Mastery of Your Anxiety and Panic: Therapist Guide 019531140X, 9780195311402

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Mastery of Your Anxiety and Panic

-- David H. Barlow, PhD    Anne Marie Albano, PhD Jack M. Gorman, MD Peter E. Nathan, PhD Paul Salkovskis, PhD Bonnie Spring, PhD John R. Weisz, PhD G. Terence Wilson, PhD

Mastery of Your Anxiety and Panic FOURTH EDITION

T h e r a p i s t

G u i d e

Michelle G. Craske • David H. Barlow

1 

1 Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam

Copyright ©  by Oxford University Press, Inc. Published by Oxford University Press, Inc.  Madison Avenue, New York, New York  www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Craske, Michelle Genevieve, ‒ Mastery of your anxiety and panic : therapist guide / Michelle G. Craske and David H. Barlow. —th ed. p. cm.—(Treatments that work) Includes bibliographical references. ISBN- ---- ISBN ---X . Panic disorders—Treatment. . Anxiety disorders—Treatment. I. Barlow, David H. II. Title. [DNLM: . Anxiety Disorders—therapy. . Panic Disorder—therapy. . Agoraphobia—therapy. . Psychotherapy—methods. WM  Cm ] RC.B  .⬘—dc 

         Printed in the United States of America on acid-free paper

About TreatmentsThatWork ™

Stunning developments in healthcare have taken place over the last several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine have been brought into question by research evidence as not only lacking benefit but, perhaps, inducing harm. Other strategies have been proven effective using the best current standards of evidence, resulting in broad-based recommendations to make these practices more available to the public. Several recent developments are behind this revolution. First, we have arrived at a much deeper understanding of pathology, both psychological and physical, which has led to the development of new, more precisely targeted interventions. Second, our research methodologies have improved substantially, so that we have reduced threats to internal and external validity, making the outcomes more directly applicable to clinical situations. Third, governments, healthcare systems, and policymakers around the world have decided that the quality of care should improve, that it should be evidence based, and that it is in the public’s interest to ensure that this happens (Barlow, ; Institute of Medicine, ). Of course, the major stumbling block for clinicians everywhere is the accessibility of newly developed, evidence-based psychological interventions. Workshops and books can go only so far in acquainting responsible and conscientious practitioners with the latest behavioral healthcare practices and their applicability to individual patients. This new series, TreatmentsThatWork™, is devoted to communicating these exciting new interventions to clinicians on the frontlines of practice. The manuals and workbooks in this series contain step-by-step, detailed procedures for assessing and treating specific problems and diagnoses.

But this series also goes beyond the books and manuals by providing ancillary materials that will approximate the supervisory process in assisting practitioners in the implementation of these procedures in their practice. In our emerging healthcare system, the growing consensus is that evidence-based practice offers the most responsible course of action for the mental health professional. All behavioral healthcare clinicians deeply desire to provide the best possible care for their patients. In this series, our aim is to close the dissemination and information gap and thus make that possible. The Mastery of Your Anxiety and Panic, Fourth Edition (MAP–IV ), program updates, extends, and improves on the previous program in numerous ways. Among the major changes reflected in this revision is the incorporation of treatment for agoraphobic behavior; agoraphobia was addressed minimally in the previous Mastery of Your Anxiety and Panic, Third Edition (MAP–III ), because clients with moderate to severe agoraphobia were directed to the accompanying Client Workbook for Agoraphobia. First, in MAP–IV, the panic and agoraphobia workbooks have been combined. Second, the structure of the workbook has changed, so that each chapter represents a module of treatment rather than a session of treatment. This was done because of the recognition that clients vary dramatically in the pace at which they proceed through each part of the treatment. Third, relaxation training has been dropped from this edition since the evidence to date does not suggest that relaxation training as a stand-alone treatment is effective for panic disorder and agoraphobia or that it is more effective than breathing skills training. Fourth, breathing skills and thinking skills (i.e., cognitive restructuring) are now framed as skills to help clients move toward and face their fear and anxiety, as well as anxiety-producing situations; they are not intended to reduce fear and anxiety immediately. Fifth, the method by which exposure therapy is conducted, either to feared interoceptive cues (i.e., physical sensations) or feared external situations, is substantially changed, so that the focus is no longer on immediate fear reduction but instead on learning to withstand and tolerate fear and anxiety. The reasons for this change are detailed in later sections. Sixth, the chapter on medications and their interactions with cognitive behavioral therapy (the type of therapy that is described in MAP–IV ) is updated with the latest advances in issues per-

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taining to pharmacology. Finally, MAP–IV has been completely rewritten with a new and more accessible reading level to make it easier for all clients to understand. David H. Barlow, Editor-in-Chief, TreatmentsThatWork™ Boston, Massachusetts

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Contents

Chapter 

Introductory Information for Therapists 

Chapter 

The Nature of Panic Disorder and Agoraphobia 

Chapter 

Outline of Treatment Procedures and Basic Principles Underlying Treatment 

Chapter 

Introduction to the Program 

Chapter 

Learning to Record Panic and Anxiety 

Chapter 

Negative Cycles of Panic and Agoraphobia 

Chapter 

Panic Attacks Are Not Harmful 

Chapter 

Establishing a Hierarchy of Agoraphobia Situations 

Chapter 

Breathing Skills 

Chapter 

Thinking Skills 

Chapter 

Facing Agoraphobia Situations 

Chapter 

Involving Others 

Chapter 

Facing Physical Symptoms 

Chapter 

Medications 

Chapter 

Accomplishments, Maintenance, and Relapse Prevention 

Chapter 

Modification for Primary Care Settings  References  About the Authors 

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Chapter 1

Introductory Information for Therapists

Development of This Treatment Program and Its Evidence Base Research on the efficacy of nonpharmacological treatments for the various anxiety disorders has been ongoing for over two decades at our institutions, the Center for Anxiety and Related Disorders at Boston University and the University of California, Los Angeles, Anxiety Disorders Behavioral Research Program. Developments in the conceptualization of panic attacks and Panic Disorder (PD) in the s made possible significant improvements in the psychological treatment of PD and the development of panic control treatment (PCT ), a treatment for panic disorder with proven effectiveness. As a result, we received many requests to inform mental health professionals of the ways in which the treatment is conducted. After completing a series of workshops, we recognized the value of a guide outlining the treatment procedures. Hence, the Mastery of Your Anxiety and Panic, Workbook and Mastery of Your Anxiety and Panic, Therapist Guide were written and have now been revised. Now in its fourth edition, the revised client workbook is written in a style suitable for the client’s direct use, under the supervision of a trained professional.

Efficacy of Panic Control Treatment The PCT described has undergone many independent evaluations. Specifically, PCT is more effective than general relaxation training (Barlow, Craske, Cerny, & Klosko, ) and typically yields panic-free rates in the range of –% and high end-state rates (i.e., within normative ranges of functioning) in the range of –% (e.g., see Barlow, et al., ). Also, results generally maintain over follow-up intervals for as long as  years (Craske, Brown, & Barlow, ). This contrasts with the higher

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relapse rates typically found with medication approaches to the treatment of PD, particularly, high potency benzodiazepines (e.g., Gould, Otto, & Pollack, ). One analysis of individual profiles over time suggested a less optimistic picture in that one third of clients who were panic free  months after PCT had experienced a panic attack in the preceding year, and % had received additional treatment for panic over that same interval of time (Brown & Barlow, ). Nevertheless, this approach to analysis did not take into account the general trend toward continuing improvement over time. Thus, rates of eventual therapeutic success may be underestimated when success is defined by continuous panic-free status since the end of active treatment. The effectiveness extends to patients who experience nocturnal panic attacks, panic attacks from out of sleep (Craske, Lang, Aikins, & Mystkowski, ). Also, PCT is effective even when there is comorbidity and some studies indicate that comorbidity does not reduce the effectiveness of PCT for PD (e.g., Brown, Antony, & Barlow, ; McLean, Woody, Taylor, & Koch, ). Furthermore, PCT results in improvements in comorbid conditions (Brown, Antony, & Barlow, ; Tsao, Lewin, & Craske, ; Tsao, Mystkowski, Zucker, & Craske, , ). In other words, co-occurring symptoms of depression and other anxiety disorders tend to improve after PCT for PD. However, one study suggests that the benefits for comorbid conditions may lessen over time when they are assessed two years after PCT (Brown et al., ). Nonetheless, the general finding of improvement in comorbidity is significant since it suggests the value of remaining focused on the treatment for PD even when comorbidity is present since the comorbidity will be benefited as well, at least up to one year. In fact, there is preliminary evidence to suggest that attempting to address PD simultaneously along with comorbidity using cognitive-behavioral therapy (CBT ) tailored to each disorder may be less effective in general than remaining focused on PD (Craske et al., ), although this finding is in need of replication. Also, applications of PCT have proven very helpful in lowering relapse rates on discontinuation of high-potency benzodiazepines (e.g., Otto, Pollack, Sachs, Reiter, & Rosenbaum, ; Spiegel, Bruce, Gregg, & Nuzzarello, ). Procedures for benzodiazepine withdrawal are detailed in Stopping Anxiety Medication: Panic Control Therapy for Benzodiazepine Discontinuation, Therapist Guide (Otto, Jones, Craske, & Barlow, ),

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and Stopping Anxiety Medication: Panic Control Therapy for Benzodiazepine Discontinuation, Patient Workbook (Otto, Pollack, & Barlow, ), available as part of the TreatmentsThatWork™ series from Oxford University Press. The efficacy of psychological treatments for panic has been demonstrated in several other institutions around the world, using the same or similar approaches, by clinicians and researchers such as Beck (); Clark, Salkovskis, and Chalkley (); Clark, Salkovskis, Hackmann, et al. (); and Ost (). Although they are derived from somewhat different theoretical perspectives, most of these treatments to some degree involve: (a) re-education about the nature of panic attacks; (b) breathing skills training or relaxation; (c) cognitive therapy directed at negative cognitions associated with panic; and (d) exposure to interoceptive somatic cues. PCT highlights interoceptive exposure to feared bodily sensations by providing a variety of unique methods of provoking these sensations in a mild way in the office. In , the National Institute of Mental Health published the results of a consensus conference recommending that the treatments of choice for PD, based on research to date, are cognitive-behavioral approaches, such as PCT; medications; or both. Empirical studies since then continue to uphold the strong efficacy of PCT for PD, leading to its classification as an empirically validated treatment (Chambless et al., ). Two meta-analyses reported very large effect sizes of . and . for CBT (including PCT ) for PD (Mitte, ; Westin & Morrison, ).

Efficacy of Cognitive-Behavioral Treatment for Agoraphobia The CBT for agoraphobia typically incorporates cognitive restructuring, some form of breathing skills training, and in vivo exposure to feared agoraphobia situations. In this guide, these methods are combined with strategies for deliberately facing feared somatic sensations in agoraphobia situations. Researchers since the s have established the efficacy of this type of CBT, in one form or another, for agoraphobia. Randomized controlled studies that include an index of clinically significant change yield the following average statistics: after an average of  treatment sessions and a % rate of attrition, % of participants show

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some level of clinically significant improvement by posttreatment, as do the same percentage by follow-up assessment. High end-state, meaning normative levels of functioning, is attained by % by posttreatment and by % by follow-up (see Craske, ). The trend for continuing improvement over time is noteworthy in this regard. Furthermore, Fava, Zielezny, Savron, and Grandi () found that only .% of their panic-free clients relapsed over a period of five to seven years after exposure-based treatment for agoraphobia. Some research suggests that the trend for improvement after acute treatment is facilitated by the involvement of significant others in every aspect of treatment (e.g., Cerny, Barlow, Craske, & Himadi, ). For this reason, our program describes methods for involving significant others in the treatment process. As with PCT, CBT for agoraphobia is considered an empirically validated treatment (Chambless et al., ). Recently, an intensive, -day treatment, using a sensation-focused PCT approach was developed for individuals with moderate to severe agoraphobia, and initial results are promising (Morissette, Spiegel, & Heinrichs, ).

Dismantling CBT for Panic and Agoraphobia Attempts have been made to dismantle the different components of PCT and CBT for agoraphobia. The results are somewhat confusing, and they are dependent on the samples used (e.g., mild versus severe levels of agoraphobia) and the exact comparisons made. It appears that the cognitive therapy component may be effective (e.g., Williams & Falbo, ), even when conducted in full isolation from exposure and behavioral procedures (e.g., Salkovskis, Clark, & Hackman, ), and is more effective than applied relaxation (e.g., Arntz & van den Hout, ; Beck et al., ; Clark et al., ). On the other hand, some studies find that cognitive therapy does not improve outcome when added to in vivo exposure treatment for agoraphobia (e.g., van den Hout, Arntz, & Hoekstra, ; Rijiken, Kraaimaat, De Ruiter, & Garssen, ). Similarly, one study found that for agoraphobia, breathing skills training and repeated interoceptive exposure to hyperventilation did not improve outcome beyond in vivo exposure alone (de Beurs, Lange, van Dyck, & Koele, ), and we found that breathing skills training was slightly less effective than interoceptive exposure when each was added to cognitive

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restructuring (Craske, Rowe, Lewin, Noriego-Dimitri, ). Clearly, more dismantling research is needed.

Cost-Effective Treatments for Panic and Agoraphobia Group formats appear to be as effective as individual-treatment formats for PCT and behavioral treatment for agoraphobia (Neron, Lacroix, & Chaput, ; Lidren et al., ). One possible exception is that individual, one-on-one formats may be better in the long term with respect to symptoms of generalized anxiety and depression (Neron et al., ). However, more direct comparison between group and individual formats is warranted before firm conclusions can be made. Most of the studies described above averaged around – treatment sessions. Four to six sessions of PCT (Craske, Maidenberg, & Bystritsky, ; Roy-Byrne, Craske, Stein, Sherbourne, Bystritsky, Golinelli, Katon, & Sullivan, ) seem effective also, although the results were not as effective as those typically seen with – treatment sessions. On the other hand, another study demonstrated equally effective results when delivering CBT for PD across the standard  sessions versus approximately six sessions (Clark, Salkovskis, Hackmann, Wells, et al., ), and a pilot study indicated good effectiveness with intensive CBT over two days (Deacon & Abramowitz, ). Computerized versions of CBT for PD now exist. Computer-assisted and Internet-based versions of CBT are effective for PD (e.g., Richards, Klein, & Carlbring, ). In one study, a four-session, computer-assisted CBT for PD was less effective than a -session PCT at posttreatment, although they were equally effective at follow-up (Newman, Kenardy, Herman, & Taylor, ). However, findings from computerized programs for emotional disorders in general indicate that such treatments are more acceptable and successful when they are combined with therapist involvement (e.g., Carlbring, Ekselius, & Andersson, ). Finally, self-directed treatments, with minimal direct contact with a therapist, are very beneficial to highly motivated and educated clients (e.g., Ghosh & Marks, ; Gould & Clum, ; Gould, Clum, &

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Shapiro, ). Nevertheless, we generally recommend that a mental health professional conduct and supervise this treatment because not all clients are highly motivated, educated, or able to fully appreciate the nuances of the cognitive and behavioral therapeutic strategies.

Pharmacological Treatments for Panic and Agoraphobia Currently, serotonin-specific reuptake inhibitors (SSRIs) are the medication treatment of choice for PD, based on  positive, placebo-controlled, randomized clinical trials (Roy-Byrne & Cowley, ). Meta-analyses and reviews have reported medium to large effect sizes compared to placebo (e.g., Mitte, ; Bakker, van Balkom, & Spinhoven, ). The majority of trials have been short term, although several have examined and confirmed longer-term efficacy up to one year. Benzodiazepines are effective agents for PD. They work rapidly, within days to one week, and are even better tolerated than the very tolerable SSRI class of agents. However, they are limited by their risk of physiologic dependence and withdrawal and by the risk of abuse (Roy-Byrne & Cowley, ) Numerous studies clearly show that discontinuation of medication results in relapse in a significant proportion of patients, with placebocontrolled discontinuation studies showing rates between –% within  months, depending on each study’s design. In addition, SSRIs, serotoninnorepinepherine reuptake inhibitors (SNRIs) and benzodiazepines are associated with a time-limited withdrawal syndrome (considerably worse for the benzodiazepines), which itself may serve as an interoceptive stimulus that promotes or contributes to PD relapse. In terms of comparison between pharmacological and psychological approaches to the treatment of PD, we compared the antidepressant imipramine, CBT, placebo, a combination of CBT and placebo, and a combination of CBT and imipramine in patients with PD uncomplicated by depression or significant agoraphobia (Barlow et al., ). This landmark study showed that all four active treatments were equivalent at the end of the acute (-month) phase and that the combination of imipramine and CBT was marginally superior to either treatment alone

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at  months (consistent with prior reports of the superiority of combined treatment in more complicated panic). Following discontinuation, however, patients receiving the CBT plus imipramine combination fared somewhat worse than those receiving CBT alone, suggesting the possibility that state- or context-dependent learning in the presence of imipramine may have attenuated the new learning that occurs during CBT (Bouton, Mineka, & Barlow, ). Findings from the combination of fast-acting anxiolytics—and, specifically, the high-potency benzodiazepines with behavioral treatments for agoraphobia—are contradictory (e.g., Marks et al., ; Wardle et al., ). Nevertheless, several studies reliably show detrimental effects from chronic use of high-potency benzodiazepines on short-term and longterm outcome from PCT and cognitive-behavioral treatments for agoraphobia (e.g., Otto, Pollack, & Sabatino, ; van Balkom, de Beurs, Koele, Lange, & van Dyck, ; Wardle et al., ). Specifically, there is evidence for more attrition, poorer outcome, and more relapse with chronic use of high-potency benzodiazepines.

