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Cbt for panic disorder abasseya
 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.
   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 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.
   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
   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.
   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.
   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.
 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.”
 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.
   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.
 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.
   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.
   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,
   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
 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.
   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)
Cbt for panic disorder abasseya
   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.
Cbt for panic disorder abasseya
Alarm reaction             Uh-oh reaction
  Heart rate               What’s wrong?!?
  sweating                 What’s happening?
  dizziness                What if I…
  depersonalization        ..have a heart attack?
  sob                      ..embarrass myself?
  chest pain               ..go crazy?
  etc.                     ..lose control?
                                    memories


        Increased bodily
        sensations
                           Anxiety/fear
                           hurry up/tense up
                           (get out)
Links between Panic-Relevant Internal Sensations &
Their Corresponding Physiological or Mental Threat Schema
 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
 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.
 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.
   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 abasseya
   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
   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)
Cbt for panic disorder abasseya
 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
Cbt for panic disorder abasseya
Cbt for panic disorder abasseya
Cbt for panic disorder abasseya
   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.
   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.
 Review assigned reading and homework
 Discuss the physiological component of
  anxiety
 Conduct hyperventilation exercise
 Discuss physiology of hyperventilation
 Conduct slow breathing exercise
 Assign homework
 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.
 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.
 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.
   Diaphagramatic Breathing

   Progressive Muscle Relaxation

   Cued Relaxation
   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.
   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.
 Review assigned reading and homework
 Discuss the cognitive component of
  anxiety
 Introduce probability overestimation
 Introduce catastrophic thinking
 Practice monitoring anxiety/panic
  triggers and thoughts
 Assign homework
 Overestimating
Definition: Overestimating the probability of
  something negative happening
Eg: 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.
   Catastrophizing
    Definition: 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?
What if I faint?     What if I faint?

I’ll make a fool of
        myself        I won’t wake up

Catastrophizing
                      Overestimating
Cbt for panic disorder abasseya
   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
   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?”
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 include:
    › Going Crazy
    › Losing Control
    › Nervous Collapse or Fainting
    › Heart Attack
    › The Panic Attack Will Never End
 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
 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.
 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).
   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)
   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.
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.
   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.
   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.
Diaphragmatic Breathing Retraining Protocol for Cognitive Therapy of Panic
Diaphragmatic Breathing Retraining Protocol for Cognitive Therapy of Panic
 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
   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.
 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.
 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.
 Review assigned reading and homework
 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 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.
 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
 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.
   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.
   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.
   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 )
   Interoceptive exposure

   Naturalistic exposure

   In-vivo exposure
 Straw breathing
 Headrolling/spinning
 Stair running
 Hyperventilation
 Hand staring
 Throat constriction
Symptom Induction Exercises Commonly Used in the Treatment of Panic Disorder
   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.
   Caffeine                Showering with the
   Alcohol                  door closed
   Exercise                Amusement park
   Sex                      rides
   Sauna/whirlpool         Eating certain foods
   Suspense/scary          Sugar
    movies                  Allowing self to
   Getting overheated       become hungary
   Common situations include
    bridges, malls, theatres

   Use Mobility Inventory to assist in
    hierarchy construction

   Watch for use of safety signals
 Medication
 Cell phone
 Vomit bag
 Paper bag for rebreathing
 Alcohol
 Water
 Comfort person
   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
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
 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
   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?
 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)
   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.
   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.
   Distinguish among:
    › (1) expected normal symptom fluctuations,
    › (2) a lapse or setback, and
    › (3) a relapse.
 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.
   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.
 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.
 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.
   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.
Cbt for panic disorder abasseya

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Cbt for panic disorder abasseya

