Psychotherapy of Panic Disorder: Revisiting Past and Present Research and Moving toward Future Directions

Abstract

Panic disorder is one of the most debilitating mental disorders. Therefore, it is necessary to apply treatments for this problem to eliminate the disability of patients. Both psychotherapy and medication have been shown to reduce the frequency and severity of panic attacks and panic disorder. In this chapter, we first mentioned cognitive-behavioral therapy as the cornerstone of psychotherapy for panic disorder and then, medication as one of the most common treatments for this disorder. Cognitive-behavioral therapy has been found by numerous studies to be the most important psychotherapy for panic attacks and panic disorder. Medication is another effective treatment because some medications can be very helpful in managing the symptoms of a panic attack as well as anxiety and depression. Finally, emotion regulation therapies for the treatment of panic disorder will be introduced and explained for the first time.

1. Introduction

A severe acute attack of anxiety with a feeling of imminent harm is called panic disorder. People with panic disorder suffer from multiple panic attacks that are unrelated to specific situations. These attacks are periods of intense fear and physical discomfort; so the sick people feel that they cannot control themselves. The onset of these attacks is sudden and usually reaches its peak in 10 min. For a panic attack to be diagnosed as panic disorder, a person must have certain reactions to these attacks, including constant worry about the recurrence of attacks or worry about the consequences of the attacks, avoiding activities that may cause the physiological feelings associated with panic, or participation in safety-related behaviors, such as carrying a cell phone or medication [1]. Concerns about the consequences of attacks may include fear of having a fatal heart attack or fainting in front of others. Panic disorder is a unique disorder among anxiety disorders whose symptoms and signs are physical in the first stage. These patients are highly sensitive to unpredictable events, and their symptoms are almost related to one of three systems, including the autonomic nervous system (heart palpitations and sweating), the respiratory system (shortness of breath and chest tightness), and the cognitive system (personalization, fear of loss of control, and fear of death). This disorder is one of the most common disorders in the mental health system, so its prevalence is estimated at 5–9%. This disorder is associated with an increase in cardiovascular complications and mortality [2].

2. Investigating cognitive models of a panic attack

A panic attack is considered an acquired fear of bodily sensations (heart palpitations, dizziness, nausea, etc.), especially sensations associated with automatic arousal. In simple terms, after having panic attacks, people become over-sensitive to their physical feelings and feel threatened by any slight physical sensation and consider it as the possibility of starting a panic attack. Therefore, those who have panic disorder, after experiencing an unexpected panic attack, become anxious about experiencing such attacks in the future and are always worried about having these attacks again. Therefore, they become very sensitive to the smallest changes in their body to avoid panic attacks [3].

3. Why do we experience panic attacks?

From an evolutionary point of view, the reaction of fear or panic in the presence of a threatening situation is adaptive. It is assumed that panic occurs in the absence of a threatening stimulus, as a result of the interaction of stressful life events and psychological and biological vulnerabilities. The tendency to experience negative emotions, often labeled as neuroticism, is largely heritable and has been shown to predict panic attacks. This temperament probably acts as a biological vulnerability to experience fear (a rapid alarm response characterized by strong arousal of the nervous system) and experience anxiety (a negative mood state characterized by worry about future events and signs of physical tension) [4].

Environmental factors in childhood can play a key role in the formation of people’s confidence and their abilities to control future life events. Such a sense of control or lack of control can act as a psychological vulnerability in the experience of fear and anxiety. Stressful life events, such as a new job or the death of a family member, may combine with biological and psychological vulnerabilities to trigger an emotional fear response or panic attack. Accumulated stressors built up over time by stressful life events can trigger a panic attack, even though the person perceives it as “unexpected” because there is no immediate threatening stimulus [5]. Therefore, three factors play a role in the occurrence of panic: (1) inheritance, (2) family environment in childhood, and (3) environmental factors.

4. After an unexpected panic attack, what causes the attacks to continue?

General vulnerabilities (heredity, family environment, and environmental factors) may play a key role in determining whether a person develops “anxious fear” about experiencing attacks in the future or not. In addition to general vulnerabilities in experiencing panic and anxiety, it is believed that there are specific vulnerabilities that contribute to the formation of panic attacks. An example is anxiety sensitivity. According to this belief, anxiety and its symptoms cause harmful physical, social, and psychological consequences beyond the physical discomfort of a panic attack. After a panic attack, a person becomes sensitive to the discovery of his bodily arousal, which leads to vulnerability to subsequent panic attacks [6].

Anxiety about unexpected panic attacks is linked to fear of physical sensations (such as heart racing) that accompany the attacks. At first, the person is anxious about their physical sensations and worries that it will lead to a panic attack. At this time, automatic thoughts such as catastrophizing (e.g., I will be ashamed if I have a panic attack) and over probability (e.g., If I go out I will have a panic attack) cause a person’s anxiety to increase and as a result, physical feelings such as heart rate and dizziness increase. The increase in bodily sensations strengthens automatic thoughts and the person becomes more certain of the correctness of his beliefs, and as a result, these thoughts become stronger and cause more anxiety again. This self-perpetuating cycle continues until it results in a panic attack again [7].

5. Conditioning in a panic attack

Accompanying physical feelings with a panic attack makes a person more conditioned, and consequently becomes more sensitive to physical feelings. Then, physical feelings occur in all people sometimes and are resolved after a while; for a person with panic disorder, it means the beginning of a panic attack. Such anxiety about bodily sensations plays an essential role in the persistence of panic disorder. Physical sensations can be caused by physical activity, chemicals such as caffeine, a frightening environmental stimulus, and anxious images or thoughts. When physical sensations are noticed by a person suffering from panic disorder, they create fear. This fear intensifies bodily sensations and leads to an increase in that fear, and in turn, as a self-perpetuating cycle of fear and bodily sensations, leads to a further increase in bodily sensations, which ultimately leads to a panic attack. Therefore, the fear of experiencing physical sensations of arousal leads to a full-blown panic attack and reinforces the belief that these sensations should be feared [8].

