Cbt for panic disorder abasseya

CBT for Panic DisorderDr. Reham Abdel-Samie Aly

MD PsychiatryFellow of the Arab Board of Psychiatry

Academy of Cognitive Therapy Diplomate & Member

The Nature of Panic

Discrete occurrences of intense fear or discomfort of sudden onset, accompanied by a surge of physiological hyperarousal.

In addition to strong autonomic arousal, panic is characterized by a faulty verbal or imaginal ideation of physical or mental catastrophe (e.g., dying, going insane), intense uncontrollable anxiety, & a strong urge to escape.

The Nature of Panic (cont.)

DSM-IV-TR defines panic attacks as “a discrete period of intense fear or discomfort in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes” (APA, 2000, p. 432).

The typical panic attack lasts between 5-20 minutes, although a heightened state of anxiety can linger long after the panic episode subsides.

According to DSM-IV-TR, the defining symptoms of panic are:› Elevated heart rate or palpitations› Sweating› Trembling or shaking› Smothering sensation or shortness of breath› Feeling of choking› Chest tightness, pain, or discomfort› Abdominal distress or nausea› Dizziness, lightheadedness, faintness, or feeling unsteady› Feelings of unreality (derealization) or detachment from oneself (depersonalization)› Numbness or tingling sensations› Chills or hot flushes› Fear of losing control or going crazy› Fear of dying

The Nature of Panic (cont.)

The panic experience is very aversive that many patients have a strong apprehension about having another attack & develop extensive avoidance of situations thought to trigger panic.

As a result panic & agoraphobia are closely associated.

Critical Features of Panic Attacks

Situational triggers Abrupt onset of physiological arousal Heightened self-focus, hypervigilance of bodily

sensations Perceived physical, mental, or behavioral

catastrophe Apprehension, fear of future panic attacks Extensive safety seeking (escape, avoidance,

etc.) Perceived lack of controllability Qualitatively distinct from anxiety

Situational Triggers

majority of panic episodes are anticipated because they are provoked by exposure to an identifiable stressor; theaters, supermarkets, restaurants, department stores, buses, trains, airplanes, subways, driving in the car, walking on the street, staying alone at home, or being far away from home.

Hypervigilance of Bodily SensationsIs panic disorder characterized by heightened interoceptive acuity?

Panic is characterized by a heightened vigilance and responsiveness to specific physical symptoms linked to a core fear.› i.e. individuals may be more sensitive to the particular body

sensations linked to their central fear (e.g., increased pulse rate for those afraid of heart attacks).

This does not mean that individuals with panic disorder are better at detecting changes in their physical state.› fearing bodily sensations does not mean that a person will

necessarily be better at detecting interoceptive cues. individuals with panic have heightened anxiety

sensitivity & greater vigilance for the physical sensations associated with anxiety.

Hypervigilance of Bodily Sensations

Individuals with panic disorder are not more autonomically hyperactive to standard laboratory stressors than nonpanickers.

24-hour ambulatory heart rate monitoring of panic patients indicates that 40% of self-reported attacks are not associated with actual increase in heart rate or other physiological responses and most episodes of physiological hyperarousal (i.e., tachycardia) occur without self-reported panic episodes.

Individuals with panic disorder do not have more cardiac arrhythmias than nonpanic patients.

Thus it is not the presence of physiological symptoms that is critical in the pathogenesis of panic but rather how these symptoms are interpreted.

Catastrophic Interpretations

A key feature of panic episodes is the tendency to interpret the occurrence of certain bodily sensations in terms of an impending biological (e.g., death), mental (i.e., insanity), or behavioral (e.g., loss of control) disaster.

For example, individuals with panic disorder may interpret› (a) chest pain or a sudden increase in heart rate as

sign of a possible heart attack, › (b) shaking or trembling as a loss of control, or (c)

feelings of unreality or depersonalization as a sign of mental instability or “going crazy.”

Apprehension of Panic

Individuals with panic disorder report extreme distress, even terror, during panic attacks & so quickly develop considerable apprehension about having future attacks.

