There are various therapeutic strategies to enhance the treatment of bipolar disorder. For people who have co-occurring anxiety problems many of the same techniques, with some adaptation, have been shown to be quite effective. The best studied is cognitive-behavioral therapy (CBT), which helps people learn to identify distorted thoughts, challenge them, and change them. With practice, this becomes an extremely helpful technique that gives people a greater sense of control. While CBT focuses on the present, the here and now, over time, and with practice, CBT can help people work backwards in their lives to where they can examine how their thought distortions may have come to exist.
For someone with panic attacks CBT might involve identifying the triggering thoughts for the panic attack. For example: “If I have to get up to speak I’m going to die.” Then the person would quickly challenge, “Are you really going to die? You’ve gotten up to speak before and you’re still breathing.” And finally they would reframe the thought: “While public speaking clearly makes you anxious, some of that is normal nerves. You know the material you’re supposed to present and if you just focus on that it’s going to be fine.”
Alternatively, if someone is already in the midst of a panic attack, CBT can help get her through and make it less severe. Here, the catastrophic thoughts that typically accompany the panic attack are identified, challenged, and reframed. “Oh my God, I’m having a heart attack! I need to go to the emergency room.” The challenge and reframe might be, “No, you’ve had a full cardiac workup from the twelve other times you went to the emergency room; this is a panic attack and if you can get yourself to calm down the adrenalin rushing through your system will get broken down by your body in just a few minutes. Then the palpitations will stop.” You could even add in additional behavioral techniques such as distraction or a grounding exercise, “Why don’t you watch TV (listen to music, bake something, go for a walk, play with the cat, do some house cleaning, try to feel your feet on the floor)?” to further diminish the severity of the attack.
With obsessive-compulsive disorder and with phobias, an often used technique is something called graded exposure and reciprocal inhibition (response prevention). This is typically done with a therapist over a series of weekly sessions and it involves identifying the feared thing/event and gently and consistently confronting it. At first this might involve just thinking about the thing (germs, spiders, heights, public speaking, or the need to count things or check the stove repeatedly) and eventually introducing the real thing. After the person confronts his fear, he is then instructed in techniques to either lower his anxiety or just sit with the anxiety, and in the case of OCD, not engage in compulsive behavior (hand-washing, counting, checking rituals, etc). In time the fear diminishes and the anxiety is reduced. In order for this technique to work, practice on a daily basis is important.
A related technique that no one seems to like but which is mentioned throughout the literature is a process called flooding. Here, instead of gradually introducing the fear, one is made to come face to face with it, and to sit with the anxiety that is generated. The similar principle applies; over time the reality that the person is in fact not being hurt by the thing she’s afraid of diminishes the anxiety. This can be traumatic, however, and while the literature may support its efficacy, getting people to come back for a second session can be difficult.