To condition a person, it is sometimes enough to experience physical sensations with a panic attack once, and after that, other factors such as safety seeking and avoidance, which are explained below, cause the panic disorder to continue. People with panic disorder are often not aware that panic attacks can be triggered in this way (by bodily sensations or internal and external stimuli). For people with panic disorder, this means that panic attacks often occur unexpectedly and unpredictably. Because they cannot stop panic attack symptoms once they begin, they consider such attacks uncontrollable. The unpredictability and uncontrollability of a panic attack can fuel chronic anxiety levels, resulting in constant fear of another attack. Higher levels of chronic anxiety can lead to increased physical arousal as well as increased attention to one’s bodily sensations. Increasing physical sensations and increasing attention to these sensations lead to an increase in the probability of panic attacks in the future [9].

6. How do avoidance and safety-seeking behaviors perpetuate panic attacks?

Behavioral responses to panic, especially safety-seeking behaviors (such as walking slowly to avoid elevated heart rate, not going to heights to avoid dizziness, and eating less food to prevent nausea) and avoidance (not leaving the house for fear of being attacked and avoiding lonely situations) apply as perpetuating factors of the panic disorder. A person with panic disorder mistakenly believes that a panic attack will cause catastrophic physical or mental harm, such as a heart attack, going crazy, passing out, or losing control. Therefore, experiencing panic attacks in which none of these things occur should necessarily undermine these beliefs [10].

However, people with panic disorder engage in certain safety-seeking behaviors that they believe enable them to escape or avoid the consequences of fear. For example, if a person believes they are going to pass out during a panic attack, they may sit or hold an object. Engaging in safety-seeking behaviors prevents a person from realizing that a panic attack does not cause a physical or psychological catastrophe because he believes that if he does not have a disaster, it is because he is sitting on a chair, or walking slowly, and not because a panic attack does not hurt him. Disconfirming false beliefs about panic attacks help to maintain the panic disorder. People may engage in safety-seeking behaviors designed to prevent panic or its feared consequences, such as taking antianxiety medication with them or traveling with people who make them feel safe [10].

Another behavioral response that perpetuates fear is overt avoidance. People tend to avoid certain places or situations that they believe are more likely to trigger a panic attack. Avoidance prevents the disconfirmation of false and catastrophic appraisals and reinforces the belief that these particular situations are dangerous, and increases the likelihood of having a panic attack in those situations in the future. Furthermore, if a person avoids situations in which they experienced an unexpected panic attack in the past, future attacks will inevitably spread to new, previously safe situations. Therefore, the range of safe conditions is limited. So most places become dangerous places where a panic attack is likely to occur. This pattern can increase behavioral avoidance and chronic levels of anxiety perception. Now let us look at useful techniques and therapies for treating panic disorder.

7. Psychological training in the treatment of the panic disorder

In the method of treating panic through psychoeducation, the therapist provides information to help correct the client’s misconceptions about panic attacks and anxiety and to normalize the situation for him, which are effective for treating panic. In the first session of treatment, the therapist explains things about panic attacks so that these attacks become unpredictable and uncontrollable in the person’s mind, and the person’s misconceptions about panic symptoms, including the idea of going crazy, disappear, such as “When our ancestors were in the forests, they were residents, they were exposed to all kinds of natural disasters.” Naturally, if they did not sleep at night with the fear of a lion or leopard attack, they would fall into such a deep sleep that they would not notice the presence of a lion or a leopard and become their prey [11]. Therefore, we are the descendants of ancestors who were worried about the dangers around them and were in a state of alertness.

8. The function of anxiety

The function of anxiety is to preserve the survival of the generation, and it is used when a person feels threatened. Now this danger can be real or imagined. At this time, anxiety is activated in the person’s body and prepares him for fight or flight. That is, where it is possible to attack, attack the cause of fear, and otherwise, escape from the cause of fear. To prepare the body for fight or flight, changes are made in the body. Among other things, increasing the arousal of the autonomic nervous system, which controls many of our bodily processes, such as the cardiovascular and gastrointestinal systems. During anxiety, blood flow to the extremities of the body such as hands, feet, and arms increases, and blood flow to the head and internal organs decreases. Heart rate and breathing speed up and digestion slow down. These changes cause symptoms such as increased heart rate, shortness of breath, dizziness, and feelings of weakness and nausea. These symptoms all mean that the body is ready to face a dangerous factor, but it is not dangerous because they are used for the preservation and survival of the person and not to harm it. The problem arises when this survival protection system becomes overly sensitive, such as an over-sensitive burglar alarm that goes off at unnecessary and unhelpful times [12].

9. Cognitive factors in panic attacks

Another factor in panic attacks is the cognitive factor. The cognitive factor comes into action in the form of internal conversations: “Oh, what if my heart rate goes up? If I faint, my reputation will go down. I will have an attack at a party. How badly will they judge me if I have a panic attack? I’m going crazy.” These negative thoughts intensify physical feelings. That is, they increase heart rate, intensify dizziness, and... The intensification of physical feelings, in turn, makes the person’s negative thoughts stronger [13]. Also, he is more sure of the correctness of his belief that the attack will start. And he says to himself, “So I think I’m right that I’m having an attack.” These symptoms are due to the negative cycle of physical feelings and negative thoughts that have intensified in the person. Finally, the arousal reaches the point where the person sometimes has an attack. As the number of these attacks increases, the person becomes more conditioned and more sensitive to his physical changes. He also noticed very small changes in his body and assumed it was a sign of the beginning of an attack.

10. Behavioral factors in panic attacks

Another factor in panic attacks is the behavioral factor. After the panic attack happened, the person adopts two strategies to deal with the risk of its recurrence [14], both of which cause the panic attack cycle to continue in the person: (1) Seeking safety and (2) avoid.

10.1 Seeking safety

In seeking safety, a person tries to reduce his sense of internal danger by using things that give him a sense of security. For example, wherever he goes, he takes his friend or his parents with him. In the case of each client, it should be investigated what factors he uses as safety so that after identifying its cases, little by little the client will face his imagined danger without them. In some cases, the use of sedatives is also considered a safety measure. Because the person thinks that these drugs have reduced his anxiety. Therefore, it is necessary to make exposure after some time when stopping the drug so that the person feels confident about himself [15].