  • 2.  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.
  • 3. 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
  • 4.  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.
  • 5. 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
  • 6. 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.
  • 7. 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.
  • 8. 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.
  • 9.  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.”
  • 10.  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.
  • 11. 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.
  • 12.  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.
  • 13. 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.
  • 14. 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,
  • 15. 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
  • 16.  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.
  • 17. 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)
  • 19. 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.
  • 21. Alarm reaction Uh-oh reaction Heart rate What’s wrong?!? sweating What’s happening? dizziness What if I… depersonalization ..have a heart attack? sob ..embarrass myself? chest pain ..go crazy? etc. ..lose control? memories Increased bodily sensations Anxiety/fear hurry up/tense up (get out)
  • 22. Links between Panic-Relevant Internal Sensations & Their Corresponding Physiological or Mental Threat Schema
  • 23.  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
  • 24.  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.
  • 25.  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.
  • 26. 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.
  • 28. 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
  • 29. 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)
  • 31.  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
  • 35. 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.
  • 36. 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.
  • 37.  Review assigned reading and homework  Discuss the physiological component of anxiety  Conduct hyperventilation exercise  Discuss physiology of hyperventilation  Conduct slow breathing exercise  Assign homework
  • 38.  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.
  • 39.  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.
  • 40.  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.
  • 41.  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.
  • 42.  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.
  • 43. Diaphagramatic Breathing  Progressive Muscle Relaxation  Cued Relaxation
  • 44. 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.
  • 45. 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.
  • 46.  Review assigned reading and homework  Discuss the cognitive component of anxiety  Introduce probability overestimation  Introduce catastrophic thinking  Practice monitoring anxiety/panic triggers and thoughts  Assign homework
  • 47.  Overestimating Definition: Overestimating the probability of something negative happening Eg: 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.
  • 48. Catastrophizing Definition: 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?
  • 49. What if I faint? What if I faint? I’ll make a fool of myself I won’t wake up Catastrophizing Overestimating
  • 51. 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
  • 52. 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?”
  • 53. 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?”
  • 54. Myths include: › Going Crazy › Losing Control › Nervous Collapse or Fainting › Heart Attack › The Panic Attack Will Never End
  • 55.  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
  • 56.  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.
  • 57.  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).
  • 58. 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)
  • 59. 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.
  • 60. 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.
  • 61. 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.
  • 62. 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.
  • 63. Diaphragmatic Breathing Retraining Protocol for Cognitive Therapy of Panic
  • 64. Diaphragmatic Breathing Retraining Protocol for Cognitive Therapy of Panic
  • 65.  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
  • 66. 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.
  • 67.  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.
  • 68.  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.
  • 69.  Review assigned reading and homework  Review safety behaviors  Discuss rationale for eliminating safety behaviors  List patient’s safety behaviors  Plan for situational exposure  Conduct situational exposure  Assign homework
  • 70. 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.
  • 71.  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
  • 72.  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.
  • 73. 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.
  • 74. 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.
  • 75. 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 )
  • 76. Interoceptive exposure  Naturalistic exposure  In-vivo exposure
  • 77.  Straw breathing  Headrolling/spinning  Stair running  Hyperventilation  Hand staring  Throat constriction
  • 78. Symptom Induction Exercises Commonly Used in the Treatment of Panic Disorder
  • 79. 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.
  • 80. Caffeine  Showering with the  Alcohol door closed  Exercise  Amusement park  Sex rides  Sauna/whirlpool  Eating certain foods  Suspense/scary  Sugar movies  Allowing self to  Getting overheated become hungary
  • 81. Common situations include bridges, malls, theatres  Use Mobility Inventory to assist in hierarchy construction  Watch for use of safety signals
  • 82.  Medication  Cell phone  Vomit bag  Paper bag for rebreathing  Alcohol  Water  Comfort person
  • 83. 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
  • 84. 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
  • 85.  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
  • 86. 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?
  • 87.  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)
  • 88. 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.
  • 89. 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.
  • 90. Distinguish among: › (1) expected normal symptom fluctuations, › (2) a lapse or setback, and › (3) a relapse.
  • 91.  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.
  • 92. 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.
  • 93.  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.
  • 94.  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.
  • 95. 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.