CBT for Panic Disorder

Anam Bibi
 Characteristics of Panic Attacks
• Panic attacks are defined as rapid occurrences of anxiety
or rapid escalations in current anxiety in which there are
at least 4 of 13 somatic or cognitive symptoms (DSM-IV;
APA, 1994).
• Four or more symptoms have to escalate or occur within
a ten-minute period, to meet panic criteria.
• These symptoms include physical responses such as
palpitations, dizziness, sweating, choking, trembling or
shaking, breathlessness, depersonalisation, and cognitive
symptoms such as fear of dying, suffocating, going crazy,
and so on.
 Characteristics of Panic Attacks
• More specifically, panics may be situational (cued) or
spontaneous (uncued).
• Spontaneous panics occur unexpectedly, while
situational panics occur in situations that almost always
cause anxiety.
• In order for an individual to meet criteria for panic
disorder in accordance with DSM-IV (APA, 1994), the
presence of recurrent, unexpected panic attacks
followed by at least one month of persistent concern
about having another panic attack or a significant
behavioural change related to the attack is required.
 Cognitive Model of Panic
• The model of panic proposed by Clark (1986) is one of the most
useful for the cognitive conceptualisation and treatment of the
disorder.
• The model has become known as the 'vicious circle model' of panic.
• In Clark's model, panic attacks result from the 'catastrophic
misinterpretation' of bodily or mental events.
• These events are misinterpreted as a sign of an immediate
impending disaster, such as the sign of having a heart attack, of
collapsing, suffocating, or going crazy.
• For example, physical sensations such as dizziness may be
interpreted as a sign of fainting, and speeded heart rate as a sign of
a heart attack.
 Cognitive Model of Panic
• Mental events such as difficulty concentrating or the
experience of racing thoughts can also be misinterpreted,
often as a sign of a mental or social catastrophe such as
losing control of one's mind or behavior.
• In this model any internal or external stimulus which is
appraised as threatening produces a state of anxiety and
bodily symptoms associated with that state. If these
symptoms are interpreted in a catastrophic way a further
elevation in anxiety occurs and the individual becomes
trapped in a vicious circle that culminates in a panic attack.
 Cognitive Model of Panic
• Once panic attacks have occurred at least
three other factors contribute to the
maintenance of the problem: (1) selective
attention to bodily events; (2) in-situation
safety behaviours; (3) avoidance (e.g. Clark,
1988; Salkovskis, 1991; Wells, 1990).
 Internal/External Trigger

Perceived Threat

Anxiety

Misinterpretation Physical/Cognitive
Symptoms
 Cognitive Model of Panic
• Selective attention to bodily events and increased bodily
focus can contribute to a lowered threshold for perceiving
sensations and may also be involved in increasing the
subjective intensity of these events.
• Panic patients develop situational safety behaviours aimed at
preventing feared catastrophes. These responses prevent
disconfirmation of belief in catastrophe and can intensify
bodily symptoms. For example, patients who misinterpret
feelings of weakness in the legs as a sign of imminent collapse
may sit down, hold onto or lean on something, crouch down,
put themselves on the floor, or tense the muscles in their legs
in order to prevent collapse.
 Cognitive Model of Panic
• Finally, avoidance is a maintaining factor in
panic. Avoidance of anxiety-provoking
situations, such as crowded shops, or activities
such as exercise restrict the panicker's
opportunity to experience anxiety and to
discover that it does not lead to catastrophe.
• These maintaining factors should be fully
explored and included in idiosyncratic case
conceptualisations.
 Assessment
• Cognitive-behavioural assessment in panic is aimed at
eliciting idiosyncratic data for construction of a vicious circle
model.
• The main information sought concerns: (1) the nature of
catastrophic misinterpretations (content and belief levels); (2)
detailed descriptions of the main feared sensations; and (3)
the nature of safety and avoidance behaviours.
• One of the main outcome measures in the treatment of panic
should be a measure of panic frequency and intensity,
although measures of general anxiety (the Beck Anxiety
Inventory) and of avoidance should also be used on a regular
basis.
 Assessment
• Panic frequency data can be collected in the form of a daily
panic diary.
• When you feel panicky make a note of the situation in which
panic occurred (e.g. driving in a car) in the Situation column.
Write down your main bodily sensation in the Main bodily
sensation column. Write down the frightening negative
thoughts that you had during your attack in the Negative
thought column. Under the Answer to negative thought
heading, write in your answer or rational response to your
negative thought, this may be a verbal answer or a particular
behaviour. Make a note of the total number of panic attacks
you have each day in the Number of panic attacks column.
 Felt Unreal