10.2 Avoidance

In avoidance, a person avoids being in places or situations where he believes that the probability of a panic attack is high. This makes him never understand that these situations are not dangerous. Rather, the assumption is strengthened that if he was not attacked, it is because he avoided these situations [16]. The problem is that avoidance does not remain in one area and is constantly expanding. First, the lonely person is afraid of being attacked outside the city. He tells himself that in order not to be attacked, it is better not to go too far from the city. If he does what he thinks and avoids, the internal conversations become more threatening and this time he tells him not to be attacked from somewhere in the city. After some time, his inner dialog tells him again not to have a panic attack at a distance of more than 1 km from home. Finally, he reaches a stage where he cannot leave the house. Because he believed that it was his avoidance and seeking safety that caused him not to have a panic attack. In this case, it should be said that what helps a person treat panic without drugs is facing the issue of anxiety [17].

After being taught the three important components of fear and anxiety—physical symptoms, thoughts (cognitions), and behavior—as well as how they interact to contribute to panic disorder survival, clients are encouraged to list physical symptoms, thoughts, and behaviors related to their most recent episode of panic, and find out how their responses may prolong or exacerbate panic attacks. For example, when Tina realizes that her heart rate is fast, she is overcome with fear and has a panic attack, and faints. This alarming thought leads to a faster heart rate and other physical signs of anxiety, which ultimately increases his fear of having a panic attack. His behavior (rushing home, where it is safe) reinforces his belief that anywhere else is unsafe. Treatment aims to break this negative cycle by addressing the three main components of anxiety: changing self-talk or beliefs, controlling physiological responses, and confronting objects, situations, and places that cause fear [18].

11. Self-monitoring in the treatment of panic attack disease

In the treatment of panic attacks, the self-monitoring method helps the patients to observe their emotional reactions as an external observer instead of judging them subjectively. Self-monitoring can reduce anxiety, increase awareness of emotional reactions, and increase feelings of control [19]. For example, Tina’s mental appraisal “I feel anxious, so there is no way I can go shopping” could be objectively described as “My heart beats faster. I think that if I go to the store, I will have a panic attack and faint.” Clients are asked to complete a monitoring form for a recent panic attack that includes the following details: physical sensations, thoughts and behavioral reactions, the situation in which the attack occurred, and the degree of fear.

12. Teaching relaxation techniques in the treatment of panic

Breathing retraining is introduced as an adaptive skill in stopping physiological overreactions in the treatment of panic. The mechanisms by which breathing retraining is effective and the extent to which it is effective for panic are still under investigation. However, therapists must not use it as a means of avoiding negative emotions. The client is taught diaphragmatic breathing: breathing from the belly instead of the chest. The client is supposed to focus on his breathing by counting breaths (one) and thinking of the word “relaxation” as he exhales. For the first week of training, the therapist should breathe at a normal rate and speed. After 3–5 min of practice in the session, the client is assigned a breathing retraining task for the next week: 10 minu of practice, twice a day in a comfortable and quiet place [20].

13. Cognitive restructuring in the treatment of panic

Cognitive restructuring is the process of displacing automatic anxious thoughts or cognitive errors, such as risk overestimation and catastrophizing. In this case, therapists are taught how to identify their automatic anxious thoughts. Then, they are taught how to treat these thoughts as hypotheses and gather evidence to support or disprove them. Finally, they are encouraged to develop alternative hypotheses and gather evidence to support and reject them. Clients are explained that although anxious thoughts can be “automatic” and occur very quickly without full awareness, they can influence feelings and actions. The content of these thoughts is specific and may be different in different situations and times. Subsequently, it is important to identify or predict the specific content that creates anxiety in certain situations [21].

14. The “down arrow” technique for identifying automatic thoughts

Subjects are taught to use the “down arrow” technique to identify these automatic thoughts. The technique works like this: therapists ask themselves, for example, what they fear in a hypothetical situation. Then, they figure out what those fears would mean and what would happen if they were real. Then, the meaning of the thoughts of the lower layers is examined, and this process continues until the central anxious automatic thought is identified [22].

For example, Tina writes on her monitoring form: While driving, she became frightened when her heart rate increased. So she left the car and her mother sat behind the wheel instead. To uncover her automatic thinking, the therapist should ask her what would happen if her heart continued to beat. The therapist responds to Tina saying, “That is horrible!” she can ask what she imagines is happening that she finds terrifying. Again, in response to Tina saying, “My heart would beat faster, I would start shaking, and I would pass out,” the therapist can ask what she thinks would happen if she experienced those feelings. The therapist can continue these questions until she gets to the central belief of her anxiety. The belief is that if she did not move the car, she would faint, have an accident, and kill herself and her mother. It is explained that identifying automatic thought is the first step in cognitive restructuring. And it should be practiced as part of this week’s self-assessment assignment [23].

Then, they teach the audience to view their thoughts not as absolute facts, but as hypotheses. The Socratic questioning method is used to help them gather evidence to determine a more realistic possibility. For example, Tina thinks that the probability of losing control of the car and crashing during a panic attack is close to 100%. She is asked if this has happened before. Do you have any proof of its occurrence or nonoccurrence? After arriving at a more realistic possibility, the referent is assisted in generating alternative thoughts. For Tina, the alternative hypothesis might be: I’m just experiencing anxiety, and I’m also able to drive while experiencing anxious thoughts and bodily sensations [23].

15. Exposure in the treatment of panic

Repeated exposure to fearful physical feelings (physical exposure) and fearful situations (exposure in natural situations) to reject the incorrect cognitive evaluation and turn off conditioned emotional reactions to these feelings and situations is considered one of the main methods of panic treatment [24]. Using breathing retraining and cognitive restructuring to deal with these feelings and situations provides corrective experiences to therapists, which are not achieved by avoiding or running away from these feelings and fearful situations [24].