Therapist Variables Therapist variables have been understudied with respect to cognitivebehavioral treatments. Williams and Chambless () found that patients who rated their therapists as caring or involved and as modeling self-confidence achieved better outcomes on behavioral-approach tests. However, an important confound in this study is that client ratings of therapist qualities may have depended on client responses to treatment. Keijsers, Schaap, Hoogduin, and Lammers () reviewed findings regarding therapist-relationship factors and behavioral outcome. They conclude that empathy, warmth, positive regard, and genuineness assessed early in treatment predict positive outcome. Second, patients who view their therapists as understanding and respectful improve the most. Also, patient perceptions of therapist expertness, self-confidence, and directiveness related positively to outcome, although not consistently. In their own study of junior therapists who provided cognitive-behavioral treatment for panic disorder and agoraphobia (PDA), Keijsers, et al. () found that therapists used more empathic statements and more questioning in the first session than in later sessions. In the third session,

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therapists became more active and offered more instructions and explanations. In the tenth session, therapists employed more interpretations and confrontations than previously. In fact, directive statements and explanations in the first session predicted poorer outcome. Empathic listening in the first session related to better behavioral outcome, whereas empathic listening in the third session related to poorer behavioral outcome. Thus, they demonstrated the advantages of different interactional styles at different points in therapy. Finally, Huppert, Bufka, Barlow, Gorman, Shear, & Woods () demonstrated that the experience of therapists positively influenced outcome, seemingly because these therapists were more flexible in administering the treatment and better able to adapt it to the individual being treated (Huppert, et al., ).

Outline of This Treatment Program It is our intention that the Mastery of Your Anxiety and Panic, Fourth Edition (MAP–IV ), although written for the client, be carried out under the supervision of a mental health professional. We recommend this practice because many of the concepts and procedures are relatively complex. The most effective implementation requires an understanding of the principles underlying the different procedures. Therefore, the mental health professional should be fully familiar with the therapist guide and client workbook and aware of the conceptual bases for the different techniques. The following outline presents a recommended pace for working through the chapters in the workbook. It is important to realize that the pace is likely to shift based on the client’s own profile of panic, anxiety, and agoraphobia. For example, clients will spend much less time on chapter  if they avoid only a limited number of agoraphobia situations. Week 

Chapter : Learning to Record Panic and Anxiety Chapter : Negative Cycles of Panic and Agoraphobia Chapter : Panic Attacks Are Not Harmful Chapter , Section : Medications (Education)

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Week 

Chapter : Establishing Your Hierarchy of Agoraphobia Situations Chapter , Section : Breathing Skills (Diaphragmatic Breathing) Chapter , Sections  and : Thinking Skills (Basics; Realistic Odds)

Week 

Chapter , Section : Breathing Skills (Slow Breathing) Chapter , Section : Thinking Skills (Putting Things Into Perspective)

Week 

Chapter , Section : Breathing Skills (Coping Application) Chapter , Section : Thinking Skills (Review; Memories) Chapter , Section : Facing Agoraphobia Situations (Planning) Chapter : Involving Others

Week 

Chapter , Section : Breathing Skills (Review) Chapter , Section : Facing Agoraphobia Situations (Review and Planning) Chapter , Section : Facing Physical Symptoms (Assessment and Practice)

Week 

Chapter , Section : Facing Agoraphobia Situations (Review and Planning) Chapter , Section : Facing Physical Symptoms (Review and Practice)

Week 

Chapter , Section : Facing Agoraphobia Situations (Review and Planning) Chapter , Section : Facing Physical Symptoms (Review and Practice)

Week 

Chapter , Section : Facing Agoraphobia Situations (Review and Planning)

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Chapter , Section : Facing Physical Symptoms (Review and Practice; Activities Planning) Week 

Chapter , Section : Facing Agoraphobia Situations (Review and Planning) Chapter , Section : Facing Physical Symptoms (Review and Practice; Activities Planning)

Week 

Chapter , Section : Facing Agoraphobia Situations (Symptoms) Chapter , Section : Facing Physical Symptoms (Review and Practice; Activities Planning)

Week 

Chapter , Section : Facing Agoraphobia Situations (Symptoms) Chapter , Section : Facing Physical Symptoms (Review and Practice; Activities Planning)

Week 

Chapter , Section : Medications (Stopping Medications) Chapter : Accomplishments, Maintenance, and Relapse Prevention

Ideally, clients will meet with their therapist to cover the material in the introductory chapter and to review the principles of chapter  (“Learning to Record Panic and Anxiety”) of the workbook. The client is asked to read chapter , begin to record panic and anxiety, and read chapters  and , as well as chapter , section . At the second visit, the therapist reviews the material in chapters  and  and chapter , Section, and then assists clients in establishing a hierarchy of agoraphobia situations and in beginning to use coping skills, and so on. At the end of each visit with the therapist, we suggest that clients read the chapters relevant to the material to be covered in the next visit with the therapist. If preferred, therapists may suggest that clients only read the relevant chapters after the material is discussed in session. This therapist guide provides session outlines, the concepts and principles underlying the therapeutic procedures, the relevant therapist behaviors, vignettes depicting typical questions asked by clients, and problems that may arise in each chapter. Each chapter in this guide is

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structured as follows: (a) materials needed; (b) session outline; (c) therapist behaviors; (d) main concepts and principles underlying the particular treatment procedures included in the chapter; (e) case vignettes that reflect typical types of questions asked in each chapter and examples of therapist responses; and (f ) atypical or problematic client responses. A final chapter in the therapist guide discusses ways in which this treatment is modified for primary care settings. A separate workbook for this six-session program is available from Oxford University Press.

Who Will Benefit From This Program? The MAP–IV workbook is geared toward people who suffer from panic or anxiety attacks and agoraphobia. It is ideal for those who meet the criteria for PD, with or without agoraphobia, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (), fourth edition (DSM–IV ). However, it will be useful for clients who suffer occasional panic attacks but who do not meet the severity criteria for PD or who show only mild signs of agoraphobia. In addition, it will be useful for people suffering from more discrete phobias such as claustrophobia, fear of heights, or fear of driving. This is because many of these phobias are associated with unexpected panic attacks, although the avoidance behavior that develops is very circumscribed. However, we also have a therapist guide and a workbook especially designed for specific phobias: Mastery of Your Fears and Phobias, Therapist Guide (Craske, Antony, & Barlow, ) and Mastery of Your Fears and Phobias, Workbook (Antony, Craske, & Barlow, ) are available from Oxford University Press.

What If Other Problems Are Present? It is not at all uncommon for people with panic attacks and agoraphobia to be depressed, to have other anxiety disorders, or to exhibit features of a variety of personality disorders. None of these problems precludes treatment using MAP–IV. However, we have taken the approach that the most severe and disabling problem should be the problem that is targeted first for treatment. For example, if certain clients present with a

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major depressive episode that is clearly more severe than their panic attacks, then the depression should be treated first, and they can perhaps return to treating their panic and agoraphobia after the depressed mood has alleviated. This would be our recommendation even if the depression developed secondary to, or as a consequence of, panic and agoraphobia. On the other hand, if clients present with both conditions, but the PD and agoraphobia are clearly equally or more severe than the depression, then it is appropriate to proceed with our workbook. The same is true for other comorbidities. Keep in mind that comorbid conditions tend to improve, at least for some period of time, with successful treatment of PD. That being said, our assumptions about which constellation of symptoms should be treated first are based on clinical experience and have not been empirically tested. This program is not appropriate for clients who are generally anxious or depressed without the complication of panic attacks and agoraphobia. Different treatment protocols have been developed and evaluated for people suffering from more generalized anxiety, stress, and associated depression. On occasion, people with a broad pattern of hypochondriacal complaints may think this program is appropriate. However, other approaches exist that are more suited to hyponchondriasis. Thus, it is important to distinguish people suffering from PD from those with a more generalized anxiety, stress, depression, or somatoform disorder. Finally, clients who are undergoing major life stressors, such as marital or financial crises, may not have the time or energy to devote to this type of treatment program and are best advised to postpone beginning such a treatment until their other major problems are resolved.

Assessment Mental health professionals may wish to screen clients using the Anxiety Disorders Interview Schedule for DSM-IV (ADIS–IV), which was designed for this purpose. Specifically, this semistructured interview provides a very detailed analysis of the nature of the anxiety or panic, the ability to determine if one or more anxiety and/or mood disorders is present, as well as the ability to measure the relative severity of each disorder. A par-

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ticular strength of this interview is that it helps to differentiate among the different anxiety and somatoform disorders. ADIS–IV is available from Oxford University Press. Furthermore, a medical evaluation is generally recommended because several medical conditions should be ruled out before assigning the diagnosis of PD. These include thyroid conditions, caffeine or amphetamine intoxication, drug withdrawal, or pheochromocytoma (a tumor on the adrenal gland which produces excess adrenaline). Fortunately, most PD clients have had complete medical evaluations already. Furthermore, certain medical conditions can exacerbate Panic Disorder, although PD is likely to continue despite those conditions’ medical control. Mitral valve prolapse, asthma, allergies, and hypoglycemia fall into this category. These medical conditions exacerbate PD to the extent that they elicit the types of physical sensations now feared by the individual. For example, mitral valve prolapse can produce heart murmurs; asthma results in shortness of breath; and hypoglycemia causes dizziness and weak feelings. Several standardized self-report inventories provide useful information for treatment planning, as well as being sensitive markers of therapeutic change. The Mobility Inventory (Chambless et al., ) lists common agoraphobia situations that are rated in terms of degree avoidance, both when alone and when accompanied. This instrument is very useful for establishing in vivo exposure hierarchies. The Anxiety Sensitivity Index (Reiss, Peterson, Gursky, & McNally, ) has received wide acceptance as a trait measure of threatening beliefs about bodily sensations. It has good psychometric properties and tends to discriminate PD from other types of anxiety disorders. More specific information about which particular bodily sensations are feared the most, and what specific misappraisals occur most often, can be obtained from the “Body Sensations Questionnaire” and the “Agoraphobia Cognitions Questionnaire” (Chambless et al., ). Ongoing assessment throughout treatment is provided by the selfmonitoring procedures outlined in chapter  of the workbook.

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Medication Many people suffering from panic attacks and agoraphobia will be referred to mental health professionals while already on psychotropic medication, most often prescribed by primary care physicians. In our experience, almost three quarters of our clients take low doses of benzodiazepines or minor tranquilizers, tricyclic antidepressants, or selective SSRIs. Issues surrounding the combination of medications with CBTs are complex and not fully understood. The most effective ways of combining CBTs with an already-existing medication regimen are yet to be empirically tested. Thus, we make no recommendation that alreadymedicated clients decrease their medication before beginning our workbook. Rather, we suggest that they continue with whatever dosage of medication they are taking until they complete the workbook. We do discourage clients from increasing dosages of medication, particularly benzodiazepines, during the course of treatment because, as reviewed, there is some evidence that high dosages of benzodiazepines may interfere with the effects of PCT. It is believed that high doses of these drugs may have a number of negative effects; they may lessen the motivation to practice cognitive-behavioral skills; result in such little fear and anxiety that exposure-based treatments are no longer valuable; generate a strong attribution of therapeutic improvement to the medication in a way that detracts from the development of self-efficacy; cause medications to become safety signals that detract from learning to correct misappraisals of danger; or cause state dependency of learning, so that skills learned under the influence of the drug may not generalize to times when the drug is discontinued. In our experience, a large proportion of clients successfully completing the workbook stop all medication use on their own, without any encouragement to do so. Nevertheless, issues of medication withdrawal are discussed in chapter  of the workbook. We have found it helpful to use the MAP–IV program as an aid for discontinuing medication if clients and prescribing physicians so desire. The program assists clients in tolerating the withdrawal effects of certain medications, particularly, the benzodiazepines. A modification of the MAP–IV program has been developed as a tool for facilitating the discontinuation of high doses of

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benzodiazepines in clients who have become dependent on them (Otto, Pollack, & Barlow, ). Stopping Anxiety Medication: Panic Control Therapy for Benzodiazepine Discontinuation, Therapist Guide (Otto, Jones, et al., ) and accompanying Patient Workbook (Otto, Pollack, & Barlow, ) are available from Oxford University Press.

Who Should Administer the Program? The MAP–IV workbook is presented in sufficient detail, so that most mental health professionals should be able to supervise its implementation. Efforts are underway to evaluate the issue of program leadership in more detail; there are already studies in primary care settings showing that these kinds of treatments can be delivered without years of specialized clinical expertise. However, we do have some recommendations for minimal requirements. Of most importance is familiarity with the nature of anxiety and panic; some basic information on these topics is presented in chapter . Familiarity with the basic principles of cognitive and behavioral intervention is another recommended minimal requirement. In addition, we believe it is important that therapists have sufficient knowledge of the principles underlying the specific treatment in this workbook to allow adaptation of the material to best suit each client. Provision of this knowledge is the purpose of this therapist guide. (More in-depth information can be found in the References and Additional Readings sections.)

Should Former Clients Be Cotherapists? Many programs, particularly those targeting agoraphobia avoidance behavior, utilize ex-clients as cotherapists or team leaders. These therapists often act as supervisors during in vivo exposure exercises. The philosophy behind this approach is that these ex-clients have struggled through similar problems and can therefore act as good role models for clients currently struggling with panic and associated problems. In addition, these individuals tend to be very understanding and supportive during the process. This is the positive side of the picture.

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On the other hand, some less positive aspects have been reported. Sometimes, ex-clients, because of their own success, believe that there is only one correct way to accomplish various tasks. They may not understand the reasons why a client does not wish to work in the same way that they did or to work at the same speed. In other words, they may not be as adept at tailoring the program to individual clients as is the fully trained, professional therapist. Therapists will have to decide whether the positive aspects of using exclients outweigh the potential negatives. Obviously, this decision will depend on the individual ex-client. To date, no research has determined the effectiveness of working with ex-clients. What we do know is that our workbook program has been evaluated and shown to be successful when administered by mental health professionals without the help of ex-clients.

Additional Training Opportunities For more information on training opportunities, please visit the TreatmentsThatWork™ website (http://www.oup.com/us/ttw).

Group Versus Individual Sessions We have administered this program in both individual and group formats. As noted, there are few direct empirical evaluations of individual versus group formats, but those that exist suggest that they are about equally effective. Possible exceptions are that generalized symptoms of anxiety and depression may be helped more by an individual format, and rates of attrition may be higher from group than from individual sessions. The decision for group versus individual treatments should probably be determined on a site-by-site basis in accord with therapist preferences. Health maintenance organizations (HMOs) typically administer our program in groups of six to eight to take advantage of the economies afforded by this mode of administration. On the other hand, private practitioners who do not wish to make clients wait until a group forms

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may find individual administration more convenient. When we deliver group treatments, we limit the number of group members to no more than eight because it is difficult to allocate individual attention to clients during a -minute session in larger groups. However, other therapists have reported successful use of this program in groups of  or more.

Frequency of Meetings Usually, therapists meet with clients or groups once per week and assign readings from the workbook and exercises to be conducted during the week before the next meeting. Some therapists speed treatment by offering two sessions per week, thus cutting the length of treatment in half.

Does Every Person Require the Entire Program? It is strongly recommend that each client complete the entire workbook (aside from the few chapters that may not be directly relevant because they concern medication issues or involvement of significant others), even if he or she feels considerably better after fewer sessions. It has been our experience that people who stop early because they feel better (a not infrequent occurrence) may be subject to higher rates of relapse than those who complete the entire program.

Benefits of Using a Manual The first “revolution” in the development of effective psychosocial treatments was the manualization of these treatments. Because these are structured programs for specific disorders, they can be written in sufficient detail to allow trained therapists to administer them in roughly the same manner in which they were proven effective. This does not, however, imply that therapeutic skills are no longer required. The second phase of this revolution is the preparation of the structured program in a manner suitable for direct distribution to clients working under therapeutic supervision. The MAP–IV workbook is one of a few

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examples of a scientifically sound guide written at the client’s level which can be a valuable supplement to programs delivered by professionals from a number of disciplines. There are several advantages to this.

Self-Paced Progress

Clients can move at their own individual pace. As stated previously, some therapists or clients may wish to shorten the program by scheduling more frequent sessions. Other clients may choose to move more slowly, due to conflicting demands such as travel schedules. Having the client workbook available between irregularly scheduled sessions for review and rereading can be quite beneficial.