This fear of panic is a distinguishing feature of the disorder & is a diagnostic criterion.

Presence of fear & avoidance of panic attacks differentiates panic disorder from other anxiety disorders.

Extensive Safety Seeking & Avoidance

Safety-seeking behavior & avoidance of panic-related situations may be seen as coping strategies to prevent the impending disaster (e.g., overwhelming panic, a heart attack, loss of control).

Phobic avoidance is elicited by the anticipation of panic attacks & not by the situations themselves.› 98% of panic disorder cases have mild to severe situational

avoidance,› 90% experiential avoidance (i.e., use safety signals or thought

strategies to withdraw or minimize contact with a phobic stimulus), &

› 80% interoceptive avoidance refusal of substances or activities that could produce the physical sensations associated with panic.

Perceived Lack of Control

A striking characteristic of panic attacks is the feeling of being overwhelmed by uncontrollable anxiety.

This apparent loss of control over one’s emotions & the anticipated threat causes a fixation on the panicogenic sensations & a loss of capacity to use reason to realistically appraise one’s physical & emotional state.

Varieties of Panic

Spontaneous panic;› Unexpected (“out of the blue”) panic attacks that are not associated with

external or internal situational triggers. Situationally cued panic

› Panic attacks that occur almost invariably with exposure or anticipated exposure to a particular situation or cue.

Nocturnal panic › A sudden awaking from sleep in which the individual experiences a state

of terror and intense physiological arousal without an obvious trigger (e.g., a dream, nightmares).

Limited-symptom panic; › a discrete period of intense fear or discomfort that occurs in the absence

of a real danger but involves less than four panic attack symptoms. Nonclinical panic

› Occasional panic attacks reported in the general population that often occur in stressful or evaluative situations, involve fewer panic symptoms, and are associated with less apprehension or worry about panic.

Agoraphobic Avoidance

Is the avoidance or endurance with distress of “places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a panic attack or panic-like symptoms.

Situations include; being at home alone, crowds, department stores, supermarkets, driving, enclosed places (e.g., elevators), open spaces (e.g., crossing bridges, parking lots), theaters, restaurants, public transportation, & air travel.

AWOPD (agoraphobia without panic disorder):› relatively rare,› less likely to seek professional treatment› may be more severe and associated with less favorable

treatment outcome than panic disorder,

Psychiatric Comorbidity

Most common comorbid conditions are: › major depression (23%), › GAD (22%),› social phobia (15%), & › specific phobia (15%). › PTSD (4%)› & OCD (7%).

Substance abuse is also common in panic disorder

Panic and Suicide Attempts

Individuals with panic disorder were 2.5 times more likely to attempt suicide than individuals with other psychiatric conditions

Suicide attempts in panic disorder were due to psychiatric comorbidity & that panic itself did not directly increase risk for suicide attempts.

Increased Medical Morbidity

A number of medical conditions are elevated in panic disorder such as cardiac disease, hypertension, asthma, ulcers, and migraines.

Medical conditions that can produce physical symptoms similar to panic disorder include› endocrine disorders (e.g., hypoglycemia, hyperthyroidism,

hyperparathyroidism), › cardiovascular disorders (e.g., mitral valve prolapse, cardiac

arrhythmias, congestive heart failure, hypertension, myocardial infarction),

› respiratory disease, › neurological disorders (e.g., epilepsy, vestibular disorders), › and substance use (e.g., drug/alcohol intoxication, or

withdrawal)

The Cognitive Model of Panic Disorder

Description of the Model

The cognitive model of panic was first articulated in the mid- to late 1980s by Beck & colleagues.

The cognitive model was formulated to explain the pathogenesis of recurrent panic attacks or panic disorder.

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The fear of fear model

Alarm reaction

Heart ratesweatingdizzinessdepersonalizationsobchest painetc.

Uh-oh reaction

What’s wrong?!?What’s happening?What if I…..have a heart attack?..embarrass myself?..go crazy?..lose control?