15.1 Exposure based on emotional arousal

First, physical exposure is done to increase learning about bodily sensations. Clients are told that their anxiety-provoking physical sensations are stimulated. To learn that these feelings are not harmful and can be tolerated. They remind them of the conditioning of bodily sensations and how minor changes in physiology can trigger anxious thoughts and physiological over-arousal in them due to prior pairing of bodily sensations with a panic attack [25].

Clients are reminded that avoiding changes in physical state or avoiding activities that cause changes in physical state (such as avoiding running because it raises the heart rate and evokes a panic attack) prevents remedial learning. Learning that physical symptoms are not harmful and can be tolerated. It is explained that avoidance perpetuates fear. By facing uncomfortable bodily sensations, they learn not to fear them [26].

Clients are directed to perform activities (e.g., climbing stairs, turning, gasping, etc.) to reexperience the bodily sensations experienced during a panic attack. They should continue the activity for 30 s after they first notice their bodily sensations. Then, record the bodily sensations they had, their level of anxiety, and how similar these sensations were to the bodily sensations experienced during the panic attack. An activity with a moderate degree of fear and little resemblance to the actual feelings of a panic attack is used to practice exposure to physical feelings within sessions and is assigned as a task (to be practiced three times a day) [27].

Clients are taught how to control the exercises by arousing emotions, assessing fear levels, using breathing retraining, and cognitive restructuring of adaptive skills [28]. Clients should answer these questions in each exercise: Did the disaster they feared (e.g., loss of control) happen? Did they survive from being scared? Did their fear subside with repetition?

15.2 Exposure to the natural environment

The next type of exposure is exposure in the natural environment: exposure in places and situations that clients avoid or fear. For the assignment, therapists must arrange a hierarchy of these situations by rating the intensity of the fear of each situation. A driving hierarchy for Tina (with fear rates in parentheses) might look like this: (1) Sitting in the car, (2) one-mile drive with mother in the car, (3) driving to the local store with mother, (4) five miles driving on the highway with mother, (5) driving to the local store alone, and (6) five miles of highway driving alone [29].

Subsequent sessions are devoted to safety cues, which include specific people and objects that make a person feel safe from anxiety, loss of control, physical injury, or embarrassment. In Tina’s case, her house, her parents, and her inhaler were all signs of safety. Clients were explained that the removal of safety cues would improve the learning effect of the exposure [29]. When faced with situations with safety cues, the client still believes that the situations are dangerous, but the danger is prevented by safety signs. Abandoning safety cues are combined with direct exposure hierarchies [29].

16. Medication in the treatment of panic

Medication is one of the most popular and effective treatment options for panic disorder, panic attacks, and agoraphobia. Doctors may prescribe medication to reduce the severity of panic attacks, reduce overall feelings of anxiety, and potentially treat co-morbid conditions such as depression. Panic disorder medications usually fall into one of two categories: antidepressants and antianxiety medications.

17. Antidepressants for panic

Antidepressants are now commonly used to treat many anxiety disorders, including panic disorder and agoraphobia. Antidepressants affect the brain’s chemical messengers known as neurotransmitters. It is thought that different types of these chemical messengers communicate between brain cells.

18. Types of antidepressants for panic disorder

18.1 Selective serotonin reuptake inhibitors

Selective serotonin reuptake inhibitors (SSRIs) are a popular class of antidepressants prescribed to reduce symptoms of anxiety and depression. Serotonin is a natural neurotransmitter in the brain. Studies have shown the long-term effects of SSRIs. These drugs have also been found to cause limited side effects, making them the prescription drugs of choice for panic disorder.

18.2 Tricyclic antidepressants

Since the introduction of SSRIs, tricyclic antidepressants (TCAs) have become less popular in the treatment of anxiety and mood disorders. However, TCAs are still an effective treatment option for people with anxiety disorders, including panic disorders. Like SSRIs, TCAs work by blocking the reuptake of the chemical messenger serotonin. In addition, many TCAs inhibit the reuptake of norepinephrine, another neurotransmitter in the brain that is often associated with the fight-or-flight stress response.

18.3 Monoamine oxidase inhibitors

Monoamine oxidase inhibitors (MAOIs) are one of the first antidepressants developed to effectively treat mood and anxiety disorders. MAOIs work by inhibiting the activity of the enzyme monoamine oxidase. This enzyme is involved in breaking down neurotransmitters, such as norepinephrine, serotonin, and dopamine. Dopamine helps to regulate many functions, including movement, physical energy levels, and feelings of motivation. Despite their effectiveness, MAOIs are used because of the dietary restrictions necessary and the potential for significant drug interactions that can occur when taking MAOIs with other medications.

18.4 Antianxiety drugs for panic

Antianxiety medications are prescribed to quickly relieve panic symptoms. These drugs work to calm the central nervous system, which can reduce the severity of panic attacks and make the person feel relaxed. Because of their sedative effect and quick relief, antianxiety drugs are often prescribed to treat panic disorder.

18.5 Benzodiazepines

Benzodiazepines are the most common class of antianxiety medications prescribed for panic disorder. Known for their sedative effect, these drugs can quickly reduce panic attack symptoms and induce a more relaxed state. By targeting gamma-aminobutyric acid (GABA) receptors in the brain, benzodiazepines slow down the central nervous system and induce a sense of relaxation. Despite the potential risks and side effects of these drugs, benzodiazepines provide safe and effective treatment.

18.6 Effective psychotherapies for panic disorder

18.6.1 Cognitive-behavioral therapy

Cognitive-behavioral therapy (CBT) in patients with mental disorders was initially developed to provide additional treatments for residual symptoms based on the principles and strategies of intervention previously developed for anxiety and depression. About 1% of psychiatric patients with persistent positive and negative symptoms do not need medication, even if they are compatible with prescription medications. However, despite the introduction of unusual antipsychotics, patient compliance with the drug is still a major problem. Studies have shown that 4% of outpatient and inpatient patients have stopped their treatment [30].