Ready Reference for Clients

Although concepts may be perfectly clear to the therapist, clients who seem to understand material during the session often become confused after leaving. One of the greatest benefits of the client workbook is the opportunity for clients to review relevant conceptualizations, explanations, and instructions between sessions. The authors have found that during treatment, the MAP–IV workbook frequently becomes the client’s “bible.” Many clients take the client workbook with them wherever they go for handy reference and have found this availability extremely useful. Certainly, research in memory stresses the importance of such repetition and rehearsal for the consolidation of newly acquired information.

Availability to Family Members and Friends

We have demonstrated a significant advantage from having family members, particularly spouses or other partners, be aware of and involved in treatment (e.g., Barlow, O’Brien, & Last, ; Carter, Turovsky, & Barlow, ; Cerny et al., ). For example, clients whose partners were included in treatment did better at a -year follow-up than did those clients whose partners were not included. Family participation can be beneficial in several ways. First, attempts to sabotage the program, either

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purposely or unwittingly, are offset if family members become familiar with the nature of the disorder and the rationale underlying treatment. Second, family members can be helpful in overcoming some of the avoidance behavior that often accompanies panic. Of course, some clients prefer that their partners or family members remain unaware of their problem. In these cases, we attempt to persuade clients of the advantage of sharing the problem with their partners and thereby to allay any concerns. Typically these concerns revolve around worries that family members will think they are insane or will be openly hostile to their efforts. These reactions almost never happen. Nevertheless, occasionally, there may be clear signs that it is inappropriate to involve the significant other (e.g., severe marital discord), in which case we do not encourage the significant other’s involvement. When the decision is made to incorporate the significant other, we usually bring the partner into treatment sessions, either initially or throughout the entire treatment.

Clients Can Refer to the Manual After the Program Ends

The MAP–IV workbook will help clients deal effectively with occasional recurrences of panic attacks or agoraphobia after treatment is over. This kind of recurrence is most likely under particularly stressful situations. The client workbook can be a source of great comfort during these periods and can often prevent escalation of panic attacks into a full-blown relapse. The final chapter of the workbook, chapter , outlines ways of maintaining progress and dealing with occasional recurrences of panic and agoraphobia. In addition to the availability of useful information and prompts to use the skills learned during treatment, having the client workbook available in and of itself seems to be anxiolytic. In fact, the workbook may function as a cue or reminder that simply by its presence increases the recall of information and skills learned during treatment.

Full Workbook Versus Installments Some therapists who have been using the MAP–IV program since its inception in  report that they prefer to distribute the chapters in installments. In this way, they prevent clients from skipping ahead and thus

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encourage better concentration on one chapter at a time. These therapists have adopted loose-leaf binders or other mechanisms of putting the client workbook together. Based on this feedback, we considered supplying the workbook in such formats but ultimately decided against it. The downside of this practice is that individual chapters are more likely to be misplaced, so, when the program ends, clients will have incomplete workbooks. This causes difficulties in later months, when clients wish to refer to specific chapters. In addition, we are not particularly concerned if clients do a little skipping around. In general, we find that the more time clients spend reviewing the workbooks, the deeper their understanding, and the greater their benefit. During the sessions, if clients mention material that they have read in future chapters, the therapist can simply refocus the clients’ attention to the current assignments. Nevertheless, we do not discourage therapists from distributing the client workbooks in installments if they prefer that practice.

Fees for the Workbook Different therapists and programs will obviously have their own fee structures. The cost of the workbooks is typically incorporated into this fee structure in one of two ways. First, client workbooks can be purchased in bulk by the program or therapist, and these costs are then incorporated into the costs of the therapy session or program. Alternatively, some therapists and programs, particularly those with rather inflexible rate structures, have the clients themselves assume the cost of purchasing the client workbook. In these cases, workbooks may be purchased in bulk for resale at the beginning of treatment.

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Chapter 2

The Nature of Panic Disorder and Agoraphobia

Diagnostic Criteria for Panic Disorder A. Both  and : . Recurrent unexpected panic attacks. . At least one of the attacks has been followed by one month (or more) of one (or more) of the following: a. a persistent concern about having additional attacks; b. worrying about the implications of the attack or its consequences (e.g., losing control, having a heart attack, going crazy insane); c. a significant change in behavior related to the attacks. B. The panic attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism). C. The panic attacks are not better accounted for by another mental disorder, such as social phobia (e.g., occurring on exposure to feared social situations), specific phobia (e.g., on exposure to a specific phobia situation), obsessive-compulsive disorder (OCD) (e.g., on exposure to dirt in someone with an obsession about contamination), posttraumatic stress disorder (PTSD) (e.g., in response to stimuli associated with a severe stressor), or separation anxiety disorder (e.g., in response to being away from home or close relatives). Panic Disorder (PD) is divided into categories of with or without agoraphobia.

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Diagnostic Criteria for Agoraphobia A. Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or automobile. B. The situations are avoided (e.g., travel is restricted), or else are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion. C. The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as social phobia (e.g., avoidance limited to social situations because of fear of embarrassment), specific phobia (e.g., avoidance limited to a single situation like elevators), OCD (e.g., avoidance of dirt in someone with an obsession about contamination), PTSD (e.g., avoidance of stimuli associated with a severe stressor), or separation anxiety disorder (e.g., avoidance of leaving home or relatives).

Diagnostic Criteria for a Panic Attack The diagnostic criteria for a panic attack include a discrete period of intense fear or discomfort in which four (or more) of the following symptoms develop abruptly and reach a peak within  minutes: . heart palpitations, pounding heart, or accelerated heart rate; . sweating; . trembling or shaking; . sensations of shortness of breath or smothering; . feeling of choking; . chest pain or discomfort;

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. nausea or abdominal distress; . feeling dizzy, unsteady, lightheaded, or faint; . derealization (feelings of unreality) or depersonalization (being detached from oneself ); . fear of losing control or going insane; . fear of dying; . paresthesias (numbness or tingling sensations); . chills or hot flushes.

Features of Panic Disorder and Agoraphobia Panic Disorder is characterized by recurrent panic attacks (or, sudden rushes of intense fear or discomfort). A panic attack is defined by a cluster of physical and cognitive symptoms, including heart palpitations, shortness of breath, derealization, paresthesia, trembling, and fears of dying, going insane, or losing control. Panic attacks are common to all anxiety disorders. PD is distinguished by unexpected attacks, that is, attacks that occur without an obvious trigger; and at least one month of persistent apprehension about the recurrence of panic or its consequences; or a significant behavioral change. Agoraphobia refers to avoidance or endurance with dread of situations from which escape might be difficult or help unavailable in the event of a panic attack, or panic-like symptoms, such as loss of bowel control. Typical agoraphobia situations include shopping malls, waiting in lines, being at movie theaters, traveling by car or bus, being in crowded restaurants and stores, and being alone. The National Comorbidity Survey-Replication (NCS-R) provides prevalence estimates of -month and lifetime PD as .% and .%, respectively (Kessler, Chiu, Demler, Merikangas, & Walters, ; Kessler, Berglund, Demler, Jin, Merikangas, & Walters, ). Conservative estimates suggest that an additional .–.% experience nonclinical panic (or, occasional panic attacks). The level of anxiety about the re-

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currence of panic and catastrophic cognitions during panic seem to differentiate nonclinical panic from PD. Epidemiological studies report relatively high rates for agoraphobia without a history of PD: .% in the last  months and .% in a lifetime (Kessler, Berglund, et al., ). In contrast, individuals with agoraphobia who seek treatment almost always report a history of panic which preceded development of their avoidance (Wittchen, Reed, & Kessler, ). There are at least two explanations for the contrast between population-based and clinic-based data. First, epidemiological data may vastly overestimate the prevalence of agoraphobia due to misdiagnosis of specific phobias, generalized anxiety, or “normal” cautiousness about certain situations (e.g., walking in unsafe urban districts) as agoraphobia. Second, individuals who panic are more likely to seek help. Rarely does the diagnosis of PD, with or without agoraphobia, occur in isolation. Commonly co-occurring Axis I conditions include specific phobias, social phobia, dysthymia, generalized anxiety disorder, major depressive disorder, and substance abuse. From  to % of persons with PD also meet criteria for a personality disorder, mostly avoidant and dependent personality disorders (see Roy-Byrne, Craske, Stein, Sullivan, Bystrisky, & Katon, et al., ). The modal age of onset is late teenage years and early adulthood (Kessler, Chiu, et al., ), although treatment is usually sought at a much later age, around  years. A large percentage (approximately %) report the presence of identifiable stressors around the time of the first panic attack. Finally, PD and agoraphobia tend to be chronic conditions with severe financial and interpersonal costs. That is, only a minority of patients remit without subsequent relapse within a few years (%), although a similar number experience notable improvement, albeit with a waxing and waning course (%) (Roy-Byrne & Cowley, ). Fortunately, PD responds well to specifically targeted treatments, described in our workbook.

Psychobiological Conceptualization For a full presentation and original citations for psychobiological conceptualization, see Barlow () and Craske ().

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Biological Factors From a genetic perspective, it is believed that PD, like other psychiatric disorders, is a complex disorder with multiple genes conferring vulnerability through as-yet-undetermined pathways. Either there is substantial genetic heterogeneity with multiple etiologically distinct forms of the disorder, or the superficially similar phenotype actually reflects a more unified, broad genetic vulnerability to panic and anxiety. Studies involving multivariate genetic analyses of large samples of subjects tend to support the latter model, to suggest the existence of relatively broad or nonspecific genetic factors that influence the vulnerability to panic and anxiety. Thus, the workbook educates the reader to think of certain biological factors that may be inherited or passed on through genes and thus may lead some people to be more likely to panic. Many believe that what is inherited is overly sensitive parts of the nervous system which increase the likelihood of all negative emotions, including anger, sadness, guilt, and shame, as well as anxiety and panic. However, inheriting vulnerabilities to experience negative emotions does not guarantee panic attacks or PD. In other words, panic is not inherited in the same way that eye color is inherited. Biological factors (whatever they might be) probably help explain why panic disorder tends to run in families. In other words, if one family member has PD, then another person in the same family is more likely to have PD than are others in the general population. That is, whereas –% of the American population has PD and/or agoraphobia, –% of first-degree relatives (parents, siblings, children) of someone with panic disorder themselves develop PD.

Psychological Factors The psychological conceptualization of panic disorder emphasizes fear of bodily sensations, characterized by tendencies to misappraise these sensations in a catastrophic manner or to misappraise them as being much more dangerous than they really are. Usually, the misappraisals are of impending physical or mental danger, such as believing that a feeling of breathlessness as evidence of impending breathing cessation and death,

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viewing palpitations of the heart as evidence of an impending heart attack, thinking that lightheadedness is evidence of an impending loss of consciousness, or viewing shakiness as evidence of impending loss of control and insanity. The trait of anxiety sensitivity, a set of beliefs that anxiety is harmful along social, physical and mental domains, is believed to predispose toward the fear of bodily sensations. In support, several longitudinal studies find that high scores on a measure of anxiety sensitivity are predictive of the development of panic attacks in nonclinical groups and of the maintenance of panic disorder in untreated PD groups. We believe that anxiety sensitivity is acquired insidiously from a lifetime of direct aversive experiences (such as a personal history of significant illness or injury), vicarious observations (such as exposure to significant illnesses or death among family members or to family members who display a fear of body sensations through hypochondriasis), and/or informational transmissions (such as parental warnings or overprotectiveness regarding physical well-being). Also associated with anxiety sensitivity is an enhanced attentional selectivity toward, or interoception for, physical cues. Individuals with panic disorder have heightened awareness of, or ability to detect, bodily sensations of arousal, although discrepant findings exist as to whether they are more accurate in their detection. Ability to perceive one’s heartbeat, in particular, appears to be a relatively stable individual difference variable. Thus, along with anxiety sensitivity, the ability to detect interoceptive cues may predispose an individual toward PD. Many (%) panic clients report similar but less intense or less frightening panic-like sensations prior to their first panic attack. Also, previous experiences of cardiac symptoms and shortness of breath predict later development of panic attacks and PD. Perhaps such prior experiences reflect a state of autonomic vulnerability which only develops into fullblown panic when instances of autonomic arousal occur in threatening contexts or under stressful conditions (i.e., when the sensations are more likely to be perceived as harmful). Earlier theorists emphasized separation anxiety as a specific precursor for agoraphobia and panic. Bowlby () suggested that abnormal parent-

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child bonding induces a specific form of anxious attachment in children, resulting in enduring separation anxiety, which in turn leads to agoraphobia when the individual is confronted with personally threatening situations as an adult. Some retrospective findings support the link between separation anxiety and agoraphobia. However, there is also reason to believe that separation anxiety is a vulnerability for all anxiety disorders, as well as for depression. Thus, separation anxiety may be best viewed as a component of a broader vulnerability.

Initial Panic Attacks The large majority of initial panic attacks occur outside of the home, while driving, walking, or simply being at work or at school, in public in general, and on a bus, plane, subway, or in social evaluative situations. Furthermore, settings for initial panic attacks often are rated retrospectively as somewhat difficult to escape. Situations that block escape behavior, the natural action tendency associated with panic, intensify the urgency to escape, as well as the associated fear and panic. Furthermore, initial panic attacks may be most likely to occur in situations in which feared physical sensations are perceived as particularly threatening due to possible impairment (e.g., driving), entrapment (e.g., air travel, elevators), negative social evaluation (e.g., job, formal social events), or distance from safety (e.g., unfamiliar locales). In addition to a vulnerability to instances of elevated autonomic arousal, an array of factors may explain surges of physiological sensations on the occasion of an initial panic attack. These include benign physiological events (ranging from normal variations in bodily state to illnesses), distal and proximal stress (e.g., impending divorce, rushing to an appointment, meeting a deadline), stimulants (e.g., caffeine, hallucinogenic drugs, prescription medications), environmental conditions (e.g., heat and humidity), and anticipatory anxiety about the immediate situation or an upcoming event (e.g., receiving a work evaluation). A stress-diathesis interaction seems to account for initial panic attacks. In other words, the initial panic attack is viewed as a false alarm that is prone to activation under stressful conditions. Just as some people experience irritable bowel syndrome, others experience panic attacks in re-

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sponse to stressful events. Certainly, the majority of individuals associate their initial panic attacks with stressful events. Typical stressful life events include the unexpected loss of a significant other, illness, or aversive drug experiences.

Maintenance Factors Acute “fear of fear” (really, anxiety about fear or panic) that develops after initial panic attacks refers to fear of specific bodily sensations associated with panic attacks (e.g., racing heart, dizziness, paresthesia). This anxiety is attributed to two factors. The first is interoceptive conditioning (i.e., learned anxiety focused on internal states via aversive associations— such as learning to be anxious about elevated heart rate because of a previous association between elevated heart rate and a panic attack). The second factor is the misappraisal of bodily sensations (i.e., misinterpretation of sensations as signs of imminent death, loss of control, and so forth). “Fear of fear” can be construed as the sensitization of the predisposing trait of anxiety sensitivity due to the experience of panic attacks. In support of the notion of “fear of fear,” clients with panic disorder have strong beliefs and fears of physical or mental harm arising from bodily sensations that are associated with panic attacks, and these clients are more likely to interpret bodily sensations in a catastrophic fashion. Also, persons with PD are more likely to be anxious about procedures that elicit bodily sensations similar to the ones experienced during panic attacks, including benign cardiovascular, respiratory, and audiovestibular exercises, as well as more invasive procedures, such as carbon dioxide inhalations. Furthermore, these individuals become anxious about signals that ostensibly reflect heightened arousal, even in the absence of actual height-ened arousal, as shown through false physiological feedback paradigms. Not only is misappraisal associated with anxiety, but reappraisal lessens anxiety. For example, persons with PD and nonclinical panickers report significantly less anxiety and panic during laboratorybased panic provocation procedures, such as hyperventilation and carbon dioxide inhalation, when they perceive that the procedure is safe or controllable, when accompanied by a safe person, or after successful cognitive-behavioral treatment.

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The pattern of learned anxiety to certain somatic sensations typically results in an acute sensitivity to otherwise normal bodily sensations. Hence, different daily activities that elicit sensations similar to the sensations experienced during panic may trigger panic attacks. Examples include a racing heart from exercise; sweating from hot weather conditions; excitement from suspenseful movies, arguments, or sexual arousal; trembling from ingestion of caffeine; and feelings of floating or heaviness from deep relaxation. Note, however, that anxiety focused on sensations is moderated by occasion setters, which vary greatly across individuals. For example, elevated heart rate may be anxiety provoking while sitting but not while running, depending on the individual. Furthermore, if the bodily sensation occurs in association with an established safety signal or a safe context, anxiety will be diminished. For example, a racing heart may be anxiety provoking when an individual is alone but not anxiety provoking when that person is in close proximity to others and, especially, to medical help. Several features distinguish anxiety focused on bodily sensations from anxiety triggered by external stimuli. First, autonomic arousal generated by anxiety from sensations in turn intensifies the sensations, thus creating a reciprocating cycle of anxiety and sensations. The cycle is sustained until physiological arousal is exhausted or perceptions of safety are achieved. In contrast, anxiety triggered by external stimuli does not intensify the object of fear. Second, cues that trigger panic attacks (i.e., bodily sensations) are not always immediately obvious, thus generating the perception of unexpected or “out of the blue” panic attacks. Furthermore, even when interoceptive cues are identifiable, they tend to be less predictable than external stimuli. Third, bodily sensations are more difficult to escape, on average, than external objects; that is, sensations are relatively uncontrollable. Unpredictability and uncontrollability elevate anxiety about upcoming aversive events, in general, and panic attacks, in particular. Consequently, the unpredictable and uncontrollable nature of panic attacks is hypothesized to contribute to high levels of chronic anxious apprehension and to maintaining anticipatory anxiety about the recurrence of panic. In turn, anxious apprehension increases the likelihood of panic by directly increasing the availability of sensations that have become conditioned cues for panic or by increasing attentional vigilance for these bodily cues. Thus, a maintaining cycle of panic and anxious apprehension develops.