Anxiety/fearhurry up/tense up(get out)

memories

Increased bodilysensations

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N Links between Panic-Relevant Internal Sensations & Their Corresponding Physiological or Mental Threat Schema

Catastrophic Misinterpretation of Internal Sensations

sensations are misinterpreted as representing an imminent physical or mental disaster e.g. death caused by heart attack, suffocation, seizure, or the like.

In order to precipitate panic, the catastrophic threat must be perceived as imminent; if the misinterpretation is merely exaggerated threat, then anxiety rather than panic will be roused

Symptom Intensification and Defense

The catastrophic misinterpretation of bodily sensations will cause an intensification of the feared internal sensations by heightening vigilance and an internal focus on interoceptive cues

A vicious cycle occurs in which the escalating intensity of the physiological or mental sensation further reinforces the misinterpretation that indeed a physical or mental disaster is imminent.

Loss of Reappraisal Capability

Activation of the physiological threat schemas and subsequent catastrophic misinterpretation of bodily sensations dominates information processing and inhibits the panic-stricken patient’s ability to generate alternative, more realistic, and benign interpretations of the fearful sensations.

If reappraisal of the perceived threat is possible, the catastrophic misinterpretation would be challenged and the escalation into panic would be disillusioned.

Clinical Application

A young man with panic disorder who was fearful of sudden increases in his heart rate. On some occasions, such as sitting at his computer, he would perceive an increase in heart rate that elicited the apprehensive thought “Why is my heart racing?”

His underlying physiological threat schemas were “I am vulnerable to heart attacks,” “If I let my heart rate get too high, I could have a heart attack,” and “After all, I do have a cardiac condition” (he had a diagnosed congenital cardiac condition that was benign).

Once activated, he generated a catastrophic misinterpretation (“My heart is racing, I might be having a heart attack”). At this point he was unable to generate an alternative explanation for this increased heart rate, and so he became panicky. On other occasions, such as when working out at the gym (as recommended by his physician), he would notice his heart rate increase, wonder if it could be a sign of a cardiac problem, but immediately reappraised the sensations as due to the demands of his physical activity. One of the main objectives of cognitive therapy for panic is to improve the patient’s ability to reappraise fearful internal sensations with more realistic, plausible, and benign alternative interpretations.

CBT for Panic Disorder

Treatment goals

1. Reduce sensitivity or responsiveness to panic-relevant physical or mental sensations

2. Weaken the catastrophic misinterpretation an underlying hypervalent threat schemas of bodily or mental states

3. Enhance cognitive reappraisal capabilities that result in adoption of a more benign and realistic alternative explanation for distressing symptoms

4. Eliminate avoidance and other maladaptive safety-seeking behaviors

5. Increase tolerance for anxiety or discomfort and reestablish a sense of safety

Treatment Components

Education into the cognitive model of panic Schematic activation & symptom induction Cognitive restructuring of catastrophic

misinterpretation Empirical hypothesis testing of alternative

explanation Graded in vivo exposure Symptom tolerance & safety reinterpretation Relapse prevention Breathing retraining (optional)

Outline of Sessions

Session I

Discuss the nature of anxiety Introduce the three components of

anxiety Discuss the basic model of panic attacks Provide treatment overview Discuss the importance and benefits of

practice and monitoring Set goals for treatment Assign homework

PsychoeducationThe nature of anxiety

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PsychoeducationThe Cognitive Therapy Model of Panic

Miss H identified a number of triggers from her panic log such as being at a work meeting and sitting beside the guest speaker, not being in close proximity to a hospital, flying, and driving alone some distance from home. Her initial physical sensations were feeling lightheaded, sensing that her breathing was a little irregular, and experiencing an unusual feeling of pressure in her chest. This was followed by some initial anxious cognitions such as “What’s wrong with me?”, “Why am I feeling this way?”, “Something is not right,” “I don’t like this,” “I am beginning to feel anxious,” “I feel trapped,” and so on. These anxious thoughts often led to an escalation in a few physical sensations such as feelings of suffocation or heart palpitations.