CBT in mental disorders is currently recognized as an effective intervention for mental disorders in clinical guidelines. Despite available evidence that side effects are absent, public access to this treatment in the community remains limited and low [31]. CBT is a goal-based approach to solving the problem of mental illness, especially mental disorders, to change the patterns of thinking or behavior that are behind people’s problems and change their feelings. CBT in mental disorders is a common type of speech therapy (psychotherapy). You talk to a psychologist or psychotherapist in a structured way and with a specific number of sessions. This will help you identify the wrong or negative thinking so you can see the challenging situations more clearly and respond more effectively. CBT can be a very useful tool in the treatment of mental disorders, such as schizophrenia, depression, post-traumatic stress disorder, or an eating disorder, but not everyone who benefits from CBT in schizophrenic patients may necessarily have complete mental health. This therapy can be an effective tool to help anyone learn how to manage stressful life situations [32].

18.7 The benefits of CBT in mental disorders

CBT in mental disorders patients can also be effective in treating some mental health problems, but may not be effective for everyone. Some of the benefits of CBT in mental disorders include [32]:

• It may be helpful in cases where the drug alone does not work.

• Completes in a relatively shorter period than other speech therapies.

• The highly organized nature of CBT in mental disorders means it can be presented in a variety of formats, including in groups, tutorials, and computer programs.

• It teaches you useful and practical strategies that can be used in everyday life, even after treatment is completed.

The stages of CBT in mental disorders [33] usually include the following:

• Identify difficult situations in your life. These conditions may include medical conditions, divorce, sadness, anger, or symptoms of mental illness. You and your therapist may take some time to decide what goals you want to focus on.

• Know your thoughts, feelings, and beliefs about these problems. Once you have identified the problems you want to work on, your doctor will encourage you to share your thoughts about them. This sharing of thoughts may include talking to yourself about an experience, your interpretation of a situation, and your beliefs about yourself, your surroundings, and events. Your therapist may suggest that you record your thoughts.

• Identify negative or false thoughts. To help identify patterns of thinking and behavior that may help solve the problem, your doctor may ask you to consider your physical, emotional, and behavioral responses in different situations.

• Change negative or negative thoughts. The therapist encourages you to ask yourself whether your view of a situation is based on reality or a misunderstanding of what is happening! This step may be difficult for you because you probably need to spend a lot of time thinking about your life and yourself. Useful patterns of thought and behavior can become a habit with a practice that does not require much effort to use.

18.7.1 Treatment duration

CBT in mental disorders is generally a short-term therapy requiring approximately two to four sessions. You and your therapist can talk about the number of sessions that are right for you. Factors affecting the number of treatment sessions are as follows:

• Type of disorder or condition.

• Severity of symptoms.

• The length of time a person has had symptoms and spent with this condition.

• Speed up one’s progress.

• The amount of stress the patient has.

• How much support do you get from family members and other people?

In general, CBT in mental disorders is of low risk. As this treatment usually relieves the patient’s painful feelings and experiences, in some cases the person may feel unwell. You may be upset, crying, angry, or maybe physically weak during a challenging meeting. Some types of cognitive-behavioral therapy in mental disorders, such as the exposure phase, may put you in a situation where you have always wanted to escape. For example, if you are afraid of flying, you may be asked to board a plane. This situation can lead to temporary stress or anxiety. However, working with a skilled expert minimizes any risks. The coping skills you learn can help you manage and overcome negative emotions and fears [33].

Studies have shown that the results of short-term CBT continue for a long time after treatment. The effectiveness of cognitive therapies has been proven for most anxiety disorders. All kinds of psychological treatments are suggested to effectively deal with this disorder and also to deal with the problems caused by medication, but what should be considered is the difference between these interventions in terms of ease of implementation and continuity of treatment results. The treatment of muscle relaxation plays an important role in the new treatments of anxiety disorders. In research, Conrad and Ruth showed the effectiveness of relaxation therapy for anxiety disorders (generalized anxiety disorder and panic disorder). CBT is one of the basic treatments for panic disorder. In a study by Salkovskis and Warwick [34], the effectiveness of CBT on panic disorder was investigated. The results of this study showed that this treatment is very effective and the rate of recurrence of attacks after the implementation of this treatment method is insignificant.

18.8 Dialectal behavior therapy

Dialectical behavioral therapy (DBT) is a form of cognitive-behavioral therapy (CBT) that consists of a set of different techniques and treatments. These two treatments are technically different. DBT uses different languages, in addition to acceptance and mindfulness techniques. DBT considers judgment beyond CBT and is a way for clients to think, but it is not intended to change the way they think. Instead, the DBT acknowledges that there is a problem with how clients think, but the therapist first encourages clients to accept it instead of judging it and then helps them to do what they want. They can change, and look to make their thinking more balanced [35].

Although DBT was primarily designed to treat BPD, research has shown that it is helpful for other disorders [36, 37, 38, 39]. We now know that this type of treatment is helpful for people who have difficulty adjusting their emotions, even if the cause is not related to a mental disorder. Due to the success of DBT in helping people learn to manage their emotions more effectively, today this treatment is increasingly being pursued by mental health professionals. Given the number of people seeking this form of treatment to help with their problems, there are unfortunately very few therapists who have been prominently trained in DBT.

18.9 DBT patterns

As mentioned earlier, the DBT model is made up of four components. Although DBT can be effectively presented to clients without these components, most research on BDT for BPD focuses on the whole pattern, which includes group skills training, individual therapy, telephone counseling, and counseling.

18.10 Group treatment

Group skills training is a structured and psychological group form of training designed to grow and increase clients’ abilities. The group is formed once a week and is divided into four patterns: basic mindfulness skills, interpersonal effectiveness skills, emotion regulation skills, and distress tolerance skills.

18.10.1 Mindfulness skills

Linehan et al. [40] divided mindfulness skills into smaller sections to make it easier for clients to understand and integrate with their lives. The goal of mindfulness in treating disorders is to increase self-awareness. Increasing self-awareness helps clients become aware of their thoughts, motivations, and emotions and gradually learn to control them in more effective ways. Through mindfulness, clients also learn to tolerate thoughts, emotions, and motivations that they cannot tolerate and that they do not need to disclose their inner experiences, but can easily accept. Until these experiences gradually disappear.