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Also, anxiety develops over specific contexts in which the occurrence of panic would be particularly troubling (i.e., situations involving impairment, entrapment, negative social evaluation, or distance from safety). These anxieties contribute to agoraphobia. Note, however, that agoraphobia is predicted by other variables as well, as described in the next section. Finally, subtle avoidance behaviors are believed to maintain negative beliefs about feared bodily sensations. Examples include holding on to objects or persons for fears of fainting, sitting and remaining still for fears of heart attack, and moving slowly or searching for an escape for fears of acting foolish.

Development of Agoraphobia Not all persons who panic develop agoraphobia, and the extent of agoraphobia that emerges is highly variable. Agoraphobia tends to increase as an individual’s history of panic lengthens; however, a significant proportion of persons panic for many years without developing agoraphobic limitations. Nor is agoraphobia avoidance related to age of onset or frequency of panic. Some researchers report more intense symptomatology during panic attacks in individuals who are more agoraphobic. Others fail to find such differences. Agoraphobic individuals may be more concerned with social consequences of panicking, and the anticipation of panic in specific agoraphobia situations predicts agoraphobia avoidance. Whether the latter two variables are precursors or are secondary to agoraphobia remains to be determined. Occupational status predicts agoraphobia avoidance, accounting for % of the variance: the more one is forced to leave the house by means of employment, the less one is likely to suffer from agoraphobia. Perhaps the strongest predictor of agoraphobia, however, is gender. Females increasingly predominate the sample as agoraphobia worsens. Sex-role expectations and behaviors may contribute to these effects.

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Generalized biological vulnerability

Generalized psychological vulnerability Stress due to life events False alarm

Associated with somatic sensations (interoceptive cues, e.g., pounding heart)

Learned alarm

Specific psychological vulnerability (unexplained physical sensations are dangerous)

Anxious apprehension

Development of agoraphobia

(focused on somatic sensations)

Panic Disorder

(determined by cultural, social, and pragmatic factors, and moderated by presence or absence of safety signals)

PDA

Figure 2.1.

Model of the etiology of panic disorder and agoraphobia

Nocturnal Panic The psychobiological model described above applies equally to nocturnal panic, that is, waking from sleep in a state of panic (a recent review is provided by Craske & Tsao, ). Nocturnal panic does not refer to waking from sleep and panicking after a lapse of waking time, nighttime arousals induced by nightmares or environmental intrusions, night terrors, sleep paralysis, sleep seizures, or flashbacks to traumatic events. Nocturnal panics occur without apparent reason and are similar symptomatically to daytime panic attacks. They tend to occur in non-REM sleep and, particularly, during the transition between late Stage  and early Stage  sleep. While epidemiological studies have not been conducted, surveys of select clinical and nonclinical groups suggest that nocturnal panic is a relatively common phenomenon. From  to % of PD clients report having experienced nocturnal panic at least once, and from  to % have regular and frequent occurrences. We believe that fears of bodily sensations contribute directly to nocturnal panic. In support of this claim, we find that individuals who are re-

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assured that episodes of physiological arousal during sleep are safe and expected are less fearful of signals of such arousal than individuals who are not reassured and who do not expect episodes of arousal to occur. In other words, we found that the latter group awoke with more selfreported distress, panic, and symptoms in response to these signals of arousal. We propose that, like daytime panic attacks, nocturnal panics are triggered by changes in an individual’s physiological state during sleep through a process of interoceptive conditioning, whereby low-level somatic sensations of arousal or anxiety become conditional stimuli, so that early somatic components of the anxiety response come to elicit anxiety or panic. In addition, interoceptive conditional responses are not dependent on conscious awareness of triggering cues such that, once acquired, these responses can be elicited under anesthesia, even in humans. Consequently, changes in relevant bodily functions which are not consciously recognized due to sleep or sleep-like states may elicit conditional fear due to previous pairings with panic. The role of precipitating physiological events has received some support from reports of short muscle twitches, increased EEG frequency, body movements, breathing irregularities, and increases in heart rate and skin conductance in the minutes and seconds preceding panicky awakenings. It may be necessary for these physiological events to co-occur with Stage  or Stage  sleep, as one shifts from semivigilance to nonvigilance; a shift that may be particularly anxiety provoking for individuals who have frequent nocturnal panic attacks. Fortunately, as mentioned earlier, panic control treatment modified slightly for sleep is effective for nocturnal panic attacks (Craske, Lang, Aikins, & Mystkowksi, ).

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Chapter 3

Outline of Treatment Procedures and Basic Principles Underlying Treatment

Procedure Outline There are four main sections to the Mastery of Your Anxiety and Panic, Fourth Edition (MAP–IV ), Workbook. The first is Basics, and it involves (a) information and education designed to correct misinformation and misinterpretations of somatic sensations and of panic and anxiety; and (b) self-recording, which is intended to enhance objective self-awareness and a personal scientist approach to panic and anxiety. The second is Coping Skills, which involves (a) breathing skills training (called Breathing Skills), which is designed to teach slow and diaphragmatic breathing; and (b) cognitive restructuring (called Thinking Skills), which has been designed to identify and replace anxious, biased thoughts with more realistic, evidence-based thinking. The third section is Exposure, which involves (a) in vivo exposure to situations where panic attacks or panic-like symptoms are anticipated to occur. Examples include movie theaters, restaurants, shopping malls, and waiting in lines. Integral to the method of in vivo exposure is the removal of all unnecessary safety behaviors (e.g., holding on for support) and safety signals (e.g., empty medication bottles) that inadvertently reinforce fear. Exposure also involves (b) interoceptive exposure, designed to elicit, in a systematic, controlled manner, the salient somatic sensations. Through repeated exposures and increasing tolerance of the sensations without engaging in overt, covert, subtle, or obvious avoidance, individuals eventually learn to be less afraid of the sensations. Interoceptive exposure extends from simulation exercises (e.g., spinning, forced hyperventilation) to naturalistic activities (e.g., exercise classes, driving in hot weather conditions). Again, the removal of all safety behaviors and safety

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signals is critical to interoceptive exposure. In addition, interoceptive exposure is incorporated into in vivo exposure. The fourth section is Planning for the Future, which involves (a) discussion of medications and ways to wean from medications; and (b) relapse prevention.

Therapeutic Mechanisms of Exposure Therapy We believe that there are multiple mechanisms accountable for therapeutic change. The most relevant mechanisms are reviewed briefly because knowledge of these mechanisms facilitates the design of treatment in the most effective way possible.

Habituation The term habituation refers simply to reduction in response strength with repeated stimulus presentations. Thus, fear declines as feared objects are faced over and over again. Excessively high levels of arousal are likely to impede habituation. In addition, habituation is impeded by lengthy intervals between each occasion of exposure. However, habituation is unlikely to account for long-term fear reduction since it is a nonlearning process, and habituated responses dishabituate over time.

Extinction Extinction refers to decrements in responding through repetition of unreinforced responding: repeated encounters with feared stimuli (conditioned stimulus, CS) without aversive consequences (unconditioned stimulus, US). Thus, the person who is fearful of heights learns by repeated exposures that he or she does not fall. Extinction accounts are supported by the finding that a single lengthy exposure session is generally more effective than a series of short exposures for the same total duration, as lengthy exposure provides sufficient time to learn that aversive outcomes

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do not occur. It is for this reason that the workbook recommends extending interoceptive exposure well beyond the point at which the bodily sensations are first noticed; and it also recommends lengthy in vivo exposures to feared agoraphobic situations. Wolpe () attributed extinction to counterconditioning or reciprocal inhibition. Specifically, when a response antagonistic to anxiety can be made to occur in the presence of anxiety-provoking stimuli, and this results in a complete or partial suppression of the anxiety response, then the bond between the stimulus and the anxiety response is weakened. However, his model was criticized because exposure can proceed effectively without including specific antagonists to anxiety. The response by Wolpe () to this criticism was that there are many unintended reciprocal inhibitors, including the presence of the therapist, that work to compete with anxiety during exposure therapy. However, this awaits empirical examination. Recent conditioning models maintain that extinction involves the learning of new, inhibitory CS-US associations, as opposed to the unlearning of original CS-US associations. Thus, Bouton and colleagues (see Bouton, ) propose that the original excitatory meaning of the CS is not erased during extinction but, rather, that an additional inhibitory meaning is learned. The resulting dual meaning of the CS creates an ambiguity that is resolved only by the current context of the CS. Bouton uses the analogy of an ambiguous word. That is, reaction to the word “fire” depends largely on the context in which it occurs; “fire” may elicit a panic reaction in a crowded theater, but it will probably elicit very little reaction in a carnival shooting gallery. Thus, the context determines which meaning is expressed at any given time. In terms of anxiety treatments, bodily sensations may mean “sudden death” when experienced in a context that reminds the person of intense panic attacks before treatment, whereas the same sensations may mean “unpleasant but harmless” when experienced in a context that reminds a person of their success with treatment. The main implication from this theory is that exposure is best conducted in as many contexts as possible to minimize context specificity of fear reduction and to enhance the likelihood of inhibitory or nonfearful meanings in whatever context the stimulus is encountered once treatment is over.

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Self-Efficacy and Control According to self-efficacy theory, therapeutic gains are dependent on the degree to which self-efficacy, that is, confidence to perform a certain task, is generated (Bandura, ). Self-efficacy is theoretically distinct from outcome expectancies, which refer to the perceived likelihood and valence of negative events. Efficacy expectations are claimed to influence the choice of activities and settings, and they determine the degree of effort expended and persistence in the face of obstacles or aversive experiences. In other words, self-efficacy is believed to influence coping in threatening situations. Self-efficacy judgments are posited to derive from four main sources of information: performance accomplishment, verbal persuasion, vicarious experience, and physiological arousal. The strongest source is the first, as it is through performance accomplishment that one obtains most evidence for personal achievement and skills. Related to self-efficacy is the notion that fear declines as perceived control increases (Barlow, ). In particular, a reversal of the fear action tendency, or reduction of escape urges or behaviors, leads to a sense that events or emotions are no longer proceeding uncontrollably, which in turn lessens fear and anxiety. This process can be set in motion by preventing the fear action tendency or by introducing specific competing tendencies, such as those characteristic of positively valent emotional states (e.g., humor).

Emotional Processing The concept of emotional processing, first introduced by Rachman () and extended by Foa and Kozak (), combines the concepts of habituation and cognitive modification. They hypothesized two necessary conditions for fear reduction: full activation of fear; and incorporation of new material that is incompatible with fear memories, so that new memories are formed. The most effective method for activating fear is direct exposure to feared stimuli. With repeated exposure, the model states that incompatible information is derived from short-term physiological habituation that dissociates stimulus and response (i.e., recognition that the stimulus can occur in the absence of arousal). Between-session

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habituation is attributed to changes in the meaning of the stimulus and response (i.e., risk of harm is lowered, and the affective valence becomes less negative). So, outcome expectancies are altered. Thus, there are three indicators of emotional processing: evidence of initial physiological arousal and self-report distress (i.e., fear activation); reactions gradually reduce during exposure (i.e., within-session habituation); and initial reactions to the stimulus reduce across exposures (i.e., between-session habituation).

Violation of Expectancies and Fear Toleration However, given the recent advances in research, showing that neither physiological habituation nor the amount of fear reduction within an exposure trial is predictive of overall outcome (see Craske & Mystkowski, ), and given that self-efficacy through performance accomplishment is predictive of overall phobia reductions (e.g., Williams, ) and that toleration of fear and anxiety may be a more critical learning experience than the elimination of fear and anxiety (see Eifert & Forsyth, ), the focus now is on staying in the phobic situation until the specified time at which clients learn that what they are most worried about never or rarely happens or that they can cope with the phobic stimulus and tolerate the anxiety. Thus, the length of a given exposure trial is not based on fear reduction but on the conditions necessary for new learning, which eventually leads fear and anxiety to subside across trials of exposure. Essentially, the level of fear or fear reduction within a given trial of exposure is no longer considered an index of learning but, rather, a reflection of performance; learning is best measured by the level of anxiety which is experienced the next time the phobic situation is encountered, or at some later time. This is also the reason why it is essential to replace escape and avoidance behavior, including safety behaviors and reliance on safety signals, with toleration of fear and anxiety. Active escape is central to the construct of fear. Indeed, the autonomic discharge associated with states of intense fear or panic is interpreted as a survival mechanism (i.e., the fight-flight reaction), the primary purpose of which is to prepare the body to engage in protective behaviors of fleeing, fighting, or freezing. Preparatory avoid-

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ance in anticipation of danger (i.e., agoraphobia avoidance) is more variable and influenced by individual differences in learned methods of approach and avoidance. Nevertheless, almost every client with Panic Disorder (PD) engages in some type of preparatory avoidance, whether it be relying on safety signals (e.g., remaining in close proximity to medical facilities, carrying anxiolytic medication at all times), using safety behaviors (such as keeping one’s mind preoccupied to avoid thinking about panic, maintaining steady body movements to prevent the experience of strange sensations, standing close to walls in order to prevent falling, attempting to prevent arguments or other sources of emotional arousal), or avoiding specific situations. The workbook outlines ways of weaning from active escape and preparatory avoidance.

Case Example When she presented for treatment, S. was a -year-old married woman with two children, aged  and  years. S. had experienced her first panic attack approximately one year prior to the time of initial assessment. Her father had died  months before her first panic attack; his death was unexpected, the result of a stroke. In addition to grieving for her father, S. became extremely concerned about the possibility of herself having a stroke. S. reported that she had never experienced anything similar to panic attacks before her father’s death, nor did she report being overly concerned about her health in general. Apparently, the loss of her father produced an abrupt change in the focus of her attention, and a cycle of anxiety began. The unexpected nature of her father’s death led S. to increase her awareness of the imminence of her own death, given that “nothing in life was predictable.” Hence, from the time of her father’s death to the time of her first panic attack, S. became increasingly aware of her own bodily sensations. Following her first panic attack, S. was highly vigilant for tingling sensations in her scalp, pain around her eyes, and numbness in her arms and legs, especially on her left side. She interpreted all of these symptoms as indicative of an impending stroke. Moreover, her concerns became more generalized, so that she began to fear other physical symptoms as well, such as shortness of breath and heart palpitations.

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Her concerns led to significant changes in her lifestyle, although her pattern of avoidance was not severely agoraphobic. She continued to function at home and at work in her roles as a mother and clerical worker. Nevertheless, as a result of being anxious about panicking, S. began to avoid having unstructured time in the event that she might dwell on “how she felt” and, by so doing, panic. In fact, S. became involved in as many committees and activities as time allowed, distracting herself from her feelings. S. had difficulty falling asleep and developed a pattern of doing so while watching television. Physical exercise was limited because of the symptoms it brought on, although S. had previously been an avid jogger. She avoided checkups because she was afraid that the doctor would find evidence of minor strokes or an impending major stroke. Emotional arousal was kept at a minimum, so S. avoided stressful situations, interpersonally and at work, for fear of such arousal bringing on a panic. She avoided caffeine because of the symptoms it elicited. Also, she avoided thinking about the loss of her father because the grief would quickly turn into fear and panic. S. felt that her life revolved around preventing the experience of panic and stroke. Although the concerns about stroke were most salient in the midst of panic attacks, her worries about having a stroke were present at other times as well. S. was healthy (a medical evaluation revealed no physical abnormalities) and was not taking any medication. Over the year since her first attack, the frequency of panic had varied but never remitted completely. Her high level of anxiety about the recurrence of panic and its associated threat continued throughout the year. Interview and self-monitoring measures showed that S.’s most severe panic symptoms were numbness, tingling, difficulty breathing, a racing heart, and fear of dying. In addition to concerns about a stroke, S. also was very concerned about the way in which her family would be affected if she died, leaving her children without a mother. This concern seemed to arise in direct relation to the suffering that she experienced following her father’s death. S. underwent our treatment program. She initially responded very well to the corrective information and cognitive restructuring because she was able to counter her thoughts of stroke by examining the medical evidence and the actual risk. She realized that she was vastly overestimating the chance of stroke and misinterpreting physical symptoms as an im-

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pending stroke. However, as sometimes occurs, S. used this information in a reassuring way without fully understanding the role of anxious thinking. That is, the information reassured her but was not fully integrated into a new way of thinking. She continued to be sensitive to signs of impending panic, such as rapid heartbeat or shortness of breath, which were elicited by physical activities or which resulted from normal fluctuations in her bodily state. It was not until the interoceptive exposure phase of treatment was implemented that her sensitivity to physical symptoms and her concerns about suffering a stroke truly diminished. S. was taught breathing skills training and used it successfully to help herself continue in whatever activity she was involved in at the moments of being anxious rather than retreating to “safety.” Initially, she used breathing skills training to prevent more negative experiences, such as panic or stroke. However, S. learned to apply breathing skills training as an adaptive strategy for facing her fears rather than as a way of trying to prevent a dire consequence from occurring. S. found the following interoceptive exercises to elicit sensations most similar to her naturally occurring experiences: hyperventilation, holding her breath, straw-breathing, and step-ups. These also produced the most anxiety. Initially, the exercises increased S.’s vigilance to bodily sensations, and she panicked more frequently than she had in the preceding months. However, her sensitivity eventually reduced with repeated practice. Activities that produced bodily symptoms included lying in bed without the television on and letting herself simply think about her bodily sensations objectively, walking alone quickly, drinking coffee, reading information about strokes, thinking about her father’s death, and swimming. Some of these activities were more difficult because S. was unable to rid herself quickly of the physical sensations. However, the importance of tolerating the sensations and not connecting their presence with evidence for physical risk was pointed out, and eventually, S. was less anxious. S. experienced few panic attacks in the first few weeks of treatment and experienced more panics when interoceptive exposure began, after which the panic attacks declined. Her belief in the possibility that she was having a stroke and her concerns about the well-being of her children reduced along with the reduction of general anxiety and panic. By the end of treatment, several other aspects of her life had changed without direct

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instruction from the therapist. S. reported that she was engaging in work-related and family-related activities no longer as distractions but rather for the direct involvement and enjoyment. In addition, S. underwent an ophthalmological exam, which she had avoided for the previous  or  months for fear that evidence of mini-strokes would be found. At the end of the program, S. was reevaluated and found to experience very little evidence of PD. Her status was maintained for  months after treatment completion, when she was reassessed.