PsychoeducationThe Cognitive Therapy Model of Panic (cont.)

Once these intense physical sensations occurred, H identified a number of catastrophic cognitions like “I’m not getting enough air, I’m going to die of suffocation,” “What if I’m having a heart attack?”, or “If I don’t stop I’m going to have a full-blown panic attack.” The catastrophic misinterpretation led to various control efforts such as escape, reassurance seeking from others, controlled breathing, or distraction, which together often ended in intense anxiety or panic attacks.

Session 2Physiology of Panic & Breathing Awareness

Review assigned reading and homework

Discuss the physiological component of anxiety

Conduct hyperventilation exercise Discuss physiology of hyperventilation Conduct slow breathing exercise Assign homework

The Physiology of Anxiety

Anxiety has a survival function; it alerts us to potential danger.

The sensations experienced during panic reflect the natural physiological processes that are associated with the fight-or-flight response.

Panic sensations are not harmful in any way. Furthermore, these sensations will eventually dissipate once the fight-or-flight system is no longer activated.

PsychoeducationThe physiology of Hyperventilation

For more oxygen to be circulated, one must breathe faster and deeper.

This can be felt as heavy breathing, pains and tightness in the chest and, in some instances, as feelings of breathlessness. In addition, since blood is being redirected toward large muscle groups, areas that are getting less blood are also getting less oxygen, although not enough to be dangerous.

This can be felt as tingling or numbness in fingers, dizziness, and lightheadedness.


For more oxygen to be circulated, one must breathe faster and deeper.

This can be felt as heavy breathing, pains and tightness in the chest and, in some instances, as feelings of breathlessness. In addition, since blood is being redirected toward large muscle groups, areas that are getting less blood are also getting less oxygen, although not enough to be dangerous.

This can be felt as tingling or numbness in fingers, dizziness, and lightheadedness.


The purpose of breathing is to provide the body with oxygen and to get rid of carbon dioxide. While hyperventilation doesn’t change the amount of oxygen in the body, it does cause a low level of carbon dioxide.

This low level of carbon dioxide is not dangerous, but often causes disturbing physical sensations.

During the hyperventilation exercise, the patient did not get more oxygen into her body, but she did get rid of more carbon dioxide than usual.

Psychoeducation Hyperventilation Exercises

Briefly demonstrate the exercise for the patient. Take three or four deep breaths and exhale very hard at about three times the normal rate.

Have the patient stand up; instruct her to breathe very fast and very deeply (as if trying to blow up a balloon) until you tell her to stop (after 90 seconds).

Have the patient engage in the HV exercise. Be sure that she maintains an adequate speed and depth of breathing. You should do the exercise along with the patient for encouragement & modeling.

Continue the exercise for seconds, unless the patient wants to stop earlier. If only a few seconds have elapsed, encourage the patient to try again.

At the conclusion of the HV exercise, have the patient sit down & breathe slowly until all symptoms have abated.

Somatic Management

Diaphagramatic Breathing

Progressive Muscle Relaxation

Cued Relaxation

Breathing Retraining

The patient should be able to breathe comfortably at the normal rate (10-14 breaths per minute) and be able to breathe even more slowly during anxiety/panic episodes.

Breathing Retraining

First, demonstrate taking this kind of breath for the patient. Then have the patient practice by having her place one hand on her chest and the other hand on her

stomach, just above the navel. This posture should ensure that respiration is coming from the diaphragm (i.e.,only the lower hand should

move). If the patient has difficulty, try using any of the following suggestions:› Imagine that there is a thin tube extending from your mouth to the bottom of your lungs. At the bottom

of this tube is a bubble. Imagine breathing into this tube to fill the bubble.› Forcefully push out your stomach before taking a breath. This will help expand the diaphragm and

make room for air.› Place a light book on your stomach. You should strive to push the book up and down while breathing.› Lay on your stomach while on the floor or a bed. Your arms should be cradled under your head. This

posture makes it very difficult to chest breathe. Once the patient has learned to breathe diaphragmatically, continue with the slow breathing exercise

following these steps:› Have the patient relax for a few seconds before starting.› Do not have the patient do slow breathing yet. Tell the patient that she should breathe at her normal

rate and depth. Each breath should be smooth and even.› Have the patient place one hand on her chest and one hand on her diaphragm.› As the patient inhales, count out loud at a rate that matches the patient’s normal rate of breathing.