18.10.2 Interpersonal effectiveness skills

The goal of these skills is to help clients reduce the interpersonal turmoil that often occurs in their lives and is basically about how to be more determined. Clients are taught to think about something that will allow them to make an acceptable interaction, and then they will learn techniques that will make them more likely to achieve this goal.

18.10.3 Emotion regulation skills

The goal of these skills is to reduce mood instability. Clients are taught general information about emotions, such as why we need them, and why we do not want to get rid of them even when they are completely painful. Clients learn the connection between their thoughts, feelings, and behaviors, and that changing one can affect the other. Self-validation through other techniques helps clients manage their emotions more effectively.

18.10.4 Disturbance tolerance skills

These skills are also known as “crisis survival” skills and aim to help clients without resorting to problematic behaviors, such as suicide attempts, self-harm, and substance abuse, to make something worse, to survive the crisis. These skills help clients stay calm and distract themselves from problems.

Group skills training as opposed to individual therapy for a variety of reasons: First, clients with problems with emotion regulation often go from one crisis to another, and when clients seek help because of this crisis, techniques training in an individual meeting is very difficult. In addition, an important aspect of any group meeting is credibility, for example, clients gain the experience of being in a group where others have a similar problem. Another advantage of the group is that the learning experience can be richer, such as when each client learns to follow the experience of other members. Finally, because interpersonal issues often arise in a group, this can be a great way to practice the techniques learned, as well as allow clients to learn how the technique works, use them more effectively, and get guidance [41].

18.11 Individual treatment

Clients usually attend one-on-one sessions with a DBT therapist once a week. The purpose of individual sessions is to help clients apply the skills learned in the group to reduce harmful behaviors, such as suicide, self-harm, drug use, and more. Like group meetings, individual meetings have a very clear shape and structure that will be discussed in detail in the following sections.

18.12 Telephone consultation

Telephone counseling is done to guide clients to use their skills. Telephone counseling means a brief interaction to help clients identify which techniques may be more helpful in the situation they are facing. It helps them overcome the barriers to using these skills and act more effectively.

18.13 Counseling team

According to Linehan et al. [40], DBT is meaningless without a counseling team. The structure of the DBT counseling team will vary depending on the therapist’s environment. The team usually includes all DBT therapists in the clinic, such as social workers, psychologists, psychiatrists, and anyone working in individual therapy and skills training groups with DBT clients. For therapists who work privately, this is a little more complicated. Because teamwork is important in pursuing practice, private therapists may want to create a team that includes other private DBT therapists in their environment or even online, provided they adhere to it in secret. It does not have to be a big team. Depending on your situation, the team is used in two ways: First, to provide support to therapists and help them continue to develop techniques for working with clients using the DBT model, and second, to discuss the case. During the case study, the team assists the therapist to ensure that DBT techniques and strategies are adhered to. The team also feels exhausted and ineffective. In counseling sessions, the team uses DBT techniques such as taking a dialectical and nonjudgmental stance to prevent team members from engaging in power struggles and other dynamics that can disrupt the team and the healing process.

19. Effects of DBT on psychiatric disorders

Much research has been done on the use of DBT to treat other disorders besides BPD. Due to the large volume of research, only a summary of them is provided here, which is given below:

Researchers	Participants	Findings
Afshari and Hasani [37]	GAD patients	DBT helped to promote emotion regulation and mindfulness skills in the treatment of generalized anxiety disorder.
Afshari et al. [42]	Bipolar patients	DBT helped to promote executive function, emotion regulation, and mindfulness skills in the treatment of bipolar disorder.
Harley et al. [43]	treatment-resistant depressive patients	DBT leads to a significant improvement in treatment-resistant depressive patients.
Goldstein et al. [44]	Bipolar patients	DBT helps treat bipolar disorder in adolescents, and DBT techniques are also helpful in treating bipolar disorder in adults.
Nelson-Gray et al. [45]	Oppositional defiant disorder	Teaching DBT techniques to improve adolescent behavior with disobedience has been confrontational, practical, and promising.
Keuthen et al. [46]	Trichotillomania	The treatment for relapsing–remitting DBT has been a promising adaptation for obsessive–compulsive disorder (trichotillomania) with steady improvements over a six-month follow-up period.
Steil et al. [47]	PTSD	The DBT adapted for the post-traumatic stress disorder (PTSD) treatment related to sexual abuse in childhood has shown that the approach is promising.
Perepletchikova et al. [48]	Self-destructive behaviors	DBT was adapted to treat children who used self-destructive behaviors without suicide, with significant increases in coping skills and significant reductions in depression and suicidal ideation.
Rajalin et al. [49]	Family members of people with suicide attempts	The results showed a significant reduction in care responsibility, improved emotional health, and increased satisfaction with the patient.

Many specialists today are using DBT to treat illnesses and problems unrelated to the axis of a mental disorder. For example, Evershed et al. [50] used DBT to treat anger in male court patients and found that DBT had more benefits than patients who received conventional treatment. Sakdalan, Shaw, and Collier [51] found that DBT reduced the risk of suicidal ideation in patients with mental disabilities, and Drossell et al. [52] found that DBT First-degree caregivers of dementia patients helped to increase their search for appropriate behaviors, improved their psychosocial adjustment, increased their ability to cope, improved their emotional well-being, and reduced caregiver fatigue.

19.1 Stages of treatment

Linehan et al. [40] proposed a set of steps by which clients progress toward recovery: The direction of commitment and commitment (before treatment), the achievement of basic capacities (step 1), the reduction of post-traumatic stress (step 2), and increasing self-esteem and achievable goals (Step 3). In the rest of this section, we will summarize all the steps of Linehan.

19.2 Emotion regulation therapy

Emotion regulation therapy (ERT) is a manualized treatment that integrates components of cognitive-behavioral therapy, acceptance and commitment therapy, dialectical behavior therapy, mindfulness-based stress reduction, and emotion-focused treatments using a mechanistic framework drawn from basic and translational findings [37].

The goals of ERT are as follows:

1. Identifying, differentiating, and describing emotions, even in their most intense forms;

2. Increasing acceptance of affective experience;

3. Decreasing the use of emotional avoidance strategies (such as worry, rumination, and self-criticism);

4. Increase ability to utilize emotional information in identifying needs, making decisions, guiding thinking, motivating behavior, and managing interpersonal relationships and other contextual demands.

