive/behavioral methods, I draw on a wide range of approaches so that they fit the needs of my client.

My specialty is the field of anxiety disorders, which include panic disorders, phobias, obsessive-compulsive disorders, post-traumatic disorders, and the varying degrees of anxiety. I share the best information about causes and treatments, so that my client gets direction and reassurance right away. We often discuss worry controls, calming methods and desensitization, and plan for early successes. On-site coaching, self-tests, tapes and many types of literature help immensely. In addition, we handle all the barriers to recovery along the way to full recovery, such as poor sleep, unsupportive partner, and time pressure.

Visit Credentials for my education, work experience and publications. Visit Contact receive instructions on scheduling and to purchase your private counseling session with me, in either 25 minute or 50 minute time lengths.

To be panic free is a reasonable hope,

no matter how long or severe your attacks have been.