Cognitive Therapy for Panic Disorder
For individuals in the U.S. & U.S. territories
In Cognitive Therapy for Panic Disorder, Dr. David M. Clark demonstrates a brief therapy for alleviating this debilitating anxiety disorder. Dr. Clark's approach is based on the idea that panic attacks are frequently the result of misinterpreting normal bodily sensations as a sign of an impending physical or mental catastrophe (such as a heart attack or going mad). The misinterpretation generates a feedback effect in which anxiety, physical symptoms, and negative thoughts reinforce each other. Several cognitive–behavioral techniques can help clients challenge their misinterpretations of bodily sensations. In this session, Dr. Clark works with a 38-year-old man who has experienced repeated panic attacks surrounding recurring sensations that he interprets as a heart attack.
This video features a client portrayed by an actor on the basis of actual case material.
The youngest of four, Greg was the first in his family to complete college and leave the small town in Pennsylvania where his family had worked in the textile mills for generations. When Greg was 9, his brother impregnated his high school girlfriend, dropped out of school, and went to work in the textile mills. Greg remembers his mother in tears saying, "Now, he'll never make it out of here." This reinforced Greg's resolve to do something different with his life. Greg's sisters graduated high school, married, and started families soon after. When Greg began high school, his mother worked part time to save money for his college tuition. Greg studied hard and won a partial scholarship to the University of Pennsylvania.
Socially, Greg was a loner and was particularly shy around girls. He finally dated in his junior year in college, but his girlfriend left him for a more outgoing person after 4 months. Greg was heartbroken and immersed himself even more deeply in his studies. When he graduated summa cum laude, he already had a job lined up as a programmer for a mortgage banking institution in a city 5 hours from home.
By age 28, Greg had become a systems analyst, making twice what his father had ever earned. He bought a home when he was 30 and discovered that, like his mother, he had a real talent for gardening. He was well-liked by acquaintances at work, but he never got to know anyone well.
When Greg was 33, he met his wife, Allie, who was 7 years younger than Greg and a new programmer in his department. Allie seemed so shy that Greg was able to overcome his introversion and ask her for a date. They soon discovered that they came from similar working-class backgrounds and shared the same dreams. Allie introduced him to cross-country skiing, and he introduced her to gardening; they both loved old movies. After a year of dating, they married. When Greg was promoted to systems designer, they decided to start a family. Allie soon became pregnant, and they now have two children: Mark, age 4; and Juliet, age 2. Initially, Allie stayed home with the children. She recently returned to work part time.
Greg and Allie enjoy parenting but find it difficult to juggle jobs and child care and still have time for themselves as a couple. Greg's company is downsizing, and he feels he must work long hours to secure his job. He comes home tired, later than Allie would like, and works on the computer when the children are in bed. Greg and Allie have begun to argue over little things for the first time, and their sexual relationship has become strained.
Greg experienced his first panic attacks 18 years ago at college. He had been working far into the night for several weeks to complete assignments and had been drinking more coffee than usual. In the week before the end of the semester he had had two attacks in which he noticed missed heartbeats, felt short of breath, began sweating, and was slightly dizzy. He was concerned that there might be something wrong with his heart. He had no further episodes during the school vacation and remained well until 8 months prior to seeking treatment from Dr. Clark.
Once again, Greg had been working long hours. He had had a rushed morning. When walking back from a colleague's office he noticed a tight feeling in his chest, and he felt slightly dizzy and unreal. Soon his heart was racing, the dizziness intensified, he felt short of breath, and he started to sweat. He thought he might be having a heart attack, sat down behind his desk, and hoped that the symptoms would go away. A brief image of Allie caring for the children on her own passed through his mind, and he thought of calling for an ambulance. However, the symptoms disappeared after 10 to 15 minutes. He was somewhat shaken but carried on the rest of the day's work.
Greg had his next panic attack when driving to visit his parents. He had not been looking forward to the trip as he would inevitably be drawn into discussions about his brother's current financial problems and what should be done about them. Allie did not want to make the trip, so he was traveling alone. On the interstate, he experienced another panic attack and immediately pulled over to the side of the road. A state trooper stopped and called for an ambulance. At the hospital, Greg was told that his heart was fine. The doctor in the emergency room recommended that Greg have a complete physical when he returned home.
Greg's next attack came a week later while he was walking in his neighborhood with the children. He felt breathless, dizzy, and his heart raced. He feared he was going to die or, at the very least, faint. When he arrived home, he immediately scheduled a physical with his internist. He was given a clean bill of health but was told to return if the attacks reoccurred.