What if I panic

Scared/Anxiety

I am having a heart attack Shaking, Heart

Racing, Breathless
 Developing the Basic Conceptualisation:
Incorporating Safety Behaviors and Avoidance
• Avoidance behaviours may be clearly apparent
from the outset, particularly if agoraphobia is
a problem. However, more subtle forms of
avoidance and safety behaviours may be less
apparent, and they should be carefully
explored. Examples of subtle avoidance
include avoidance of strenuous activity or
exercise, avoidance of being alone, avoidance
of medical information and so on.
 Developing the Basic Conceptualisation:
Incorporating Safety Behaviors and Avoidance
• In most instances asking the question 'Are
there any situations that you are avoiding
because of your anxiety?' is sufficient to elicit
some avoidance behaviors. This should be
followed by other questions probing for
detailed information about avoidance in an
attempt to develop a comprehensive list of
feared and avoided situations associated with
panic.
 Socialisation
• Socialisation begins with building and presenting
the panic cycle. This should be done for several
panic attacks (to show that all panics fit the
sequence).
• The aim of socialisation is to offer an explanation of
panic attacks as caused by the catastrophic
misinterpretation of bodily sensations. These two
variables can be linked by explaining that belief in
catastrophe leads to an 'adrenalin rush' which
exacerbates anxiety.
Sensation(s) Misinterpretation Safety behavior/avoidance
Palpitations Heart Attack Relax
Chest Tightness Dying Slow down heart rate Sit
down, avoid exercise Avoid
physical exertion

Unreality (dissociation) Loss of control Madness Keep control of mind, Check

memory, Try to control
thoughts, Look for exits

Breathlessness Suffocate Go into open air, Suck menthol

sweets

Throat tightness Choking Carry bottle of water,

Dizzyness Fainting Collapsing Control breathing Sit down
Hold on to partner, Avoid
going out alone

Blurred vision Blindness, Stroke Check vision, Wear sunglasses,

Take aspirin

Jelly legs Falling Collapsing Leave situations Stiffen legs

while standing, Walk close to
walls, Wear flat shoes
 Sample Socialisation Experiments
• The Paired Associates Task:
• This task aims to illustrate the effect of
thinking on anxiety and associated bodily
sensations by testing the supposition that
thinking about physical catastrophes can elicit
or heighten bodily sensations and/or anxiety.
• The task is presented without an explanation
of its aims, since a rationale can interfere with
the impact of the task.
 Sample Socialisation Experiments
• The patient is asked to dwell on pairs of words
and think of their meaning while reading them
aloud. A period of about 58 seconds should be
allowed for dwelling on each word pair, which
are presented in list format. The words used
for constructing the pairs consist of common
anxiety sensations partnered with physical
calamities typical of the content of panic
misinterpretations.
 Sample Socialisation Experiments
Breathlessness Suffocate