Follow this order: “Inhale 1, 2, 3 . . . Exhale.”› Continue the practice for about 1 minute.› Inquire about and respond to any problems or questions from the adolescent. Give feedback on her

breathing if necessary.› Repeat the practice for an additional minute. The patient should count to herself during this practice.

Session 3Cognitive Component of Anxiety


Discuss the cognitive component of anxiety

Introduce probability overestimation Introduce catastrophic thinking Practice monitoring anxiety/panic

triggers and thoughts Assign homework

Cognitive Restructuring

OverestimatingDefinition: Overestimating the probability of

something negative happeningEg: What if I have a heart attack? What if I

die?Challenge: (

(1) Treat the thought as a hypothesis (2) Review evidence for and against the thought (3) Conclusion that is based upon the evidence.

Cognitive Restructuring

CatastrophizingDefinition: predicting the outcome of events

to be much worse than they actually are.E.g.: What if I embarrass myself (social)Challenge:

(1) Imagine the worst (2) critically analyze it (3) hassle or horror (4) will it change my life (5) can I cope?

The need for a downward arrow

What if I faint?

I’ll make a fool of myself

Catastrophizing

What if I faint?

I won’t wake up

Overestimating

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Session 4Cognitive Restructuring

Review assigned reading and homework Teach patient how to begin thinking like a

detective Have patient practice countering

probability overestimation Have patient practice countering

catastrophic thinking Discuss myths and misconceptions about

anxiety Assign homework

Countering Probability Overestimation

Questions patient can ask herself to counter predictions on her own. These include:› “How likely is it that my prediction will occur if I

panic?”› “How many times has that happened in the past

when I panicked?”› “What evidence do I have that it will happen? Is

there any evidence that it will not happen?”› “Have I ever seen or heard of that happening to

anyone else?”› “Are there any other possible reasons for these

sensations?”

Countering Catastrophic Thoughts

A detective thinking strategy for catastrophic thoughts involves:

Imagining the worst consequence actually happening Critical evaluation of the actual severity of the

consequence of a “catastrophic” event.

The patient can ask herself: “What is the worst that can happen? How bad is that?” “So what if ……..happens?” “Could I cope? Have I been able to cope with……. in the

past?” “Even if……….. happens, can I live through it?” “Is…………. really so terrible?”

Myths and Misconceptions

Myths include:› Going Crazy› Losing Control› Nervous Collapse or Fainting› Heart Attack› The Panic Attack Will Never End

Session 5Interoceptive Exposure(Not Letting How We Feel Scare us)

Review assigned reading and homework Review the physiology of anxiety Review the model of panic attacks Introduce the concept of interoceptive

conditioning Explain the rationale for interoceptive

exposure Conduct symptom induction exercises Assign homework

Interoceptive Conditioning

one way to explain unexpected panic attacks.

This form of conditioning happens when associations develop between certain sensations and a response of fear or panic.

E.g., if heart palpitations have been paired with fear many times, then the palpitations can trigger fear without any intervening thoughts or interpretations.

Implications of Interoceptive Conditioning for Panic Disorder

interoceptive conditioning can cause panic to occur in response to very subtle physical sensations.

slight changes in breathing can cause sensations of panic.

The occurrence of panic for no apparent reason can then result in misinterpretations (myths).

Implications of Interoceptive Conditioning for Panic Disorder (cont.)