He had another attack 2 weeks later on an overnight business trip. When he returned, he saw his internist, who suggested that his attacks might be stress related and referred him to a psychotherapist.
The therapist to whom he was referred was psychodynamically oriented. He focused on the underlying feelings Greg might be suppressing that finally erupted into panic attacks. For 2 months they explored Greg's feelings about his childhood and his current family. Greg discussed the difficulties Allie and he were having and reluctantly described his feelings of shame about being raised in poverty in the small town, feelings that were reactivated on his visits home. Greg also discussed his fears of being made redundant and not being able to provide properly for his own family. He shared that his father had been a binge drinker and that he thought that his brother might have an alcohol problem. He rarely drank alcohol, but he admitted to thinking about having a drink when the panic attacks occurred.
Greg found the sessions stressful, and he was impatient with the therapy as he continued to have at least two panic attacks a week. When the therapist suggested that he take medication for the symptoms while they worked on the underlying reasons for the anxiety, Greg balked. He felt that taking medication was for "crazy people," and he dropped out of therapy.
The attacks persisted and became more frequent, and Greg became concerned that they were interfering with his work. More than one colleague had mentioned that he did not seem his usual self. When he told his internist that the psychotherapy had not helped, the internist consulted with a colleague, who suggested that Greg try another therapist and then referred Greg to Dr. Clark.
- What is your impression of Greg?
- How typical or atypical are his life experiences and his current behavior?
- What do you believe are the core issues for Greg?
- What is the utility of these initial formulations?
- Before reading the next section, what topics and issues do you think will be addressed in the initial sessions?
Intake Interview: Greg was seen in Dr. Clark's clinic a few days after his visit with his internist for a diagnostic interview with an intake worker, who confirmed that he was experiencing panic disorder. Greg volunteered that he had some marital difficulties but felt that he and his wife could resolve these if the panic attacks could be brought under control. Greg was instructed to keep a diary of the situations in which his attacks occurred, what his symptoms were, and what he thought about during the attacks. He was asked to bring the diary to the first session.
Session 1: The first treatment session with Dr. Clark focused on obtaining more information about what happened during Greg's attacks and how he responded to them. At the time of the referral, Greg was having approximately three panic attacks a week. His main thoughts during the attacks (with belief ratings) were as follows:
- I am having a heart attack (100%)
- I am about to die (90%)
- I will faint (50%)
- I am going crazy (30%)
- People will notice that I am anxious (25%)
The main feared sensations were palpitations, a tight feeling in the chest, dizziness, shortness of breath, and feelings of unreality. During the attacks, Greg did a number of things to try to stop the things he was afraid of from happening (i.e., safety behaviors). These included sitting down and resting, monitoring his heart beat, and taking deep breaths.
Dr. Clark asked if, because of the panic attacks, Greg was avoiding any activities in which he used to be involved. Greg admitted that he had previously exercised at the gym three times a week and enjoyed jogging on the weekends. Since the attacks, he had completely stopped exercising, fearing that it might provoke another attack. He also avoided sex if he felt at all tired as he feared it may put an undue strain on his heart.
Dr. Clark and Greg reviewed the most recent panic attack and derived a vicious circle model on a white board. They also reviewed the diary that Greg had kept, and they discovered that although there was a wide range of triggers for his attacks (stress, anger, excitement, tiredness, mind wandering), these triggers all had the effect of producing mild sensations that Greg noticed and then thought, "Maybe there is something physically wrong with me." This thought would then activate the vicious circle, and his symptoms would intensify. Greg left the session relieved that this therapy focused on what actually occurred during his panic attacks and how he might be contributing to them.
Session 2: To be viewed
- Was the initial session as you expected?
- As you read this summary of the preceding session, were there any areas or topics that you thought should have been covered but were not?
- What other information would you seek to assess the patient?
- Before viewing the tape, what do you think will unfold in the taped session?
- What issues will be discussed?
- What will the relationship between Dr. Clark and Greg be like?
Stimulus Questions About the Videotaped Session
During the first few minutes of the session, Dr. Clark reviews the vicious circle model of Greg's panic attacks developed in the previous session and presents the circle on a whiteboard.
- What is the purpose of the review?
- How will it guide therapy?
- What are the advantages and disadvantages of drawing the vicious circle on a whiteboard?
- How might it differ from a simple verbal explanation or from drawing the circle on a piece of paper?
