Training Emergency Medicine and Primary Care Doctors in Early Diagnosis and Brief Education
Capturing panic disorder in its earliest, formative stages yields the ripest opportunity for rapid reversal. After the first panic attack, panic disorder patients congregate in medical settings, desperately seeking a medical explanation for their physical symptoms. Panic attack sufferers present with an array of somatic complaints include dizziness, shortness of breath, numbness and tingling in the extremities, rubbery legs, weakness, heart pounding and chest pressure. When medical tests rule out organic causes for panic attack symptoms, a brief self-administered screening instrument in conjunction with a brief diagnostic assessment can help confirm the diagnosis of panic disorder.
Level One: Education: Doctor Diagnostic Presentation and Patient Education
The Doctor presents the diagnosis of panic disorder in the same definitive fashion he would present a medical diagnosis. A detailed explanation of the nature of panic disorder combined with educational information on the mind-body connection and the activation of the flight or fight response to perceived danger can serve several important functions. Provision of a definitive diagnosis for the puzzling series of panic attack symptoms, at the outset of this condition, can help validate the reality of the patient complaints, reduce uncertainty and eliminate worry about possible undetected more serious medical illnesses that the patient has entertained. This worry elimination can immediately provide symptomatic relief and prevent “doctor doubt”, “doctor shopping and recycling with a new doctor.
Level Two: Education, Cognitive-Behavioral Treatment Self-Improvement Manuals and Books:
In Level Two intervention, for early onset panic disorder, the doctor recommends high authority brief training manuals as the next stage of intervention. A substantial body of evidence has accumulated indicating that Cognitive Behavioral Treatment (CBT) for Panic Disorder produces powerful outcomes and should be the first line of intervention. Clum has demonstrated the efficacy of a training manual approach as a viable form of CBT delivery for panic disorder. Unfortunately, as usual, the training of Behavioral Science Providers, well-versed in this method, has lagged way behind the scientific evidence for the effectiveness of CBT. Even in 2010, behavioral science experts with extensive experience delivering specialized CBT intervention for panic disorder are not readily available. Dr. Craske, in her recent book on Cognitive Behavioral Therapy, reports that only 17.8% of Behavioral Science Training Programs provide both instruction and supervision in cognitive behavior therapy. Fortunately, Dr. Barlow and Craske have authored a training manual, “Mastery of Your Anxiety and Panic”, which could be offered as a Level Two intervention. The classic work by Dr. Claire Weekes, “Hope and Help for Your Nerves,” and Dr. George Clum’s book “Coping with Panic” both serve, very well, as Level Two interventions.
Level Three: Education, a Comprehensive Multi-Media Scientifically Based Program, Delivered by an Behavioral Science Expert in the Field of CBT for Panic Disorder:
A program that replicates the exact content of an in office program in a multi-media learning format with manuals, video and audio instructions can bring learning concepts to life and provide a higher level of intervention. Multi-media presentations, while offering more intense impact on panic disorder, also require motivation and commitment to obtain maximum impact.
Level Four: Referral to a Behavioral Scientist, Who Is an Expert in the Delivery of CBT for Panic Disorder in the Local Area.
When educational intervention is not sufficient to provide the desired outcome, then the delivery of CBT for panic disorder by an expert in a face-to-face professional setting needs to be considered. Naturally, research needs to be conducted to identify well-qualified providers in specific geographic areas.
Level Five: When personally delivered, learning based interventions do not yield the expected outcome, then, anti-anxiety medications need to be considered.
There is a substantial body of scientific evidence demonstrating the benefits of specific anti-panic medications for reduction in panic attack intensity and frequency. However, additional research shows that combining medication with CBT can dampen the effectiveness of CBT.
How Can the Use of Anti-Panic Medication Interfere with the Long term effectiveness of CBT?
An essential component of CBT is exposure and desensitization to bodily sensations. When the primary use of medication is designed to block panic sensations, the exposure and desensitization process can be compromised. Facing the physical feelings without fear is the goal of interceptive exposure. If medication prevents the panic attack sufferers from learning to experience the bodily sensations as harmless, then when panic attack symptoms return, the combined CBT and medicine approach will yield higher relapses rates than CBT alone. When medications are discontinued special attention needs to be directed to minimizing relapse with the augmentation of intensive CBT. Dr. Michael Otto and his research associates at The Center for Anxiety and Related Disorders at Boston University have been at the forefront of research in this regard.
Beyond CBT; Relapse Prevention is the Cornerstone of any Effective Panic Disorder Program
Panic disorder is a complex condition with no magic, quick fix cure. A Relapse Prevention component should be the cornerstone of any effective panic disorder program. Understanding the complex set of core triggers that build up to set off the first panic attack “Out of the Blue” is essential to living panic free for life.