Certain activities can result in conditioned fear reactions, such as:› activities that enhance awareness of

sensations e.g., seeing breath in cold air, sweating in hot

temperatures) activities that produce sensations

associated with arousal of the autonomic nervous system› e.g., amusement park rides, physical exercise,

excitement)

Rationale for Interoceptive Exposure

since relatively benign and non-dangerous internal sensations may be triggering panic reactions, an important component of treatment is to decrease this overreaction to such sensations.

By experiencing the feared sensations repeatedly in a controlled way, the patient will begin to separate the experience of physical sensations from the anxiety he feels about the sensations.

He will begin to learn that the sensations he has been experiencing during panic attacks are not dangerous or harmful.

Therefore, anxiety about such sensations should steadily decrease over time, given the harmless nature of the sensations being experienced.

Symptom Induction Exercises

Proceed through each exercise according to the following steps: Briefly demonstrate the exercise. Inform the patient of the duration of the exercise (ranging from 30 seconds to 2

minutes). Have the patient engage in the exercise for the specified duration unless he wants to

stop sooner. If this occurs, encourage (but do not force) him to try the exercise again. If the patient refuses to do an exercise despite encouragement, allow him to do so but inform him that an important goal of treatment is for him to be able to engage in the exercise without fear. Thus, at some point, it will be important for him to practice the exercise.

After the exercise, obtain the following information and record: an objective description of the sensations experienced by the patient during the

exercise. a rating (0–10) of the intensity of the patient’s sensations during the exercise a rating (0–10) of the intensity of anxiety during the exercise a rating (0–10) of the degree of similarity between the sensations experienced during

the exercise and those experienced during the patient’s naturally occurring panic attacks

Allow the sensations to at least partially diminish prior to initiating the next exercise.

Specific Exercises

Shake head from side to side (does not need to be done quickly) for 30 seconds.

Place head between knees for 30 seconds, then quickly lift to an upright position (the patient should experience sensations when the head is lifted).

Run in place for 1 minute. Hold breath for 30 seconds. Tense muscles throughout the body for 1 minute or hold

a pushup position for as long as possible. Spin in a chair (relatively quickly) for 1 minute. Hyperventilate for 1 minute. Breathe through a thin straw (e.g., a coffee stirrer straw)

for 2 minutes with nostrils held together.

Individually Tailored Interoceptive Exposure Exercises

If none of the above symptom-induction exercises produced sensations at least moderately similar to those that occur during natural panic attacks, individually tailored exercises should be attempted.› Chest Pain: Take in a very deep breath and then

hyperventilate.› Heat and Sweat: Sit in a very hot room (space heaters may

be helpful).› Throat Tightness: Tie a tight scarf, necktie, collar, or the like

around the neck.› Choking: Place a tongue depressor on the back part of the

tongue or place a finger toward the back of the mouth.› Depersonalization: Stare at a bright light for 1 minute and

then read a short paragraph. Alternatively, stare at one’s hand for 3 minutes.

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Diaphragmatic Breathing Retraining Protocol for Cognitive Therapy of Panic

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Diaphragmatic Breathing Retraining Protocol for Cognitive Therapy of Panic

Session 6Situational Exposure

Review assigned reading and homework Explain rationale for exposure Deal with patient’s resistance to exposure Complete Fear and Avoidance Hierarchy

form Conduct in-session situational exposure Plan for situational exposure Assign homework

Benefits of Facing Fears

when a person repeatedly faces a feared situation, three important things happen from the standpoint of panic disorder (PD):

Patient’s thoughts about the dangerousness of the situation and her ability to cope with it change for the better. This reduces anxiety.

Conditioned fear reactions to the situation are weakened and new, healthier associations are created.

Avoidance and consequent impairment are eliminated. Because avoidance reinforces fear, this interrupts the panic cycle at the behavioral level.

Fear and Avoidance Hierarchy

rank ordering 10 situations that she tends to avoid due to fear of having a panic attack.

The situations should be those that the patient could reasonably practice during the course of treatment.

Some exposures will be completed by the patient with the therapist, others by the patient alone, & still others will be completed by the patient with her parents.

