Cognitive Therapy for Panic

Common to all anxiety disorders are irrational thoughts (cognitions) which are generally characterised by being automatic, involuntary, distorted, unhelpful yet superficially plausible. The content differs for each condition, although overlap does exist, but commonly includes catastrophisation, fear of internal or external disaster, fear of ill health or personal vulnerability, automatic assumption of danger. These thoughts are common in anxiety and phobic disorders and treatment needs to address the negative thoughts present during the panic attack (usually catastrophic thoughts of impending death or ill health), the thoughts associated with anticipatory anxiety when people are about to go into a situation where they fear a panic attack and finally thoughts linked to incomplete resolution of panic disorder and residual symptoms. It needs to be stressed that Panic Disorder is not so much a disorder of physical symptoms, but a disorder marked by misinterpretation of the importance of these symptoms.

Thinking errors can be effectively identified, evaluated, controlled and modified by cognitive therapy techniques in many cases. Most cognitions associated with panic and phobic disorders can be challenged effectively in contrast to the obsessions of OCD and thoughts in patients with severe comorbid depression which are very resistant. The process involves:

  • Becoming aware of negative thoughts - diary.

  • Answering/challenging negative thoughts.

  • Action to test negative thoughts and build up a body of contrasting evidence.

The use of pen and paper techniques is probably best either with the RET model of Ellis (ABC) or the dysfunctional thought record of Beck. David Burns' book "Feeling Good" gives simple instructions on the use of such techniques to identify and challenge negative and dysfunctional thoughts. The final step involves behavioural experiments to build up a body of evidence to convince the patient that these thoughts are incorrect.

Exposure Therapy for Panic
Graded Exposure

In theory, phobias can be overcome by facing the things that are feared. Treatment for both agoraphobia and social phobia involves reversing the vicious cycle by which a certain situation and anxiety were first linked, then the link consolidated by anticipatory anxiety and eventually avoidance. What has been learned must be unlearned and this is done by gradually re-introducing the patient to the situation in a slow and steady manner.

A detailed list of avoided or feared situations is constructed and then ranked in order to form a hierarchy of severity. Exposure commences at the lowest point on the hierarchy and needs to be graduated, repeated, prolonged and tasks must be clearly specified in advance. Tasks should be approachable and produce some anxiety but not excessive amounts. The patient needs to learn that they can "wait out" the anxiety, which naturally decays to lower levels over time. All exposure tasks require exposure until anxiety decreases significantly, usually 5 to 45 minutes is required but occasionally this may take some hours. Useful additional methods may include relaxation, distraction and challenging thoughts.

Interoceptive Exposure

A key aspect in the development of the panic attack is the cognitive misinterpretation placed on the physiological symptoms. The patients have an expectation of danger, medical catastrophe and/or a loss of control as has been demonstrated in the illustrated panic cycle. It needs to be emphasised that the physiological symptoms experienced are similar to those experienced in everyday situations such as exercise and excitement for any reason. Interoceptive exposure involves the controlled exposure to these symptoms in order to demonstrate to the patient that these symptoms are tolerable and not the harbingers of medical disaster.

Interoceptive exposure involves the careful production of symptoms followed by the control and then reduction of symptoms with techniques such as slow breathing and cognitive challenging/cognitive therapy. A good example is the production of panic symptoms by hyperventilation or running on the spot which often produce shortness of breath, palpitations, dizziness, derealisation and depersonalisation symptoms. After the patient produces these symptoms by hyperventilating for a short period of time, i.e. 15-30 seconds, the symptoms are controlled by slow breathing until they settle. The person then gradually increases the amount of hyperventilation as their tolerance to smaller amounts increases, resulting eventually in decreased reactivity to hyperventilation, the symptoms themselves and decreased cognitive misinterpretation the symptoms. This can be a frightening technique initially and should be firstly done with a therapist or helper before subsequently performing the activity alone. It can later be introduced to day-to-day life and maybe even into threatening situations to further improve the person's ability to tolerate these physiological symptoms without catastrophic misinterpretation.

My Experience with OCD

By Lori P, age 12

OCD has been a struggle from the very beginning.  It started 2 years ago.  My mom noticed it when I wouldn't wear half the clothes in my dresser.  I was scared that the colours black and red represented death.  I worried about death a lot.  I worried that my parents would die, mostly my mom.  I thought things that I did would make them die.  That anxiety passed, but then, I started to worry about chemicals.  I couldn't touch the outside of chemical bottles without washing my hands.  I washed my hands so much that I had big red blisters on all of my knuckles.  Tapping was a big part of my life.  I had to tap a certain amount of times until I felt safe.

The first thing we did to help make my OCD go away was go to a psychiatrist and have her officially diagnose me. That day she prescribed medication for me.  I also saw an art therapist for about a year, which helped very little.  It was not the art therapy, it was just the therapist.  At the same time they put me on a high dose of medication.  We soon realised the dose was too high because I developed aggression.  As soon as the dose was lowered, the aggression went away.

Finally, I went to see Tamar Chansky in Philadelphia.  We drove from Baltimore every other Friday to visit her.  I spent two hours every visit doing exposure and response prevention therapy.  Anything I worried about we would do something to help me stop worrying about it.  Everything Tamar did I did.  When I was worried about dirt we would run in the mud and come back and lick our shoes.  We scrubbed her basement sink with Comet, didn't wash our hands and then ate lunch.  When I would go home I would have homework.  I would have to do the same things every day for two weeks.

Going to Tamar’s has really helped my OCD and made me feel much better.  I trust her.  Now I see her every three months.  I still worry about some things.  Like, is it OK if I don't wash my hands after cleaning?  It mostly comes back when I am tired.  When my OCD comes back I do exposure and response just like I do with Tamar.  My OCD is not in control of my life and I am much happier.