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Chapter 4

Introduction to the Program

(Corresponds to chapter  of the workbook)

There are no materials needed.

Outline ■ To provide information about panic attacks, Panic Disorder, and agoraphobia ■ To describe the treatment program

Therapist Behaviors The therapist is to review the main points of this chapter for the client, who will read the chapter over the time before the next visit with the therapist. The therapist is to be fully informed about the phenomenology, etiology, and maintenance model of Panic Disorder (PD) and, therefore, be able to informatively answer clients’ questions and provide clarification, where necessary. In other words, the therapist is primarily an information giver in this introductory chapter. Questions asked on initial therapeutic contact most often are reassurance seeking in nature, as clients ask about particular experiences that seem most inexplicable or frightening to them. At this initial stage of treatment, it is appropriate to provide direct information and correct misconceptions. However, giving reassurance is rarely an effective strategy in the long term and, therefore, is not continued once the education phase of treatment is completed (after chapter ). Questions in the fu-

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ture which obviously reflect seeking reassurance may be deflected by asking clients to refer back to what their own experience tells them.

Information on Panic Attacks, Panic Disorder, and Agoraphobia Overall, the information presented in this introductory chapter is intended to clarify the purposes of the workbook and provide corrective information that assures clients that they are neither insane nor atypical and that there is a good chance of successful treatment. Hence, cognitive modification is begun through provision of a model for understanding panic attacks and anxiety which is more objective and less victimizing than the client’s own perspective. By describing the phenomenology of PD and the particular clustering of symptoms which characterizes PD, clients are informed that they are not alone in their experiences; some reassurance derives from recognizing that their problem is a known entity. Similarly, the psychobiological conceptualization of panic is presented to demystify the experience of panic and provide a conceptual framework within which the treatment makes sense. By understanding the nature and likely causes of panic and anxiety, a personal scientist perspective is being encouraged; a perspective that is a core element for the entire treatment. At the same time, the psychobiological model introduces the notion that panic attacks themselves are not the main issue; more important is the anticipation of and behavioral avoidance of panic attacks since these are the features that distinguish PD from the occasional panic attacks experienced by a substantial number of the population. The various unhelpful ways of coping with panic attacks (i.e., avoidance, alcohol, and so forth) are presented as understandable, given the level of anxiety experienced, but also as contributory to PD and agoraphobia in the long term. Hence, the treatment is designed to replace these unhelpful coping methods with more adaptive methods of coping. Clients learn that they might have inherited an emotional sensitivity that predisposes them to PD. From the research conducted to date, high

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levels of emotionality, particularly negative emotionality, appear to contribute to the likelihood of developing an anxiety disorder. Furthermore, some evidence indicates that the propensity to respond to stressful events with a panic attack, as opposed to other manifestations of anxiety (such as ulcers, headaches, or depression) also may be somewhat physiologically based. It is important that clients understand that the predispositional variables do not mean that they are destined to have PD for the rest of their lives because emotional vulnerabilities can be regulated in the ways described in this treatment. Similarly, the psychological vulnerabilities—tendencies to interpret bodily sensations as harmful—do not mean being destined always to suffer from PD. The treatment assumes that the beliefs can be lessened with the right experience and generation of competing and more evidencebased beliefs. Finally, by recognizing that while stress contributes to the onset of panic, it does not typically explain the perpetuation of panic attacks and PD, the client is steered away from stress reduction as a treatment option. Instead, the goal of this treatment is to target the processes that perpetuate fear and anxiety, those being the anxious thinking and avoidant behaviors.

Case Vignettes

Case Vignette 1 C: Does anyone ever faint when they panic? T: Fainting as a result of panic is very rare, although it does occur in some cases. Panic attacks are associated predominantly with sympathetic nervous system activation, whereas fainting involves an overactivation of the parasympathetic nervous system. That is, panic and fainting have opposing physiological processes. In addition, fainting is very familial, and if you have never fainted before, it is unlikely that you will faint now. Fainting is most common in people who become nervous when exposed to blood and injury. But even if you faint when you see blood or injury, chances are that you will not faint when you panic, because

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blood and injury have a very specific effect on the parasympathetic nervous system which is different from the effect of panic.

Case Vignette 2 C: I only experience one or two of the symptoms you mentioned (see the DSM–IV checklist). Does that mean that I do not have panic disorder? T: Have you ever experienced four of those symptoms at one time? C: Yes, but it was a long, long time ago. T: Are you worried about having more panic attacks? C: Well, I avoid going to shopping malls and driving because I think that I might have a really bad panic attack. T: Then whether you currently experience four or more or less than four symptoms, it is the same problem. That is, you are anxious about having panic attacks, and that anxiety places a restriction on your activities.

Case Vignette 3 C: You said that panic attacks are acute episodes of fear which are typically short-lived. My panic attacks last for weeks. T: Do you mean that the peak of panic lasts for weeks or that you are highly anxious for weeks? C: Well, I feel like I’m constantly on the edge of having another panic attack; and, in fact, I do have more of them. After the first one, I’m really anxious, and they keep recurring until somehow I am exhausted, and they stop. This whole thing takes several weeks. T: In other words, the panic attack itself is a relatively short event, but it is followed by a high level of anxiety, which is most likely contributing to the recurrence of panic attacks. So, there is a fluctuation between brief episodes of intense fear (i.e., panic) and long-lasting anxiety. C: Yes, that’s the way it feels.

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Case Vignette 4 C: I have noticed that I panic more than usual just before my menstrual period. Why does that happen? T: A combination of factors may lead to an increased frequency of panic before your period. For example, hormonal changes might lead you to experience various sensations that are not typical, and these sensations may make you anxious. Also, you may be attending very closely to your bodily sensations at those times, given your expectation of panicking. Or, maybe you are more emotional in general and, therefore, more likely to panic.

Case Vignette 5 C: I wake out of sleep in a panic attack. How can that happen? T: We will go into much more detail about the reasons why panic attacks occur at different times. However, let me just mention at this point that nocturnal panic is quite common. Approximately % of people who experience PD report at least one occasion on which they have woken from sleep in a panic. Nocturnal panic seems to involve processes similar to those that occur during daytime panic attacks.

Case Vignette 6 C: Does this mean that my children will have Panic Disorder? T: It is true that panic attacks run in families. This means that the chance of children having panic attacks is increased if their parents have experienced panic attacks. Learning ways by which to regulate your panic attacks will help buffer the risk for your children.

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Atypical and Problematic Responses Given the physical sensations experienced during panic and anxiety, a medical or chemical explanation of panic attacks is often more credible to clients than is an explanation that takes into account psychological variables. In addition, a medical or chemical account may be perceived as less stigmatizing than a psychological account. For these reasons, clients may be unwilling to give full consideration to the information discussed in the first few chapters, despite the absence of medical evidence (following extensive testing) of abnormality. Clients may attribute their panic attacks either to a physical disease process that “the doctors have overlooked” or to a “chemical imbalance” that cannot be tested. Furthermore, many clients have been told by physicians that they do indeed have a chemical imbalance. As described in the workbook, however, there are no definitive data to show that such chemical imbalances cause PD. We suggest the following ways of dealing with the situation described above. . Validate the “real” nature of symptoms of panic, and understand that these symptoms are not all “in your head.” Reiterate that biochemical changes are indeed most likely occurring during panic attacks. . Examine the evidence. What evidence does the client have from medical testing to assume a medical or chemical abnormality? Usually, there is none, or at least the panic continues despite control of the medical abnormality (e.g., thyroid medication for hyperthyroidism, diet changes for hypoglycemia, heart medication for cardiomyopathy). Educate the client more fully about the evidence to date. Specifically, evidence confirms the presence of definite biochemical processes during anxiety and panic (i.e., reassure clients that the sensations are not “all in their head” or imagined). However, the main question of why panic attacks develop in the first place cannot as yet be answered from a biochemical perspective. That is, there is no conclusive evidence yet to suggest a specific biochemical dysregulation that causes panic attacks.

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. Present the notion that even if biochemical or medical abnormalities are present and do at least partly explain panic, there is no reason to assume that the Mastery of Your Anxiety and Panic (MAP ) treatment will not be effective in treating panic. In other words, biologically based disorders can be managed effectively with psychological treatments. The evidence concerning the efficacy for the treatment described in the workbook can be highlighted. . A medical or biochemical explanation may seem more viable when clients are unable to associate their panic attacks with discernible triggers. Thus, inform clients that once they are able to recognize the triggers to their anxiety, which is one of the first components of this treatment program, then the psychological model may seem more understandable or relevant to their own experiences.

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Chapter 5

Learning to Record Panic and Anxiety

(Corresponds to chapter  of the workbook)

Materials Needed ■ Panic Attack Record ■ Daily Mood Record ■ Progress Record

Outline ■ Emphasize the importance of objective record-keeping ■ Distinguish generalized anxiety from panic ■ Introduce monitoring forms ■ Have client complete a Panic Attack Record and Daily Mood Record in session ■ Provide corrective feedback, and answer any questions the client may have ■ Assign homework

Therapist Behaviors The therapist is to provide corrective feedback and answer questions as the client completes (in session) a Panic Attack Record for a recent panic attack. Aid clients in recording their thoughts and behaviors by helping them to consider what it was that they were most worried about hap-

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pening in the panic attack, and what they did as a result. In addition, provide feedback to clients as they complete the ratings on the Daily Mood Record for today and yesterday. Clients are expected to continue to record their panic and daily mood for the remainder of the program. At the start of each session, the therapist should spend a few minutes reviewing the monitoring forms for the past week and reinforce their continued use.

Record-Keeping During this session, explain to the client that recording panic and anxiety objectively is a necessary first step to therapeutic change. Keeping records offsets the anxiety-inducing effects of avoidance, subjective monitoring, and recall biases. The goal is for clients to begin to become observers rather than victims of their anxiety. The importance of understanding panic attacks in a matter-of-fact manner, as opposed to focusing on subjective distress, is emphasized because the latter tends to maintain fear and anxiety. In contrast, objective awareness provides a way of moving out of the role of victim and into the role of being an active participant in understanding one’s own panic and anxiety. The distinction between subjective and objective recording is especially important to point out to clients who are resistant to recording because they believe that they are already constantly aware of their symptoms (that is, point out their reliance on a subjective monitoring style, and promote the value of a different, objective style). Panic attacks are always cued; but sometimes, the cue or trigger is not obvious. Recording will facilitate the detection of specific triggers and conditions under which panic attacks occur. This in turn contributes to a greater objective understanding and begins the process of identifying relevant cues for exposure therapy.

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Anxiety Versus Panic Educate the client about the differences between panic and anxiety. Panic is described as an acute episode of intense fear, whereas the state of anxiety centers on future-oriented worries and tends to develop more gradually, without a discrete onset. States of generalized anxiety may increase the likelihood of experiencing panic attacks as a function of chronic tension which elicits somatic cues and intensified attentional vigilance for somatic cues. Education about the differences between panic and anxiety again contributes to an objective, personal scientist model for the client.

Panic Attack Record Introduce the client to the Panic Attack Record. Clients should use this form whenever they experience a panic attack or a sudden rush of fear. A blank record is included in the workbook, and multiple copies can be downloaded from the TreatmentsThatWork™ website (http://www.oup .com/us/ttw). During the session, ask the client to complete a Panic Attack Record for a recent panic attack. An example of a completed Panic Attack Record is shown on page .

Daily Mood Record Introduce the client to the Daily Mood Record. This form should be completed at the end of each day. It uses a -point scale to rate daily levels of anxiety, depression, and worry about having a panic attack. A blank record is included in the workbook, and multiple copies can be downloaded from the TreatmentsThatWork™ website (http://www.oup.com/us/ttw). During the session, ask the client to complete a Daily Mood Record as practice. Once again, provide corrective feedback, and answer any questions the client may have. An example of a completed Daily Mood Record is shown on page .

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Panic Attack Record Date: 2/16/06

Time began: 5:20 p.m.

Triggers: Home alone and shortness of breath. X

Expected:

Unexpected: Maximum Fear

---------------------------------------------------------------------- None

Mild

Moderate

Check all symptoms present to at least a mild degree: Chest pain or discomfort Sweating Heart racing/palpitations/pounding Nausea/upset stomach Shortness of breath Dizzy/unsteady/lightheaded/faint Shaking/trembling Chills/hot flushes Numbness/tingling Feelings of unreality Feelings of choking Fear of dying Fear of losing control/going insane Thoughts: I am going crazy, I will lose control. Behaviors: Called my mother. Figure 5.1.

Jill’s Panic Attack Record ()

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Strong

Extreme

Daily Mood Record for Jill Rate each column at the end of the day, using a number from the –-point scale below. ---------------------------------------------------------------------- None

Mild

Moderate

Strong

Extreme

Average Anxiety

Average Depression

Average Worry About Panic

Monday 16th

7

5

7

Tuesday 17th

5

4

5

Wednesday 18th

4

4

5

Thursday 19th

4

3

4

Friday 20th

4

4

5

Saturday 21th

2

1

1

Sunday 22th

2

2

2

Date

Figure 5.2.

Jill’s Daily Mood Record

Progress Record The last monitoring form that the client will use is the Progress Record. Clients should use this chart at the end of each week to record their progress throughout the course of treatment. It will allow clients to see how they are doing and help them to put things into perspective. A blank record is included in the workbook, and multiple copies can be

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downloaded from the TreatmentsThatWork™ website (http://www.oup .com/us/ttw). It is not necessary for the client to complete a Progress Record during this initial session. The chart becomes more useful as treatment progresses. An example of a completed Progress Record is shown below.

Progress Record For each week, plot the number of panic attacks you experienced and your average anxiety level for that week.

10 9 8 7 6 5 4 3 2 1 0

1

2

3

4

5

6

Figure 5.3.

Example of completed Progress Record

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7

8 Week

9

10

11

12

13

14

15

Number of Attacks Panic Attacks Number of Panic per Week per Week AverageAverage AnxietyAnxiety per Week

Case Vignettes

Case Vignette 1 C: What am I supposed to record if I successfully avoid panics by never putting myself in the situations that could make me panic? T: If you are not panicking at all, just record your daily mood and anxiety.

Case Vignette 2 C: I can always find an explanation for my panic attacks when I think about it afterward. Doesn’t that mean that they are all expected? T: When we categorize attacks as expected or unexpected, we actually mean how it felt at the moment of the panic: was it a complete surprise at the moment, or was it something that you were anticipating or waiting for? So, you could have a completely unexpected panic attack, but you are later able to explain it once you consider possible contributing factors. For the Panic Record, consider what it was that you felt at the moment of panic.

Case Vignette 3 C: Should I record every time I notice symptoms? If so, I’ll be spending all of my time recording. T: Only record those times when you experience a sudden increase in symptoms and distress.

Case Vignette 4 C: I’m afraid that this kind of recording will make me more anxious. T: Do you typically try to avoid thinking about how you feel because you are concerned that it will lead you to panic?

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C: Yes. T: So, the recording forms will force you to face the things that frighten you. However, the more you face these things by recording your experiences, especially using the objective method of recording, the easier it will get. In other words, your anxiety will lessen. It is the same with almost everything we do: at first it is hard, but with repetition, it gets easier.