In-Session Situational Exposure

Try to start with something near the office, so there is less time for anticipatory anxiety to build.

For the same reason, try not to give away what you will be doing until you get there.

It is best to start with something that is more difficult to escape (e.g., taking an elevator as opposed to driving) as a first exposure.

Session 7Safety Behaviors & Exposures


Review safety behaviors Discuss rationale for eliminating safety

behaviors List patient’s safety behaviors Plan for situational exposure Conduct situational exposure Assign homework

Safety Behaviors

Safety behaviors are things a person does to make him feel safer or less anxious in a situation or to reduce uncomfortable sensations.

These include:› distracting oneself› carrying or taking medication› doing relaxation or slow breathing› having to be with someone› bringing along a water bottle, cell phone, etc.

Session 8-10Exposure Sessions

Review homework exposures Review the patient’s Fear and

Avoidance Hierarchy form Review the exposure procedure Conduct exposures Troubleshoot for extreme emotions &

delaying tactics Plan for homework exposures Assign homework

Anger

Warn the patient that when people feel cornered, the fight-or-flight system switches from the escape mode (flight) to defense (fight).

When that happens, people often notice it as anger.

It is likely that the patient will feel anger with you at times during the next couple weeks.

That is good, because it means that she is pushing herself to the limit of her fear, which is where the most progress will be made.

Conducting Exposures

Exposures will be more beneficial to the extent that they are› more difficult,› done without any avoidance or safety behaviors,› continued until anxiety and fear subside,› done more often, and› accompanied by more intense panic-like

sensations. Your goal for these sessions is to assist the

patient in doing as many exposures from her hierarchy as possible.

Conducting ExposuresGeneral Guidelines

Be supportive and warm, but firm. You should convey a sense of confidence that the patient will succeed,

Before each exposure, ask the patient to predict what will happen.

If the patient did anything to make herself feel less anxious or safer, or to reduce scary sensations, then she should do the exposure again without that behavior.

If the patient can think of anything that would make her feel more anxious or less safe, or would increase scary sensations, then she should do the exposure again with those thoughts in mind.

During exposures, keep conversation to a minimum.

Conducting Exposures General Guidelines (cont.)

After each exposure:› Praise the patient for her accomplishment› Review the patient’s anxiety ratings (it may be

helpful to graph these)› If the patient habituated, use that as

evidence that facing anxiety results in a decrease in anxiety

› If the patient did not habituate, examine the reasons (e.g., exposure not long enough, subtle avoidance behaviors, repeatedly scaring self )

Graded In Vivo Exposure

Interoceptive exposure

Naturalistic exposure

In-vivo exposure

Interoceptive exposure

Straw breathing Headrolling/spinning Stair running Hyperventilation Hand staring Throat constriction

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Symptom Induction Exercises Commonly Used in the Treatment of Panic Disorder

Clinical Example

Miss H presented with fairly extensive avoidance of external situations because of her fear of panic attacks and of being too distant from a hospital in case she suffered a heart attack or episode of suffocation. A fear hierarchy was constructed involving 23 situations ranging from taking a bus trip to a nearby city (rated 10 on a scale of 0–100) to taking a transcontinental flight (rated 100). Helen engaged in repeated exposure to a variety of situations on her fear hierarchy, gathering evidence against her most feared outcomes, and confirming the role of catastrophic thinking in the genesis of panic. Furthermore, the exposure suggested more benign, alternative explanations for her physical sensations, thereby enhancing her ability to reappraise unwanted feelings and sensations.