Dizziness Fainting

Chest tight Heart attack

Numbness Stroke

Palpitations Heart attack

Unreality Insane

Weakness
Collapsing
 Sample Socialisation Experiments
• After performing the task for a few minutes, the patient
should be asked if he/she noticed anything while reading
the words. Occasionally the task invokes high anxiety, but
most often a more subtle increase in anxiety or awareness
of bodily sensations is reported.
• The patient should then be asked what sense he/she makes
of this result in terms of the model, and in terms of the
impact of their thinking. The task does not work with all
patients. When it fails, closure of the exercise can be
achieved by explaining that it was a test to see what the
patient's general reaction was to reading unpleasant
material, and the fact that there was little reaction is fine.
 Sample Socialisation Experiments
• Body-Focus Task:
• A different demonstration of the effect of
'thinking', or more specifically the effect of
selective attention on symptom perception, can
be achieved with self-focused attention
manipulations. The task serves to show that
attentional strategies can increase awareness of
bodily sensations which are normally present, and
that it can exaggerate perceived symptom
intensity.
 Sample Socialisation Experiments
• Patients are asked to focus attention on
sensations in particular parts of the body such
as the feet, or sensations in the fingertips.
After a couple of minutes monitoring they are
asked to report what is noticed. The
procedure is normally used in conjunction
with questions which facilitate the framing of
the results of the task in terms of the panic
model.
 Sample Socialisation Experiments
• Typical questions include the following: ·
• Were you aware of the sensations before you
focused on that part of your body? ·
• What happened to the sensations when you
focused on them? ·
• If focusing your thoughts on your body leads
you to notice sensations that you were not
previously aware of, how might that contribute
to the vicious circle?
 Sample Socialisation Experiments
• A variant of the self-focus task involves visual
fixation on parts of the body, such as staring at
the back of one's left or right hand, and
noticing what happens to perception, such as
perception of size, clearness of the image, and
extent to which the hand seems part of the
individual.
 Sample Socialisation Experiments
• Metaphors and Allegories as Socialisation:
• The effect of safety behaviours in preventing disconfirmation of belief can be
illustrated with metaphors and allegories. Two examples are given below:
• 1. In South America there are a tribe of people who believe they are the
guardians of the world. In order to keep the world spinning and human-kind
existing they have to conduct a special ceremony each year. They fear in case
something should prevent them from doing this. They believe that if they did
not perform their ceremony the world would end. How can they discover that
their belief is false?
• (Probe: Can you discover that nothing bad will happen so long as you use
safety behaviours?)
• 2. Some people believe in vampires, and so they become very anxious when
it's time to sleep at night. In order to keep safe they sleep with cloves of garlic
around their neck. Of course no one has seen a vampire and so the garlic must
be working. How can these people discover that there are no vampires?
The Evolution of Treatment
Strategies in Panic
 Reattribution Strategies
Behavioral Experiments
• Many of the behavioral experiments used in
the treatment of panic involve the active
induction of panic sensations in order to
challenge belief in misinterpretations. So-
called 'panic inductions' are therefore the
cornerstone of behavioral reattribution
experiments in this disorder, and are typically
among the first experiments employed in
treatment
Guidelines for Effective Symptom Induction
Experiments
• The therapist should have a good knowledge of the patient's
feared sensations, and the precise idiosyncratic
misinterpretations associated with them (plus belief level)
before designing and implementing an induction experiment.
• Compliance may be enhanced if the therapist first models
the induction procedure and executes the procedure in
parallel with the patient.
• In order to assess the efficacy of the induction, patient belief
in a specific feared catastrophe (misinterpretation) should be
rated before and after the experiment. If some belief remains
the reason for this should be questioned.
Guidelines for Effective Symptom Induction
Experiments
• The induction may have to be repeated several times, perhaps
more vigorously in order to maximize disconfirmation.
• In the event of minimal or no belief change a number of factors
should be explored which can contribute to the reduced
effectiveness of the procedure.
• First, the patient may have used in-situation safety behaviors
during the task which have prevented full disconfirmation
• Close observation of behavior during induction often reveals the
use of particular safety behaviors, such as suddenly disengaging
from the task, holding onto or leaning on things, sitting down,
taking deep breaths (or not taking deep enough breaths during
forced hyperventilation), tensing muscles, and so on.
Guidelines for Effective Symptom Induction
Experiments
• The second interfering factor can be a poor match between induced
symptoms and the symptoms normally misinterpreted during panic
attacks. For best results a good match should be achieved for
disconfirmation to occur.
• The third factor which modulates the degree of anxiety and belief
activation during induction, and can therefore affect experimental impact,
is the presence of rescue factors built into the environment. For example,
fear may not be fully activated by bodily sensations in the presence of the
therapist or in the clinic setting if the patient appraises the therapist or
setting as the best source of emergency help in the event of catastrophe.
Situations like this draw on the therapist's creative problem solving in
designing induction experiments that exclude perceived rescue factors. A
solution is to ask the patient to perform the induction while alone in the
consulting room, or conducting the procedure away from the clinic setting
altogether.
Guidelines for Effective Symptom Induction
Experiments
• There may be a reluctance to push patients in symptom inductions
This is often based on faulty assumptions held by the therapist.
There may be a fear that the patient will panic and the therapist will
not be able to handle the situation, or the therapist may believe
that a person can actually faint in a panic attack. It is important that
therapists identify and challenge their own unhelpful assumptions.
Some common examples of therapist thoughts/assumptions are:
• I must always make my patient feel better rather than worse
• If I ask my patient to do this he/she will get mad at me
• If I ask my patient to do this he/she will drop out of treatment.
• If I make my patient panic I won't be able to cope.
• What if my patient does lose control?