After about 8 minutes, Greg admits to becoming anxious in the session.
- How does Dr. Clark use this event in therapy?
- How might psychotherapists from other theoretical orientations respond to this event?
Approximately 18 minutes into the session, Dr. Clark asks Greg to read some pairs of words, such as palpitations–dying, which represent the kind of thoughts that go through Greg's mind during his panic attacks. Dr. Clark does not inform Greg in advance that he is likely to experience some of his panic symptoms while reading the pairs of words.
- What are some reasons for not informing Greg of the likely increase in his panic symptoms?
- How would you have responded to this lack of disclosure if you were a client?
About 27 minutes into the session, Greg mentions that one of the reasons he thinks there may be something wrong with his heart is the fact that he experiences pain on his left side during his attacks. Dr. Clark then shows Greg a picture of three groups of patients and where they typically locate pain in their bodies. He points out that Greg's pain closely resembles that reported by the anxiety patients and is quite different than that reported by the cardiac patients.
- How did you respond to this information?
- What are the advantages and disadvantages of sharing factual information in this manner?
- How might this effect the therapeutic process as compared with a simple clarification or disputation of Greg's misinterpretation of his pain as indicative of cardiac involvement?
After about 40 minutes, Dr. Clark and Greg leave the office to do some exercises and running outside.
- What is the goal of this "experiment"?
- Why does Dr. Clark accompany Greg?
- Under which circumstances would you respect a patient's fear and self-determination in declining participation in the experiment?
- Would you, as a therapist, feel comfortable taking a patient to a public setting during a session?
- Some people would argue that this method is simply interoceptive exposure in the behavioral tradition. Do you agree or disagree?
- What make this approach cognitive?
At several points throughout the session, Greg is asked to rate, on a 100-point scale, how much he believes he will die during a panic attack. He is also asked to rate, on a similar scale, how much he believes the panic symptoms are the result of cardiac disease.
- What purposes do these ratings serve during psychotherapy?
- How would you decide how often and when to request ratings during a session?
- Would you insist on a specific numerical rating or would you be as satisfied with a general verbal description of the patient's experience?
Over the course of the session, Dr. Clark reviews Greg's previous episodes of panic and creates several "experiments" to test the two competing ideas of hypotheses about the cause of Greg's panic attacks—cardiac disease or fear and anxiety. Together, Dr. Clark and Greg collect evidence and evaluate that evidence in terms of the two ideas.
- What is potentially gained and lost through this gradual process of gathering and evaluating evidence as compared with more direct or confrontational approaches?
- How does Dr. Clark's method enhance the therapeutic alliance with Greg?
In this session illustrating the treatment of panic disorder, Dr. Clark is typically perceived as a calm, respectful, and cerebral therapist who uses Socratic questioning, psychoeducational materials, in vivo "experiments," and a collaborative stance.
- As a therapist, how comfortable are you with this style of psychotherapy?
- As a client, how would you respond to this style?
- Would your responses be the same if you were being treated for a different disorder?
- Did the session progress as you anticipated?
- Was Greg as you expected? Was Dr. Clark?
- What are your general reactions to the session?
- What did you feel was effective in the therapy?
- What do you think were the strengths and the weaknesses of this approach?
- If you were not informed that this is "cognitive therapy" what would you have called it?
- What do you think makes this distinctly "cognitive"?
- Now, after reading about the patient and viewing this session, what are your diagnostic impressions or characterizations of his problem?
- How would you proceed with Greg's therapy?
- What goals would you set?
- How many sessions do you think it would take to achieve these goals?
- Would you consider offering to include Allie in some future sessions? If so, why?
- What would your goals be?
Cognitive therapy for panic is a relatively brief (8–15 sessions) treatment derived from the cognitive theory of panic disorder. According to this theory, individuals who experience repeated panic attacks do so because they have a relatively enduring tendency to misinterpret benign bodily sensations as indications of an immediately impending physical or mental catastrophe. For example, palpitations may be interpreted as evidence of an impending heart attack. This cognitive abnormality is said to lead to a "positive" feedback loop in which misinterpretations of body sensations produce increasing anxiety. This in turn strengthens sensations, producing a vicious circle that culminates in a panic attack.
Treatment starts by reviewing with the patient a recent panic attack and deriving an idiosyncratic version of the panic vicious circle. Once patient and therapist have agreed that panic attacks involve an interaction between bodily sensations and negative thoughts about the sensations, a variety of cognitive and behavioral procedures are used to help patients challenge their misinterpretations of the sensations.