Atypical and Problematic Responses Sometimes clients claim that they do not have time or energy to complete the recording forms. If lack of time or energy is due primarily to lack of motivation, then you might assume that the client’s level of motivation for conducting the entire treatment program is relatively low. If so, you might question whether now is the best time for the client to begin this type of program. On other occasions, as reflected in Case Vignette , recording may be avoided because it elicits anxiety or fear. In this situation, the possibility of becoming more anxious or fearful, at least initially, can be recognized, but the usual decline in anxiety or fear should be emphasized, especially when recording is objective. If clients state that they know how they feel and that recording is therefore redundant, point out times at which panic attacks seem to occur unexpectedly, and discuss the benefit of close monitoring in order to identify precipitants for those unexpected occasions. Again, the objective nature of the self-recording should be emphasized, as it may be quite different from ways in which clients have been preoccupied with their symptoms up until now. Furthermore, the records will provide concrete evidence for the purposes of later comparisons (i.e., to see change over time). Finally, some clients may require continuing corrective feedback in terms of the method of recording due to a lack of understanding of the procedures or the forms. Compliance with recording will be increased by spending a few minutes at the beginning of each subsequent session to review their recording forms for the preceding interval.

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Homework

✎ Instruct clients to record panic attacks and daily mood levels for at least one full week using the Panic Attack Record and the Daily Mood Record.

✎ Clients should read chapters , , , and chapter , section , in the workbook

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Chapter 6

Negative Cycles of Panic and Agoraphobia

(Corresponds to chapter  of the workbook)

Materials Needed ■ Step-by-Step Analysis of Panic Attack form

Outline ■ Help the client understand the negative cycles that contribute to panic attacks and agoraphobia ■ Illustrate how this treatment interrupts the panic and agoraphobia cycles

Therapist Behaviors The therapist is to review the main principles of the material in this chapter, tying the concepts to the client’s panic and anxiety wherever possible. In addition to being informative, the therapist is to give corrective feedback and facilitate the client’s discovery of the pattern of influences across thoughts, behaviors, and physiology, as well as the sequence of events that typify panic attacks and episodes of anxiety. That is, the therapist should assist the client in describing a recent panic attack and prompt the client to think of what happened at each step of the chain of reactions, from the first sensation, to the thought to the behavior, and so on.

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Cycles of Panic and Agoraphobia The main goals of this chapter are to provide an understanding of the ways in which thoughts, feelings, and behaviors influence each other in ways that perpetuate fear and anxiety. By so doing, this chapter continues to reinforce an objective self-awareness and behavioral scientist model. In addition, understanding these perpetuating influences provides a rationale for the treatment. A theme that is introduced here and that is central to the entire treatment is that anxiety and fear are not “all bad.” The purpose of fear and anxiety is to prepare the body and mind to deal with threat. In other words, they are designed to protect us from danger. Some level of anxiety is constructive and conducive to performance and, in some situations, necessary for survival. The goal of the treatment program is to reduce the expression of anxiety at times when it is not warranted, as opposed to removing all anxiety. By learning to differentiate between anxiety and panic on the basis of accurate descriptions of the response components (physiological, cognitive, and behavioral) that typically exemplify the respective states, clients acquire even more objective self-awareness and enhance their role as a behavioral scientist of their own reactions. Anxiety and fear are conceptualized as reactions, as opposed to entities over which the individual has no control (despite the perception of being out of control). Emphasis is given to the ways in which thoughts, behaviors, and physiology influence each other, in cycles, so that clients are able to view their anxiety and panic as reactions. In addition, detailed description of the cycles through step-by-step analyses emphasizes to clients the role of reactions to thoughts and to physical sensations as crucial elements to target in treatment. In other words, learning to replace a threatening interpretation of physical sensations with a nonthreatening interpretation, or learning to replace an avoidant response to physical sensations or to negative thoughts with a nonavoidant response, is central to overcoming fear and anxiety. The links between response components and treatment components is intended to demystify treatment and encourage a problem solving

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approach to treatment; that there exists a logical way of treating this disorder.

Step-by-Step Analysis of a Panic Attack Introduce the client to the Step-by-Step Analysis of Panic Attack form. Step-by-step analysis is a method of identifying response components and the ways in which they cycle and influence each other. For example, noticing a heart-rate fluctuation may be followed by thoughts of a potential heart attack, which may be followed by increased heart rate, which serves to confirm the possibility of heart attack, and so forth. A blank form is included in the workbook, and multiple copies can be downloaded from the TreatmentsThatWork™ website (http://www.oup .com/us/ttw). An example of a completed Step-by-Step Analysis is shown on page .

Case Vignettes

Case Vignette 1 C: How can a short-term program cure me after I have experienced these panics for so long? I could understand if the onset were recent, but this has been going on for so long that I feel that there is no way it can change so quickly. T: There are several things to keep in mind. First, it has been found that the duration of panic disorder does not predict response to treatment. Rather, it is the amount of practice and engagement you have in the treatment which is most important to the outcome and the benefit that you receive. Second, as we mentioned last time, this program is skills oriented, and learning can take place relatively quickly. Third, during this short-term program, you will acquire skills that you can apply on your own. You may continue to experience some anxiety when you finish the treatment, but you will have principles and skills to deal with the anxiety that remains. Finally, the rate of success with

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Step-by-Step Analysis of Panic Attack Where were you and what was going on when the panic attack first started? At home, watching television, just relaxing, really tired from a late night. What happened first? A physical symptom, negative thought, or a behavior? I noticed that my heart skipped a couple of beats. What happened next? How did you react to the first physical symptom or negative thought? Did you notice more physical symptoms, more negative thoughts, or did you do something, such as seek help, lie down, or exit wherever you were? I was terrified that something was wrong with my heart, I thought that maybe I did some damage the night before by exhausting myself, and immediately put a cool cloth on my forehead and lay down. What happened next? Did the physical symptoms get worse, did you become even more scared about negative things happening? My heart rate sped up, and I began to sweat. I thought of calling my husband or 911. I thought I was having a heart attack. What was next? The feelings got worse and worse—I felt weak and dizzy, and my heart was racing very fast, and I sweated and felt sick to my stomach. I really thought I was dying. I was too afraid to move, so I just lay on the couch, praying that I would not die. How did it end? Eventually, the feelings subsided, although I felt very weak and out of it for about an hour afterward. Figure 6.1.

Example of completed Step-by-Step Analysis of Panic Attack form

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this type of treatment is very high, and that in itself is reason for you to give it your best effort, or you should at least forestall a judgment until you have tried it.

Case Vignette 2 C: I understand how thinking about something anxious might produce a panicky feeling, but why do I panic when I’m not thinking of anything? Sometimes it comes right out of the blue. Sometimes when I’m watching TV and feeling relaxed, I can all of a sudden panic, and I don’t know why. T: The “out of the blue” panic attack is a hallmark feature of panic disorder. Next time, we will discuss the reasons why a panic attack may occur seemingly out of the blue. In brief, it has to do with the triggers being so subtle that you are not fully aware of them. You will soon learn to become more aware of them.

Case Vignette 3 C: I don’t spend time worrying about panicking because I don’t confront any of the situations that make me panic. As long as I can stick with my familiar places, then I am okay. So, my worry ratings on the Daily Mood Record will be zeros. T: What would happen if you had to go outside of your familiar places— if you knew that tomorrow you had to take a long trip to a new place? C: I would not do it. T: But let us just say that you had to. What would happen? C: I would become a mess—terribly anxious. T: So that illustrates that your avoidance behavior is based on being very worried and anxious about panicking. In your case, the avoidance behavior is the same as worrying about panicking.

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Case Vignette 4 C: The feeling of panic just hits me. It is so sudden that it is impossible for me to know what is happening. I don’t know what I am thinking— all I know is that I can’t stand the feeling. T: I understand that the feeling terrifies you and that it is hard to think about it objectively, especially at the moment it is happening. However, if you thought it was normal to feel the rush of adrenaline in your body, then you would not be terrified, and you would know that you could tolerate it. The goal of this treatment is to help you realize that you can tolerate these feelings.

Atypical and Problematic Responses In most cases, clients understand the interaction among the three response components, and it seems credible. Occasionally, however, it is difficult for clients to relate this model to their own experiences due to the sudden onset of panic and the frequent absence of specific danger cognitions. That is, the “out of the blue” panic attack is initially difficult to explain according to the three-response-component model. In this case, it is helpful to explain that the reciprocal influences among the response components can occur not only on a conscious level but also on a very direct, subconscious level, so that an individual may almost automatically become afraid. This is explained in more detail in the next chapter. Occasionally, clients report that because they have panicked so many times, they are no longer concerned about fainting, having a heart attack, or being embarrassed. That is, they report having no danger-laden cognitions. Nevertheless, they still panic. In these cases, it is helpful to ascertain what they think might happen if the feelings of panic were to continue longer than ever before or to become more intense than ever before. This probing usually leads to recognition of concerns about danger or to concerns about being out of control. Both imply threat, and therein, the danger-laden cognition is revealed.

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Sometimes clients report that they no longer panic but they are constantly anxious and always have physical symptoms. Unless they are experiencing bursts of arousal or peaks of fear in addition to the general anxiety, these individuals are technically not panicking. However, it is possible that their levels of anxiety and chronic symptomatology are functions of extreme anxiety about the recurrence of panic. Therefore, the same treatment procedures are appropriate.

Homework

✎ The client should continue to record anxiety and panic for one week using the Panic Attack Record and Daily Mood Record.

✎ The client should read chapters  and , and chapter , section , in the workbook.

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Chapter 7

Panic Attacks Are Not Harmful

(Corresponds to chapter  of the workbook)

There are no materials needed.

Outline ■ To provide the client with information about panic attacks

Therapist Behaviors The therapist reviews the major material and concepts in the chapter, tying them to clients’ panic and anxiety wherever possible. The therapist is to be informed so as to be able to fully address questions raised or to provide clarifications. This is the last of the series of chapters in which the focus is primarily information-giving.

Objective Understanding of Panic Overall, the informational model of panic attacks builds on the previous chapters in providing an alternative conceptual framework that is nonthreatening and contributes to a personal scientist perspective, whereby clients can gain an objective understanding of their panic and anxiety. This objective perspective is believed to be critical to the treatment process. Panic is construed as an alarm reaction, the primary function of which is to protect the organism. It is a survival mechanism that misfires. Clients

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learn that this misfiring is not dangerous, but because the reaction is perceived as dangerous, it becomes a source of anxiety. The sensations experienced are often based on physiological processes. Understanding the connections between different sensations experienced, their physiological basis, and their survival value engenders a greater sense of safety. Furthermore, it reassures clients that their sensations are not all imagined. By the same token, however, thoughts play a crucial role in intensifying and prolonging sensations. Moreover, it is sometimes possible to perceive bodily sensations in the absence of any real physiological change. In the case of severe panic attacks, however, perceptions of physical sensations are almost always accompanied by an array of actual physiological changes. A panic attack is presented as a learned fear of internal sensations. Unlike fear of an external object, fear of internal sensations generates positive feedback loops. That is, fearing an internal sensation (e.g., “I am having a heart attack”) increases arousal, which in turn increases the intensity of the physical sensation (e.g., chest pain) that is feared. Experiencing more intense physical sensations may then confirm the subjective fear (e.g., “I really am having a heart attack”), and, hence, a spiraling effect occurs. Crucial to the model of panic attacks is the role of anxiety about the recurrence of panic. Because the panic attack itself is feared as a dangerous event, it makes sense to anticipate the next time it will occur and to be very vigilant for signals of its next occurrence. Such vigilance and apprehension result in escalations of generalized arousal. Increased generalized arousal may produce more physical sensations that trigger a fear reaction. In addition, the attentional vigilance for signals of danger which accompanies anxiety tends to lead to a selective attention to bodily sensations. This selective attention leads to a heightened awareness of sensations that might not have been noticed in the past. Thus, a combination of more arousal and more attention to arousal sensations is considered central to the maintenance of panic.

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Case Vignettes

Case Vignette 1 C: If panic is an adaptive response, why do I feel unreal? What is the adaptive value of unreality? T: It is not necessarily the sensations that are adaptive for survival but the physiological processes that underlie the sensations. One might experience various sensations as a by-product of high levels of arousal. The feeling of unreality is often related to hyperventilation because in preparation for fight or flight, the body reacts by breathing faster because oxygen is a source of energy. Similarly, a tightness around the throat or chest may be the by-product of increased muscle tension and a slowing down or retardation of the digestive process, both of which are part of the survival reaction.

Case Vignette 2 C: If the crux of the problem is that I am afraid of physical sensations, how do you explain a panic attack that occurs from sleep? I’m not thinking when I am asleep. T: There are several things to keep in mind about nocturnal panic attacks. First of all, natural fluctuations in physiological arousal occur during sleep. For example, we experience peaks and valleys in heart rate as we sleep, and individuals who are more anxious in general during the day typically experience more arousal peaks during the course of sleep. If you are particularly sensitive to or afraid of arousal, it is conceivable that the peak of arousal may cause you to wake in a panic. In contrast, someone who is not afraid of their bodily symptoms may experience the same amount of physiological arousal during sleep but react with restlessness or a disturbed sleep pattern instead of panic. Think of yourself in a large crowd. You are unlikely to hear all of the conversations going on around you. However, you may hear your

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name if it is mentioned. Similarly, you may not hear the sounds of traffic while you are sleeping, but you hear the sound of your baby crying, even though the sound itself is fainter. Cues that you think mean danger will, of course, be very meaningful. Therefore, you may be likely to awaken in response to physical changes happening in your body which scare you.

Case Vignette 3 C: Why did I start to worry about the symptoms in the first place? T: It seems that certain life experiences affect how people understand ambiguous signs of arousal. For example, the unexpected death of a significant person may prime anyone to misinterpret ambiguous arousal symptoms as harmful. Or, negative personal experiences, such as a bad reaction to drugs or surgeries or an asthma attack, may have the same effect.

Case Vignette 4 C: Once I have a panic attack, the feeling stays around for weeks afterward. That seems to be different from your description of short-lived, intense sympathetic activation. T: The actual panic attack generally is very brief, as sympathetic nervous system exacerbation is counterbalanced by parasympathetic nervous system activation. However, after a panic attack, you probably experience a lot of general arousal and vigilance for signals of another panic attack. That state of general anxiety can be accompanied by various symptoms that may be similar to, although usually slightly less intense than, some of the symptoms experienced during panic, except that they are present more chronically as opposed to acutely.

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Case Vignette 5 C: I don’t think of the sensations as being dangerous but, rather, as just uncomfortable. Nobody would want to feel those kinds of sensations. So I don’t understand why I continue to experience them if I don’t think of them as being dangerous. T: When you experience the symptoms more intensely, do you typically try to stop them from occurring and hope that they will go away, or do you notice their presence and continue with whatever else you were doing? C: I try to get rid of them as quickly as I can—I try to distract onto something else. T: What do you think will happen if you focus on the sensations? C: They might get worse and worse, and then I might really lose it. T: So, actually, there is a threat in the back of your mind, although your immediate reaction is one of discomfort. C: Yes, I guess so.

Case Vignette 6 C: If I understand you correctly, you’re saying that my panic attacks are the same as the fear I experienced the time we found a burglar in our house. But it doesn’t feel the same at all. T: Yes, those two emotional states—an unexpected panic attack and fear when confronted with a burglar—are essentially the same. However, in the case of the burglar, where were you focusing your attention: on the burglar or on the way that you were feeling? C: The burglar, of course, although I did notice that my heart was racing a mile a minute. T: And when you have a panic attack, where are you focusing your attention: on the people around you or on the way that you are feeling?

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C: Well, mostly on the way that I’m feeling, although it depends on where I am at the time. T: Being most concerned about what is going on inside you—on the feelings that you are having—can lead to a very different type of experience than being concerned about a burglar, even though basically the same physiological reaction is occurring. For example, remember our description of the way in which fear of physical symptoms can intensify the physical symptoms.

Atypical and Problematic Responses Often, clients continue to be perplexed about the repeated occurrence of certain physical sensations that they never experienced prior to their first panic. Indeed, the very questioning of the source for the somatic experiences reflects their anxiety over their recurrence. The following scenario may be useful. Imagine yourself walking through a dark alley, and you have reason to believe that somewhere in the darkness lurks a killer. Under those conditions, you would be extremely attentive to any sign, any sound, or any sight of another person. If you were walking through the same alley and were sure that there were no killers, you might not hear or detect the same signals that you picked up on in the first case. Now, let us translate this to panic: the killer in the dark alley is the panic attack; and the signs, sounds, and smells are the physical sensations that you think signal the possibility of a panic attack. Given the acute degree of sensitivity to physical symptoms that signal a panic attack, it is likely that you are noticing normal “noises” in your body that you would otherwise not notice and, on occasion, immediately become fearful because of those “noises.” In other words, the sensations are often noticeable because you attend to them. Some clients may understand the concept of panic as a fight-flight response in general and yet not accept this as an explanation for their own panic attacks, because they judge the sensations experienced during panic to be very different from sensations experienced during a fear reaction to a known stimulus (such as narrowly escaping a car accident).

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The difference between these two experiences can be explained as due to different foci of attention. The focus on sensations triggered by an obvious external stimulus is quite different from the focus on sensations for which no stimulus is perceived, as in panic. The inward focus of attention which occurs during panic thus changes the experience of the sensations, so that they feel qualitatively different than those resulting from an external trigger. The physiological basis of these sensations, however, remains the same in both cases.

Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

✎ The client should read chapter , section , in the workbook over the course of the week.

✎ You may instruct the client to continue to chapter  in the workbook once the client has completed at least one week of recording panic attacks and moods and has read workbook chapters –, and chapter , section .

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Chapter 8

Establishing a Hierarchy of Agoraphobia Situations (Corresponds to chapter  of the workbook)

Materials Needed ■ List of typical agoraphobia situations ■ Agoraphobia Hierarchy

Outline ■ Review client’s records from the past week ■ Work with the client to generate a hierarchy of agoraphobia situations ■ Help the client identify unhelpful ways of coping (e.g., superstitious objects and safety signals)

Therapist Behaviors The therapist is to play an active role in reviewing the week’s worth of Panic Attack Records and Daily Mood Records and in brainstorming ways to facilitate such monitoring in the case of noncompliance. Therapists are to remind clients to enter their week’s worth of data in the Progress Record in the workbook. In addition, therapists will help clients to generate a hierarchy and to list their superstitious objects, safety signals, safety behaviors, and distractions. Both of these tasks are best done in session, although clients may review and modify their choices over the following week. The therapist can suggest possible moderators of the level of anxiety (e.g., the presence

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of others) in order to generate a hierarchy that covers a range of anxiety and to help clients identify safety behaviors and safety signals that contribute to anxiety in the long term, from which clients are to be weaned during treatment. Also, this chapter will allow the therapist to make an assessment of the degree of agoraphobia avoidance, which in turn will determine how much time is to be devoted to in vivo exposure in chapter  and, thus, the overall length of treatment.

Records Review The first section of this chapter addresses what was learned from the past week of self-recording, such as patterns of anxiety in relation to panic attacks and the conditions under which panic attacks are most likely to occur. Ways of enhancing compliance with self-recording are suggested.

Establishing a Hierarchy of Agoraphobia Situations The major focus of this chapter is the development of an individualized hierarchy of agoraphobia situations for the client in preparation for in vivo exposure. A hierarchy composed of situations that range in anxiety level from mild to moderate, and all the way up to extremely anxious, will form the basis of a graduated approach to in vivo exposure. Although exposure exercises are not scheduled to take place for the next couple of weeks, it is important to introduce the hierarchy now. Before beginning exposures, the client will need to practice the thinking skills from chapter  in relation to each situation on his hierarchy. This will help prepare the client for the upcoming in vivo exposure exercises. Work with clients to identify the specific situations that they avoid by using the following list as a guide. Have clients review the list in the workbook and put a check next to the situations they avoid or are anxious about. Instruct clients to add as many “others” as necessary. Have each client select up to  of the items on the list with a check mark. This will form the basis for the client’s individualized agoraphobia hierarchy.

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Typical Agoraphobia Situations Check those that apply Situations You Avoid or Are Anxious About

Driving Traveling by subway, bus, taxi Flying Waiting in lines Crowds Stores Restaurants Theaters Long distances from home Unfamiliar areas Hairdressers Long walks Wide-open spaces Closed-in spaces (e.g., basements) Boats At home alone Auditoriums Elevators Escalators Other Figure 8.1.

Blank Typical Agoraphobia Situations form

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Individualized Agoraphobia Hierarchy After the client has reviewed and checked off his or her items on the list of Typical Agoraphobia Situations, work with the client to develop a hierarchy by using the Agoraphobia Hierarchy form in the workbook. The situations on this list are the ones that the client will face over and over again during in vivo exposure. It is important to take into account the various conditions that moderate levels of anxiety, such as distance, being accompanied or being alone, the time of day, proximity to an exit, and so forth. Your client’s completed hierarchy may look something like the completed Agoraphobia Hierarchy on page .

Unhelpful Ways of Coping In this chapter, clients’ reliance on safety signals (such as a brown paper bag in the event of hyperventilation or an empty medication bottle), safety behaviors (such as driving only in the right-hand lane of traffic), and distractions (such as a radio) are restated as other forms of avoidance which will interfere with corrective learning and contribute to anxiety in the long term. Thus, the goal of treatment is to learn to face agoraphobia situations without these forms of avoidance.

Case Vignettes

Case Vignette 1 C: You said that treatment involves repeatedly facing my feared situation, but I’ve done that already: I have to drive every day to get to work, and my anxiety just seems to get worse each time. T: If you look over the list of unhelpful coping methods, do you see any that might apply to driving to work? C: Well, I do play my radio really loud so that I have something else to focus on, so I guess that could be distraction. And I call my mother whenever I get anxious, and that could be a safety behavior.

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Agoraphobia Hierarchy Anxiety and/or Avoidance (0–10)

Situation

Walk to the store alone (10 blocks)

3

Wait in long line at the post office

4

Shop at the mall during peak hours

5

Drive to sister’s place with family member

6

Drive to sister’s place alone

7

Attend live performance at the theater

8

Stay overnight in another town

9

Travel long distance by plane

10

Figure 8.2.

Example of a Completed Agoraphobia Hierarchy

T: So those are two big differences already between the exposures you have done on your own and the way in which we will do them in treatment. Also, we will be facing situations much more systematically, with specific preparation for the thoughts and feelings that you might experience. Have you done that before leaving for work? C: No, not really.

Case Vignette 2 C: I get very stressed at work, so let’s put that on my hierarchy. T: What is it that you are most worried about happening at work? C: That my boss won’t approve of my work, and I will be fired. T: How does that relate to your fears of panicking?

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C: It doesn’t relate to my fears of panicking. I just worry about being fired. T: Okay, so even though the work situation is stressful, it seems as if that is different from worrying about having panic attacks. For this hierarchy, we want to list only the situations that are relevant to your worries about panicking.

Atypical and Problematic Responses Clients who have had severe agoraphobia for a number of years may find it difficult to develop a hierarchy because everything seems intensely anxiety provoking. In these cases, it may be helpful to initially include safety behaviors or safety signals in the description of situations so as to generate a few less-anxious hierarchy items. Of course, these hierarchy items will be practiced without those safety signals or safety behaviors in the future. The hierarchy developed at this stage is a tool that can be adjusted as necessary throughout treatment. For example, a client might initially believe that elevators should be ranked higher than shopping lines but then realize, in preparing for exposures, that the elevators are in fact less frightening. The hierarchy can then be adjusted to reflect this new awareness. Some clients may have very limited or no avoidance of agoraphobia situations. Continue to search for safety behaviors, distractions, safety signals, or superstitious objects (e.g., clients may report not avoiding any situation on the list of agoraphobia situations and yet, on further questioning, reveal what they would avoid if they did not have their empty medication bottle on hand). Some clients may have no avoidance of agoraphobia situations and no reliance on safety behaviors or safety signals. In this case, you may assume that the client has panic disorder without agoraphobia, and you may skip this chapter.

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Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

✎ The client should read chapter , section , of the workbook.

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Chapter 9

Breathing Skills

(Corresponds to chapter  of the workbook)

This chapter is divided into four sections.

Materials Needed for All Sections ■ Breathing Skills Record

SECTION 1

Education and Diaphragmatic Breathing

Outline ■ Educate the client about overbreathing ■ Conduct a forced hyperventilation test ■ Introduce diaphragmatic breathing skill

Therapist Behaviors After reviewing the basic concepts of respiratory physiology and overbreathing, the therapist may model the method of hyperventilation before asking clients to hyperventilate, or the therapist may hyperventilate along with the client. This type of participant modeling is especially helpful for clients who are self-conscious or highly anxious about the exercise, and it can be used to validate the normalcy of symptoms experi-

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enced as a result of hyperventilation (i.e., therapists can indicate the symptoms that they experience from the exercise). Also, the therapist may demonstrate the diaphragmatic breathing techniques for the client to imitate. Then, the therapist can observe the client practice the exercise of diaphragmatic breathing and give corrective feedback. Of course, generalization from the clinic to the home setting occurs by having clients practice the exercises on a regular basis in their own environments.

Overbreathing The main goals of this section are to introduce the physiology of overbreathing as something that may contribute to the physiological sensations during panic attacks and to recognize that hyperventilatory sensations are not harmful. It is important that the client not misconstrue the discussion of overbreathing as an indication that panic and fear are a direct result of primarily physiological irregularities. That is, the role of hyperventilation is placed within the context of the interactions that occur among the three response components (i.e., behavioral, physiological, and subjective). The experience of overbreathing in isolation from catastrophic misinterpretations of bodily sensations or from learned fear of bodily sensations is unlikely to result in a panic attack.

Breathing Skills In this treatment, breathing skills training is intended to regulate breathing, but more importantly, it is also intended to interrupt the panic cycle and provide a tool to help clients face their fear, anxiety, and anxietyproducing situations. Although breathing skills training may result in a reduction in symptoms of overbreathing, this is not the primary goal. The goal is to use breathing skills training to encourage the client’s continued approach toward anxiety and anxiety-producing situations. It is important that clients do not attempt to use breathing skills to prevent dire consequences from occurring (e.g., to prevent oneself from fainting or dying) and that they do not view the skills as “magical” cures.

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The breathing skills are first practiced in relaxing environments for two reasons: first, as a way of enhancing skill development and to permit concentration on the breathing; second, to deemphasize the use of breathing skills as an immediate tool for the reduction of fear or symptoms.

Diaphragmatic Breathing Exercise The purpose of this exercise is to teach clients a method of regulating breathing that will help them to directly deal with the physical symptoms and situations that currently make them anxious. Diaphragmatic breathing has two components: (i) a breathing component, in which clients learn to slow their breathing and to breathe using their diaphragm muscles as opposed to their chest muscles; and (ii) a meditation component. Detailed instructions for diaphragmatic breathing are included in the workbook (chapter , section ). The client should practice this skill twice a day for  minutes each time and record the exercises on the Breathing Skills Record. A blank record is included in the workbook, and multiple copies can be downloaded from the Treatments ThatWork™ website (http://www.oup.com/us/ttw). An example of a completed Breathing Skills Record is shown on page .

Case Vignettes

Case Vignette 1 C: Will I pass out if I hyperventilate? T: It is rare to pass out from hyperventilating for short periods of time. Even hyperventilating for long periods of time rarely leads directly to loss of consciousness. You may stop the hyperventilating exercise when you wish, although I would encourage you to go for the specified period of time.

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Breathing Skills Record Rate your concentration on breathing and counting during the exercise and your success with relying mostly on your diaphragm for breathing, on –-point scales (where  ⫽ none and  ⫽ excellent), after each practice (twice per day). ---------------------------------------------------------------------- None

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Figure 9.1.

Example of completed Breathing Skills Record

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Case Vignette 2 C: The symptoms are similar to what I experience when I panic, but somehow, it feels different because you are here. T: Do you mean that the symptoms are less anxious for you when we do the exercise together? C: Yes, it feels as if the symptoms won’t get any worse, and they are not as intense as when I panic. T: This shows the influence of your thinking; that is, my presence is leading you to think differently about the symptoms. Remember our panic cycle?

Atypical and Problematic Responses The breathing skills exercise may, for some clients, become a form of exposure to feared sensations (as described in chapter ) because the exercise either forces attention on bodily sensations or induces new, unfamiliar bodily sensations. Clients who become anxious during breathing skills training for these reasons should be encouraged to continue with the exercises in the same way as would occur during interoceptive exposure practices. Notably, the research on the role of breathing skills training within cognitive behavioral therapy for panic disorder is not clear. There is some indication that it does not add significantly to the effect of exposure alone and that the combination of cognitive restructuring, in vivo exposure, and breathing skills is slightly less effective than the combination of cognitive restructuring, in vivo exposure, and interoceptive exposure. However, the studies to date have not clearly framed breathing skills as a tool for continuing to face anxious situations and instead have emphasized breathing skills as a way of reducing symptoms. As noted earlier, the program in this workbook focuses away from the immediate reduction in symptoms and fear and toward toleration of symptoms and fear. Thus, if breathing skills training is done in the way framed above, it may have more beneficial effects than when it is used as a means for controlling symptoms. If it appears that a client is using breathing skills as a control strategy, consider minimizing their use.

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Some clients find that the breathing exercises lack credibility. They point out that if they could simply tell themselves to breathe slowly or to relax, they would have no need for treatment, and thus, the exercise seems like a gimmick. Remind clients that the goal of breathing skills training is not to relax or calm down but to facilitate movement forward to face fear, anxiety, and anxious situations.

Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

✎ Instruct the client to practice the diaphragmatic breathing exercise

twice a day,  minutes each time, for seven days and to record practices on the Breathing Skills Record form.

✎ The client should read chapter , section , in the workbook.

SECTION 2

Slowed Breathing

Outline ■ Review the client’s practice of breathing skills over the past week ■ Introduce slowed diaphragmatic breathing technique

Therapist Behaviors The therapist is to review the client’s practice of breathing skills over the past week and brainstorm ways of overcoming problems with the breathing skills practice (e.g., noncompliance or anxiety). In addition, the thera-

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pist can model slowed diaphragmatic breathing and then provide corrective feedback as the client practices this skill.

Slowed Breathing The purpose of this exercise is to teach clients how to slow their breathing rate by matching their breathing to their counting. Detailed instructions for slowed breathing are included in the workbook (see chapter , section ). The client should practice this skill twice a day for  minutes each time and then record the exercises on the Breathing Skills Record.

Case Vignettes

Case Vignette 1 C: I feel really dizzy when I focus on the breathing, and I feel as if I have to take a deep breath. T: This suggests that you may habitually overbreathe—that is, your normal style is to overbreathe—and, therefore, trying to institute a new method of breathing is exacerbating some of your hyperventilation tendencies. However, it is important that you continue the exercise, because it will gradually get easier. If you really feel like you have to take in a deep gulp of air, hold the air in a little bit longer after you inhale and before you exhale.

Case Vignette 2 C: I haven’t had time to practice. It seems like an extra burden to have to do these exercises. T: In a sense, you are right, because there is a definite time and effort commitment involved. Does it help to realize that you are probably ex-

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erting as much effort trying to ward off feeling anxious and panicky as you would in practicing these exercises?

Case Vignette 3 C: Should I be taking big breaths? T: What you are trying to change during these exercises is not the amount of air but, rather, the rate and depth at which you breathe. Breathe in the normal amount, but do it slowly, and draw the air deeply into your lungs.

Atypical and Problematic Responses Occasionally, clients view these exercises as “magic pills” that they must use in order to prevent dire consequences from happening. For example, “I could pass out if I don’t slow down my breathing.” This is when cognitive restructuring is so essential in helping clients to realize that no calamity will result, even if their breathing cannot be slowed. Breathing skills training can be very hard for the true chronic hyperventilator, the person whose typical breathing pattern is shallow and rapid, who sighs and yawns frequently, who experiences chronic chest tightness, and who is very vulnerable to shortness of breath and paresthesia. Such a client may feel short of breath after the -minute exercise and take deep gulps of air between the slow breaths during the exercise. Our experience tells us that learning breathing skills takes a lot longer with these individuals, but it can still be a valuable tool for them. As mentioned above, breathing skills exercises may elicit panic. In these cases, the panic is occurring in response to a heightened focusing of attention on feared sensations (in contrast to the typical pattern of trying to keep one’s mind occupied to avoid noticing the sensations), an increased experience of atypical sensations, or both. Under these conditions, help clients understand the reasons why they panicked, and instruct them to continue to practice. In this way, repeated practice of breathing becomes an exposure.

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Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

✎ Instruct the client to practice the slowed breathing exercise twice a day,  minutes each time, for  days and to record practices on the Breathing Skills Record form.

✎ The client should read chapter , section , of the workbook.

SECTION 3

Breathing Skills as a Coping Technique

Outline ■ Teach the client to use breathing skills in distracting environments

Therapist Behaviors Now that slow and diaphragmatic breathing have been practiced sufficiently in relaxing environments, these skills are now ready to be used in distracting environments and in anxious situations. It is time to practice in different places. The therapist could have the client practice the breathing skills in session while providing a deliberate distractor (such as a noise). Also, the therapist can encourage the client to role play the use of breathing skills as a coping tool in an imagined anxiety-provoking situation.

Coping Application Encourage clients to use breathing skills as a coping technique to help them face fear, anxiety, and anxiety-provoking situations. A coping template is provided for use of breathing skills in combination with think-

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ing skills as tools for facing fear and anxiety rather than avoiding or retreating.

Case Vignettes

Case Vignette 1 C: When I panicked during the week, I tried to use the breathing, but it didn’t work. It made me feel worse. T: It sounds as if you might have attempted to use the breathing exercise as a desperate attempt to control the feelings that you were experiencing. C: Yes, that’s right. T: Remember that the breathing skills training is not only intended to regulate your breathing but, more importantly, is to encourage you to face whatever it is that is making you anxious. This means that you do not have to control your anxious feelings or your symptoms; instead, you have to learn to continue in your activities despite the symptoms and the feelings, because these symptoms are not dangerous.