Naturalistic exposure

Caffeine Alcohol Exercise Sex Sauna/whirlpool Suspense/scary movies Getting overheated

Showering with the door closed Amusement park rides Eating certain foods Sugar Allowing self to become hungary

In-vivo exposure

Common situations include bridges, malls, theatres

Use Mobility Inventory to assist in hierarchy construction

Watch for use of safety signals

Safety signals

Medication Cell phone Vomit bag Paper bag for rebreathing Alcohol Water Comfort person

Session 11Relapse Prevention & Therapy Termination

Review homework exposures Re-rate FAH form Revisit treatment goals & accomplishments Help patient develop a practice plan Assess the cost of improvement Prepare the patient for symptom

fluctuations Plan for symptom increases Terminate therapy

Assessing the Cost of Improvement

Assist the patient to: Identify costs of improvement that

could undermine his recovery Weigh those costs against the benefits

of improvement Make a conscious decision to pay the

costs

Preparing for Symptom Fluctuations

To identify and assist the patient to restructure any unrealistic thoughts he has about the experience of symptoms in the future

To distinguish among expected symptom fluctuations, a lapse, & a relapse

To decatastrophize symptom increases To help the patient to begin working on a

plan for coping with symptom increases

Encouraging Appropriate Expectations

How do you think things will go in the next several months?

How confident are you that you will be able to maintain or extend your improvement?

Do you anticipate any difficulties?

Encouraging Appropriate Expectations

The thoughts you are looking for fall into two broad categories:

Unrealistically optimistic expectations (e.g., never have another panic attack; never be anxious in situations again; no setbacks)

Worry about relapsing (e.g., lack of confidence about managing anxiety or panic; expectation that minor stress could undo all of his gains; belief that he will have to struggle with anxiety the rest of his life)

Symptom Fluctuation, Lapse, and Relapse

Periods of stress. Anxiety and panic attacks often begin during a period of stress, and increases in stress can make them worse. Stressful times require more skill and effort to maintain improvement and are times when symptom breakthroughs or increases are more likely to occur.

Symptom Fluctuation, Lapse, and Relapse

During illness or as an effect of medications. Aside from being stressful in general, illnesses have the added dimension of causing anxiety-related symptoms of their own. Some illnesses cause symptoms the patient may associate with panic or anxiety (e.g., a cold can cause chest tightness and breathlessness; an ear infection, dizziness; the flu, weakness and hot flushes). In addition, some medications (e.g., decongestants) and substances like caffeine have stimulating effects that may cause sensations like anxiety.

Relapse Prevention

Distinguish among: › (1) expected normal symptom fluctuations,› (2) a lapse or setback, and › (3) a relapse.

Expected Symptom Fluctuations

The experience of anxiety during stressful periods, and even occasional panic attacks, are therefore normal and, provided the patient does not misinterpret or overreact to them, are not reasons for concern.

patients who make it to maintenance therapy may have residual maladaptive thoughts and behaviors that give rise to symptom fluctuations that are greater than most people experience.

Lapse or Setback

a “lapse” is a slip or partial loss of improvement. may be conceptualized as increases in

symptoms beyond expected fluctuations or an increase in avoidance or functional impairment due to panic-related concerns.

Lapses may be due to situational or internal stressors or may simply be due to lack of practice of anxiety management skills.

Just as pounds can creep back on when a person cheats on a diet, symptoms can reemerge when the patient neglects practicing coping skills.

Relapse

a full and persistent return of symptoms or avoidance to pretreatment levels or higher.

Again, relapses typically begin as lapses that are not addressed and can be prevented if the patient applies effective coping strategies in high-risk situations & when lapses occur.

Decatastrophizing Symptom Increases

Explain that symptom fluctuations, and even occasional lapses, are common & should be anticipated.

Catastrophic thoughts about them should be handled using the cognitive countering techniques learned during treatment.

Encourage the patient to view symptom increases as reminders as well as opportunities to practice and sharpen skills that he learned during treatment.

Terminate Therapy

At the end of the session, congratulate the patient on completing the treatment.

Praise him for his accomplishments and acknowledge the efforts he made.

Be sure to tell the patient that it has been a pleasure working with him and that you are confident that he will continue to do well.

If the patient asks if he can call you if problems arise, say that if he feels unable to handle a situation on his own, he is welcome to call.

However, you are confident he can handle almost anything if he trusts in the skills he has learned. It is time now for him to be his own therapist.

THANK YOU

Health & Medicine

Cbt for panic disorder abasseya