The cognitive procedures include identifying observations that are inconsistent with the patient's beliefs, educating the patient about the symptoms of anxiety, and modifying anxiety-related images. The behavioral procedures include inducing feared sensations (by hyperventilation), focusing attention on the body or reading pairs of words (representing feared sensations and catastrophes) to demonstrate possible causes of patients' symptoms, and stopping safety behaviors (such as holding on to solid objects when feeling dizzy) to help patients disconfirm their negative predictions about the consequences of their symptoms.
As with cognitive therapy for other disorders, treatment sessions are highly structured. An agenda is agreed on at the start of each session, and repeated belief ratings are used to monitor within-session cognitive change. In addition, frequent summaries are used to guarantee mutual understanding. At the end of each session, a series of homework assignments are agreed on as well.
Controlled trials in the United States, England, Germany, the Netherlands, and Sweden (see Clark, 1997, for a review) show that cognitive therapy is an effective treatment for panic disorder. Intention-to-treat analyses indicate 74% to 94% of patients become panic free, and the gains are maintained at follow-up. The effectiveness of the treatment does not appear to be entirely due to nonspecific therapy factors, as three trials have found cognitive therapy to be superior to alternative, equally credible, psychological interventions.
Dr. Clark identifies his approach as cognitive therapy. What does this imply to you? More specifically, what do you expect of him? Will Dr. Clark be active or passive? Will the session be structured or unstructured? Directive or nondirective? Will it focus on the past or on the present? Will the session focus on behaviors, on thoughts, or on feelings? What do you expect to be the relative balance between attention to technique versus the interpersonal interaction?
David M. Clark, DPhil, is currently professor of psychiatry and Wellcome Trust Principal Research Fellow at the University of Oxford, England. He studied experimental psychology at Oxford University, where he received his BA and DPhil. He completed his clinical training at the Institute of Psychiatry (London University), where he received an MPhil in clinical psychology.
His first appointment was as lecturer in clinical psychology at Oxford. Other posts have included president of the British Association of Behavioral and Cognitive Therapies (1992), president of the International Association of Cognitive Psychotherapy (1992–1995), and visiting professor of psychology at the University of Pennsylvania (1991) and City University, London (1992–1995).
Awards have included the May Davidson Award (British Psychological Society) and the Behaviour Research and Therapy award for his article titled "A Cognitive Approach to Panic," which was considered the most outstanding article published in that journal between 1965 and 1990.
Dr. Clark's research has focused on the effects of mood on information processing and on the role of cognitive factors in the development, maintenance, and treatment of anxiety disorders. In researching anxiety disorders, his strategy has been to use patient interviews and experimental and correlational studies to identify the core cognitive abnormality in a disorder and the factors that normally prevent cognitive change. A specialized form of cognitive therapy that focuses on the core abnormality and its maintaining factors is then developed and evaluated in controlled trials.
In collaboration with other researchers, this strategy has helped produce new, effective cognitive–behavioral treatments of panic disorder and hypochondriasis. This strategy is currently being applied to two other anxiety disorders—social phobia and posttraumatic stress disorder. In addition to many journal articles and book chapters, Dr. Clark has coedited two books on cognitive behavior therapy: Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide (1989) and Science and Practice of Cognitive Behaviour Therapy (1997).
- Barlow, D. H., & Craske, M. G. (1989). Mastery of your anxiety and panic. Albany, NY: Greywind.
- Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety disorders and phobias. New York: Basic Books.
- Clark, D. M. (1986). A cognitive approach to panic disorder. Behaviour Research and Therapy, 24, 461–70
- Clark, D. M. (1997). Panic disorder and social phobia. In D. M. Clark & C. G. Fairburn (Eds.), Science and practice of cognitive behaviour therapy (pp. 121–153). New York: Oxford University Press.
- Clark, D. M., Salkovskis, P. M., Hackmann, A., Middleton, H., Anastasiades, P., & Gelder, M. G. (1994). A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. British Journal of Psychiatry, 164, 759–769.
- Ehlers, A., & Breuer, P. (1992). Increased cardiac awareness in panic disorder. Journal of Abnormal Psychology, 101, 371–382.
- McNally, R. J. (1994). Panic disorder: A critical analysis. New York: Guilford Press.
- Salkovskis, P. M. (1991). The importance of behaviour in the maintenance of anxiety and panic: A cognitive account. Behavioural Psychotherapy, 19, 6–19.
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