These skills are taught in the first half of the treatment and are then utilized by patients in an exposure/behavioral activation phase in the second half of the treatment.

19.3 Mindfulness-based cognitive therapy

Mindfulness-based cognitive therapy (MBCT) is a treatment protocol comprising meditation practices and cognitive behavior therapy skills. This treatment, which was formulated for unipolar depression, was later adapted for other psychiatric disorders [53].

Kabat-Zinn [54] argues that by adding mindfulness to the cognitive approach, it is easier to accept what has happened to the individual. The goal of mindfulness is to equip patients with ways to respond to life’s stresses so that they can get rid of the psychological reactions that often exacerbate stress and interfere with effective problem-solving methods. Mindfulness therapy progressed rapidly to reduce stress. In this method, patients were taught to monitor their thoughts with a broader perspective and to have a decentralized relationship with their mental content. In the mindfulness method, what matters is how you feel free to understand that most thoughts are just thoughts and not objects or realities [55]. The simple act of recognizing thoughts as it can free the patient from the distorted reality often gives the patient more insight and a greater sense of control over life. Sometime later, the mindfulness model emerged based on the initial view of Kabat-Zinn [54] on treatment.

Mindfulness-based cognitive therapy is a new promise in explaining the cognitive-behavioral therapy approach. Mindfulness training requires metacognitive learning and new behavioral strategies to focus on attention, prevent mental ruminants, tend to worry, and expand new thoughts and reduce unpleasant emotions.

Mindfulness-based cognitive therapy (MBCT) is a combination of meditation, yoga, and cognitive therapy exercises developed by Segal et al. [53] to alleviate and treat human suffering, especially the emotional suffering of people. Expands to prepare for depression.

Mindfulness-based cognitive therapy is based on the Kabat-Zinn Mindfulness Stress Reduction Model, and the principles of cognitive therapy are added to it. This type of cognitive therapy includes various meditations, stretching yoga, basic training on depression, body review exercises, and several cognitive therapy exercises that show the relationship between mood, thoughts, feelings, and physical sensations. All of these exercises provide some sort of attention to physical and surrounding situations in the “present moment” and reduce automatic depressurization processes.

Mindfulness-based cognitive therapy is mind-based therapy and is one of the third-wave therapies [56]. In this style, the principles of cognitive therapy integrate with the mindset of mindfulness to improve emotional well-being and mental health.

19.4 Mindfulness-based stress reduction

According to the mindfulness-based stress reduction (MBSR) developed by John Kabat-Zinn, the main goal of the MBSR is to help people to improve their relationships with their thoughts, feelings, and physical feelings [57].

The MBSR was first practiced at the University of Massachusetts by John Kabat Zinn. In his stress-relieving clinic, participants were taught to practice mental relaxation with mindfulness. These efforts led to the formation of a mindfulness model based on stress reduction.

Currently, the most common method of mindfulness is MBSR, formerly known as the stress reduction program as well as relaxation. This method was designed in the structure of behavioral medicine and for a wide range of people with stress-related disorders and chronic pain. The program runs as an 8–10-week program for groups of more than 30 participants. In addition, meetings are held weekly and each session lasts about 2 h. Meeting instructions include practicing meditation skills, discussing stress, coping techniques, and homework.

Body examination, for example, is an exercise in which participants lie on the floor with their eyes closed for about 45 min, focusing their attention on different parts of their body, and carefully observing the emotions associated with each area of ​​their body [58].

How mindfulness can act so markedly on resilience is still being studied, but it is now evident that the practice of mindfulness, if well learned, trains certain critical skills and changes the neurophysiology of the brain.

Furthermore, the MBSR is a practice-based, interactive learning program. Research shows the MBSR to be an effective complement to a wide variety of medical and psychological conditions. These include anxiety, asthma, cancer, chronic pain, depression, diabetes, fibromyalgia, gastrointestinal disorders, heart disease, hypertension, mood disorders, sleep disturbances, and stress disorders.

Mindfulness is the practice of present-moment awareness. It promotes personal well-being and enables us to experience life more fully by developing the ability to return with kindness to the present moment rather than being lost in repetitive thoughts and worries about the past or the future. In this way, we can make wise choices, rather than react unconsciously.

Becoming more aware of our thoughts, feelings, and sensations, in a way that suspends judgment and self-criticism, can have surprising results. Many people report finding inner strengths and resources that help them make wiser decisions about their health and life in general.

Most of us find ourselves “swept away” at times by a current of thoughts, feelings, worries, pressures, and responsibilities. We want things to be different from how they are right now. Feeling stuck in this way can be draining. Mindfulness can help us work directly with the struggle we sometimes have in relating to life’s experiences. In doing so, we can greatly improve the quality of our life.

The MBSR is now taught in every state in the U.S. and in more than 30 countries. MBSR classes include instruction in mindfulness meditation, mindful movement, and other mindfulness practices, all guided by a skilled tutor.

For the program to be effective, your commitment to 45 minu of daily practice and active participation in all classes as well as the daylong retreat is important. The 8-week course meets for 2.5 h weekly. The all-day silent retreat provides an opportunity for participants to experience more deeply the mindfulness techniques learned in class.

Mindfulness means paying attention on purpose, nonjudgmentally, to what is happening in the present moment, both internally (physical sensations, thoughts, and emotions) and externally (sounds, sights, and smells). Mindfulness enables us to be in the present moment and aware of our experiences. This allows us to make more purposeful and wise choices, instead of reacting automatically (often with adverse consequences) to things we cannot control. Mindfulness also involves an intention to reduce or relieve suffering through the cultivation of kindness and compassion for oneself and others [59].

MBSR is appropriate for people with a wide variety of conditions, needs, and goals, including:

• Medical conditions such as cancer, chronic pain or fatigue, heart disease, diabetes, arthritis, seizures, autoimmune disorders, and many others;

• Psychological conditions including depression, anxiety, and sleep disorders;

• Stress in the context of work, relationships, school, finances, moving, and other situations;

• Illness prevention and wellness, cultivating balance in one’s life, and developing a more consistent meditation practice;

• Health care providers, including physicians, nurses, pharmacists, physical therapists, mental health professionals, and others.

MBSR provides systematic training in both formal and informal ways to bring mindfulness into daily life. Formal practices, taught in class, include:

• The “body scan,” in which participants systematically move their attention from head to toe;

• Sitting meditation, involving awareness of breathing, sounds, sights, thoughts, and emotions;

• Gentle movement (derived from Hatha yoga) and mindful walking, attending to physical sensations generated during movement;

• Loving-kindness meditation, a practice to help cultivate compassion for oneself and others.

Participants will also learn about the physiology of stress and how to use mindfulness skills in diverse contexts, including relationships, work, daily self-care, and managing physical symptoms. A central feature of this course is that participants are asked to engage in 45 minu of daily home practice, using recordings available on the web, as well as informal practice assignments, bringing mindfulness to daily activities they are already doing.

19.5 Acceptance and commitment therapy

Acceptance and commitment therapy (ACT) was established by Hayes et al. [60]. This method is part of the third wave of behavioral therapies and followed by the second wave of these therapies such as cognitive-behavioral therapy. The ACT is affiliated with a research program called Communication System Theory. This approach accepts the change of thoughts and feelings instead of their transformation, content, or abundance [61]. This treatment is one of the most recently developed models whose key therapeutic processes are different from cognitive-behavioral therapy.

Its underlying principles include:

1. Accepting or wanting to experience pain or other disturbing events without trying to control them;

2. Value-based action or commitment combined with the desire to act as meaningful personal goals before the removal of unwanted experiences. Linguistic methods and cognitive processes interact with other nonverbal dependencies in a way that leads to healthy functioning. This approach includes practice-based exercises, language metaphors, and methods such as mental care [62].

The ACT is a model derived from the third wave of therapeutic behavior. The main goal of this model is to perform an effective action, an action that is conscious with full presence of mind and is value-oriented [61]. This model differs from traditional cognitive-behavioral therapy, which seeks to teach people almost how to control thoughts, feelings, memories, and other events, so it helps therapists with a sublime sense of self (spectator self). In general, in the third wave of therapeutic therapy, the main emphasis is on awareness of emotions and thoughts. In the ACT, the goal of the therapist is to increase psychological flexibility in clients. Accordingly, psychological flexibility means being able to go back to the present moment, be aware of and observe one’s thoughts and emotions, distance oneself from rigid beliefs, and do what is important, despite unpleasant events [63].

The ACT derives its name from its two main messages: acceptance of what is beyond your control and commitment to an action that improves your living conditions and purpose. It is to maximize man’s potential for a rich, fulfilling, and meaningful life. This is based on three main methods, which are as follows:

• Be present.

  Consider yourself here and now, so you can react to life instantly and effectively.

• Welcome.

  You will learn to change your relationship with these painful experiences, without drowning in them and instead of trying in vain to control them.

• Commit to important activities.

  Identify what matters to you (we do not value it) and then use that knowledge to guide, inspire, and motivate you to change and improve your life [64].

Acceptance and occupational therapy also look at people in a health-oriented manner, so they are opposed to clinical diagnoses and base their work on a case-by-case formulation. In other words, the ACT refers to the two hexagons of psychological flexibility and nonpsychological flexibility. According to this model, those attending counseling or psychotherapy sessions are trapped in a hexagonal psychological inflexibility hexagon and suffer from an unreasonable conflict. Instead of communicating with the present, these people become captivated by mental rumination (past) and anxiety (future). In this case, the person experiences an avoidance (doing something to get rid of painful internal experiences that reduce a person’s quality of life), intermingling (clinging to thoughts, judgments, or emotions), self-conceptualized attachment (effect verbal meaning that a person has created for himself or others), persistent inactivity (performing impulsive or passive behaviors or insisting on avoiding an experience that does not lead to a step in the direction of one’s values), and not specifying values (lack of awareness of central values self or noncontact with them). Therefore, the main goal of the ACT is to live rich and valuable. The six aspects of psychological flexibility included: (1) contact with the present moment, (2) acceptance, (3) fault, (4) communication, (5) the definition of values, and (6) the committed action [65].

19.6 Metacognitive therapy

In the field of newer psychological treatments, metacognitive therapy was first introduced by Adrienne Wells. The term metacognition refers to cognitive processes that play a role in controlling different aspects of cognition. Although, based on many kinds of research, it can be concluded that psychological treatments have longer-term therapeutic effects than drug therapy alone on patients suffering from phobias, more efficient, shorter, and more accessible types of psychological treatments should be used as well. Metacognitive therapy was invented to improve the results of cognitive therapies. The effectiveness of behavioral-metacognitive therapy on mental disorders has also been confirmed. Wells and King [66] have proven the effectiveness of this treatment on generalized anxiety disorder, obsessive–compulsive disorder, and post-traumatic stress disorder, respectively. Studies show that anxiety disorders, including generalized anxiety disorder, respond to cognitive-behavioral therapy, but Wells, as the main creator of metacognitive therapies, believes that anxiety disorders, including generalized anxiety disorder, respond only to a certain extent to cognitive-behavioral therapy. What is emphasized in metacognitive therapy are factors that control thinking and change the state of mind, not challenges with thoughts and cognitive errors or long-term and repeated exposure to beliefs about trauma or physical symptoms [33].

20. Conclusion

This chapter outlined the most effective evidence-based psychotherapies for panic disorder, namely medication, cognitive behavior therapy, dialectical behavior therapy, mindfulness-based cognitive therapy, mindfulness-based stress reduction, acceptance and commitment therapy, and metacognitive therapy. Evidence suggests that medication may have an effect on the reduction of physical sensations associated with anxiety. However, cognitive behavior therapy is the common psychotherapy that addresses dysfunctional thinking and behavior in order to alleviate psychological problems in panic. The main technique in psychotherapy of panic disorder is exposure, which is significantly effective in treating panic. Other psychotherapies are not effective than cognitive behavior therapy and exposure.