Atypical and Problematic Responses As noted before, the biggest problem is when clients begin to use breathing skills as a safety signal or a safety behavior. In other words, they believe that they will be at risk for some mental, physical, or social calamity if they do not breathe correctly. For clients who are using breathing skills in this way, discontinuation of the breathing skills may be the most effective choice. That is, design exposure exercises without the use of breathing skills so that clients learn that what they are most worried about happening either does not happen or can be managed without using the breathing skills.

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Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

✎ Instruct the client to practice breathing skills in different distracting environments and when anxious.

SECTION 4

Review of Breathing Skills

Outline ■ Review breathing skills as a way of facing anxious feelings and situations

Therapist Behaviors Therapists are to inquire about the way in which the breathing skills are being implemented in anxious situations and to provide corrective feedback and encouragement. If appropriate, therapists can have clients role play their use of breathing skills in an anxious situation.

Atypical and Problematic Responses As noted above, overreliance on breathing skills as a means for immediate fear reduction or immediate symptom alleviation, or to prevent a “catastrophe,” indicates that breathing skills are being used as a safety behavior. In these situations, remind clients of the purpose of breathing (i.e., a tool for regulating breathing and a tool for facing fear and anxiety despite physical symptoms and despite anxiety).

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Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

✎ Instruct the client to continue practicing breathing skills techniques.

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Chapter 10 Thinking Skills

(Corresponds to chapter  of the workbook)

This chapter is divided into four sections.

Materials Needed for All Sections ■ Negative Thoughts list ■ Copy of completed Hierarchy of Agoraphobia ■ Changing Your Odds form ■ Realistic Odds Pie Chart ■ Changing Your Perspective form

SECTION 1

Thoughts Influence Emotions

Outline ■ Present a reciprocal model of anxiety and negative thinking ■ Help the client identify negative thoughts

Therapist Behaviors The therapist should use Socratic questioning to help clients identify their own anxious thoughts. The downward arrow technique is a useful method of questioning to find out the details of what the client is most

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worried about happening in any given situation. The downward arrow questions are as follows. ■ If you panicked, what would happen? ■ What would it mean if . . . ? ■ What do you picture happening if . . . ? ■ What do you see happening next? It is important that the questioning does not stop at the thought of having anxiety or suffering a panic attack but, rather, that it extends to discover what it is that the person is most worried about which leads them to feel anxious or to panic or to ascertain what it is that they are most worried about if they did become anxious or panic. Clients may be encouraged to use behaviors or behavioral urges (e.g., “I wanted to leave”; “I had to leave”) as a cue to ask: “What was I thinking that motivated that behavior—what did I think would have happened had I stayed?”

Anxiety and Negative Thinking Present the client with a reciprocal model of anxiety and thinking. Explain that anxiety increases negative thinking, and in turn, negative thinking increases anxiety. These reciprocal patterns are tied to adaptive processes (e.g., it is natural for anxiety to lead to magnification of the perception of danger and for perceived danger to lead to anxiety).

Recognizing Negative Thoughts The main goal of this first section is to help clients recognize that the way they think is critical to their level of fear or anxiety at any given moment and that recognizing negative thinking at a specific and detailed level is necessary before developing different, less negative ways of thinking. Thinking skills do not simply represent positive self-statements but, rather, a skill for understanding distortions and errors in one’s own think-

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ing and for the development of alternative ways of thinking which are not biased by such distortions. Emotional responses vary across situations as a result of different interpretations. For example, heart palpitations experienced when home alone may be interpreted very differently than similar palpitations experienced while driving a car with passengers. These variations are very idiosyncratic because of each individual’s own set of concerns. For some, the palpitations may be perceived as more dangerous when driving, due to the thought that an accident will ensue. For others, heart palpitations that occur when the client is home alone seem more dangerous because of the thought that no one will be there to help if necessary. This specificity in thinking highlights the value of identifying the specific predictions that are being made in any given situation.

Negative Thoughts List Ask clients to identify negative predictions for each item on their agoraphobia hierarchy and each panic attack that they recorded over the past week, and then have them document these on the Negative Thoughts list in the workbook. Identifying specific predictions, hypotheses, or interpretations in any given situation is emphasized as the first step in cognitive restructuring.

Case Vignettes

Case Vignette 1 C: I am afraid of feeling panicky. T: What would happen if you felt panicky in that situation? C: It would be terrible. T: What do you imagine happening that would be so terrible? C: I would lose control.

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T: What would it mean if you lost control? What do you picture happening? C: I would collapse. T: And if you collapsed, then what would happen? C: I would never recover, and I would be hospitalized forever.

Case Vignette 2 C: I don’t want to feel those feelings. T: What would happen if you felt those feelings? C: I couldn’t handle it. T: What do you imagine happening? C: I would get up and go home. T: What would happen if you couldn’t leave, and you had to stay? C: The feelings would get worse. T: And then what would happen? C: I don’t know, it scares me to think about it. Maybe I would faint. T: And if you fainted, then what? C: I might die.

Atypical and Problematic Responses Sometimes, clients express reluctance to identify their negative thoughts because they worry that focusing on the thoughts will raise their anxiety. In response, acknowledge the possibility that identifying negative thoughts may initially increase anxiety. However, also stress that identifying the thought in detail is necessary to challenge it effectively. We have often found a golf analogy to be helpful in illustrating this point. The identification of negative thoughts is analogous to locating the flags in the

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holes on a golf course. While successfully locating the flag does not guarantee that the golfer will get the ball in the hole, the golfer does not have a chance without it: the golfer might not even know in what direction to go! Similarly, while identifying an automatic thought does not guarantee anxiety reduction, the client does not have a chance without doing so. (Note: There is no homework, as clients are expected to go directly to section  after completing section .)

SECTION 2

Jumping to Conclusions and Realistic Odds

Outline ■ Teach the client how to evaluate negative thoughts and generate alternative, evidence-based thoughts ■ Teach the client to examine the evidence and develop realistic odds

Therapist Behaviors During cognitive restructuring, the therapist becomes a coach who asks appropriate questions rather than simply providing direct reassurance. This approach is called Socratic questioning, and it enables clients to develop their own set of skills for dealing with anxious thoughts. For example, therapists should ask clients what their most recent medical examination revealed as opposed to telling them that they will not have a heart attack. Similarly, therapists should ask clients how many times others have commented on how insane they look as opposed to telling them that people do not think that they are deranged. Therapists can also make contrasting statements to highlight the principles of jumping to conclusions. For example, therapists may respond to clients’ statements that they believe they will have a heart attack when they panic with, “So, you must have had several heart attacks already.” (Or if a strong alliance

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has not already been established, the therapist might respond with, “So, what evidence do you have that this will happen?”) By modeling the method of asking appropriate questions, therapists help clients learn to question the evidence for themselves. When thinking skills are first introduced, the therapist will probably need to be quite active, not only asking relevant questions but sometimes supplying alternative, balanced thoughts or sources of evidence when the client draws a blank or overlooks important sources of evidence. Over the course of the remaining sessions, however, therapists should gradually fade out their contributions to the rethinking and explicitly encourage the patient to internalize the skills. For example, over time, therapists can begin to ask, “Can you imagine what questions I might ask you to consider about this?” rather than “What is the evidence for that?” or “What is an alternative to that thought?”

Evaluating Negative Thoughts The main goal of this section is to begin teaching a set of skills for evaluating negative thoughts by looking at the evidence and generating alternative, more evidence-based thoughts. Anxious thoughts tend to be regarded as if they were fact. For example, clients may emotionally respond to the thought of a potential heart attack as if they were actually about to have a heart attack. However, clients’ thoughts are more likely to be inaccurate and biased toward perceived danger when they are anxious. Thus, the need to evaluate the veracity of anxious thoughts by examining the evidence is emphasized. Evaluating the evidence is essential because judgments based purely on emotional reactivity are likely to be inaccurate. As in the previous section, emphasize that avoidance and safety-seeking behaviors, such as exiting a situation, seeking help from another person, or distracting oneself, maintain and perpetuate negative thinking. Helping clients to understand reasons why they continue to jump to conclusions is part of the process for recognizing errors in logic and developing

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alternative points of view. For example, clients may believe that the only reason why they did not die from a panic attack was because they always escaped, avoided, or distracted themselves just in time. In other words, they believe that danger really was imminent had it not been for the safety behaviors.

Realistic Odds Explain to the client that more realistic beliefs can be developed by considering all the evidence and obtaining additional information. This logical empiricism will override negative thinking. It incorporates looking at the evidence and taking into account past mistaken reasons why actual experience has not disconfirmed negative thinking. The steps for developing more realistic thinking include the following. ■ Asking whether what one is most worried about has ever happened. ■ Acknowledging the mistaken reasons for continued worry. ■ Examining the evidence. ■ Rating the realistic odds, using a –-point scale. ■ Generating possibilities, recorded in a pie chart. Ask the client to apply these steps to examples of jumping to conclusions from the list of Negative Thoughts they generated in section . Have the client complete a separate Changing Your Odds form for each example. A blank form is included in the workbook, and multiple copies can be downloaded from the TreatmentsThatWork™ website (http://www.oup .com/us/ttw). An example of a completed Changing Your Odds form is shown on page .

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Changing Your Odds Negative thought: I might faint in the shopping mall. How many times has it happened? Zero. Reasons why I continue to worry about it: X . Avoidance behavior X . Mistaken belief that past evidence does not apply . Mistaken belief that luck or my extra-cautious behaviors have prevented it from X happening . Mistaken belief that what I most worried about has come true . Mistaken belief that dangers increase with intensity of anxiety or physical X symptoms What is the evidence? I have never fainted before, even though I have panicked many times; panic attacks do not usually lead to fainting because physically, panic attacks are different from fainting. 5% What are the real odds? (–) What are different thoughts? (Fill in the pie chart, including your anxious thoughts as the shaded piece of the pie):

I’ve panicked many times before and never These fainted. are symptoms of adrenaline, but not of fainting. I can feel weak and light-headed and not faint. The chances of fainting do not change from one panic attack to the next.

Figure 10.1.

Example of completed Changing Your Odds form

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I am unlikely to faint. I will faint.

I have not fainted in I the past. probably would not have fainted if i’d stayed in the mall instead of escaping.

Case Vignettes

Case Vignette 1 C: You are asking me to rate my fears of fainting on a scale of probability. What do you mean? T: It means to judge the actual probability of fainting, given all the evidence you can gather. Use a scale from zero (not at all probable) to  (will definitely occur). What is the actual probability of fainting? C: I don’t know, perhaps a score of . T: So, that means that out of every  times you have panicked, you have fainted once? C: Well, no, I have never fainted. T: So, what is the actual probability?

Case Vignette 2 C: Sure, I can tell myself that the chance of passing out when I panic is very small. I tell myself that all the time. But what if I did pass out? It’s that one-in-a-million chance that scares me. T: By asking that type of “what if ” question, you might be dismissing the evidence and emotionally reacting as if it is going to happen. C: I guess I am, because it certainly feels like it could happen. T: Remember, feelings are not a good basis for making probability judgments. Let us check the evidence again. How many times have you felt like you would pass out, and how many times have you actually passed out?

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Case Vignette 3 C: It’s easy to ask myself these questions now, but I have no chance of thinking rationally when in the midst of a panic attack. T: Yes, it is much harder to think rationally in the midst of intense fear. But by rehearsing these thinking skills now, they will be more accessible to you when you become very anxious. It is a bit like learning anything—the more you practice, the more natural and automatic it will become, and the easier it will be to use when under high stress.

Case Vignette 4 C: My biggest fear is that I’ll have to get up and leave. And that is exactly what I do, so how can I say that what I am afraid of is not likely to happen? T: What do you think will happen if you stay in the situation? C: If I don’t leave, who knows what will happen? That’s exactly why I do leave. T: Imagine yourself feeling panicky and trapped—you cannot leave. What is going to happen to you? C: That’s difficult. I don’t usually let myself think of that possibility. I think I’m afraid that I’ll get so scared that I’ll just lose it and flip out. T: What other pieces of evidence do you have to lead you to suspect that you will “flip out” if you do not leave? C: None, really. T: Is it possible that you are jumping to conclusions about the chances of “flipping out” if you stay and that your escape behavior has been guided by the belief that “flipping out” is a very real possibility? C: Yes.

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Case Vignette 5 C: Last week, I was sick, but I was determined to interpret the symptoms as being anxiety related and not dangerous. It turns out that I had the flu. T: It sounds like you were going to the other extreme; you might have been ignoring pieces of evidence which, under normal conditions, would suggest the flu. But in the absence of objective evidence, I would rather that you ignore the symptom than magnify its meaning.

Atypical and Problematic Responses Three problems sometimes arise during discussion of jumping to conclusions. First, clients may report that although they know the chances are slim, they are still afraid in the event that “it” did happen. By focusing on a recognized, slim-chance event, clients are again engaging in overestimation, because their emotional response (i.e., fear) is occurring in association with an event that is actually unlikely to happen. The fact that they are overestimating can be pointed out, and an evidence-based analysis can again be used. Remind clients that the idea is not to guarantee that an event absolutely will not happen but, rather, that they are reacting as if it is much more likely to happen than it really is. For example, it is always a possibility that when we cross a street, we will get hit by a car. However, most of us are willing to take that risk because the likelihood of that event occurring is fairly slim; thus, we believe that the trade-off of that small chance in exchange for normal activity is worth it. Second, clients might report that they are fully aware of their safety when not panicking, but in the midst of panic, they are convinced that they are in danger. It can be pointed out that the state dependency of cognitions is a very common feature of anxiety; that is, people often are able to recognize that their fears are irrational when feeling calm. Furthermore, with practice and rehearsal of more realistic ways of thinking, it will become easier to challenge their anxious thoughts, even in the midst of distress. However, there may well be limited capacity for complex cognitive processing during the height of intense distress; sometimes,

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the most effective thinking skill at the height of panic is a simple statement, such as “This is a panic attack, it will pass.” Finally, clients will occasionally say that their worst fear “came true”— they have fainted or screamed. In these cases, the therapist may either continue to point out that the chances of that event happening again are small (e.g., of all the times you have panicked, how many times have you fainted?) or use strategies of putting things back into perspective, as discussed in the next section.

Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

✎ Instruct the client to complete a Changing Your Odds form for each example of jumping to conclusions on the Negative Thoughts list, as well as for any panic attacks that occur over the next week.

SECTION 3

Putting Things Into Perspective

Outline ■ Help the client learn ways of putting things back into perspective

Therapist Behaviors As in the previous section, the therapist coaches the client to identify times when things are blown out of proportion and ways of putting things back into perspective. Alternative ways of interpreting a given sit-

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uation are offered. For example, if a client views an episode of embarrassment as disastrous, the therapist may point out that someone else could view an episode of embarrassment as a relatively minor event. The impact of different ways of viewing a situation can then be understood. Asking clients to imagine the worst possible thing they believe could happen is useful for identifying catastrophic thought processes. There is neither an assumption that the person’s style of thinking is to blow things out of proportion across all situations, nor that catastrophizing reflects an underlying personality trait. Instead, blowing things out of proportion is viewed as a learned cognitive style in response to specific stimuli, which, in this case, are mainly somatic sensations. Facing the worst head-on can be quite emotionally evocative. For clients in distress, the therapist is to gently encourage continuation of facing head-on what they are most worried about happening by visualizing the scene as if it were actually happening (e.g., fainting, embarrassment, others commenting on their anxiety, screaming in public). Then, clients will learn to tolerate the distress caused by the image and also generate ways of coping by visualizing what would happen at the moment of the worst event and then how events would unfold the next day, and so forth. By visualizing events unfolding over time, the client is being encouraged to recognize that the worst is time limited and that life continues. If the therapist were to discontinue the exercise of facing the worst for clients who show acute distress, then the therapist is inadvertently reinforcing the client’s inability to tolerate distress.

Blowing Things Out of Proportion In addition to jumping to conclusions, blowing things out of proportion is a mistaken thought typical of anxiety and panic. This type of thinking refers to viewing relatively benign events as if they were insufferable, intolerable, or much worse than they really are. The tendency to view events as insufferable, unbearable, or intolerable only contributes to unnecessary anxiety. A key principle underlying decatastrophizing (i.e., putting things back in perspective) is that events can be endured even though they may not be comfortable. Recognition

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of the time-limited nature of discomfort contributes to the development of a sense of being able to cope. The message is that there is a way of coping with feared outcomes, such as fainting or being told that one appears extremely anxious. The critical distinction here is that although clients may prefer for these events not to occur, if necessary, they can tolerate the discomfort of them. Furthermore, if negative events are viewed as unbearable and unmanageable, they contribute to anxiety. By recognizing how one would cope, as difficult as that may be, the client learns that anxiety eventually lessens. The goal of thinking skills is to correct distortions in thinking. As with the breathing skills, thinking skills are not intended to achieve immediate reductions in fear or in the physical symptoms, although this style of evidence-based thinking is expected to lead to eventual reductions in anxiety about the physical symptoms and, in turn, fewer symptoms.

Changing Your Perspective Ask the client to use the Changing Your Perspective form for each example of blowing things out of proportion from the list of Negative Thoughts from section . A blank form is included in the workbook, and multiple copies can be downloaded from the TreatmentsThatWork™ website (http://www.oup.com/us/ttw). An example of a completed Changing Your Perspective form is shown on page .

Case Vignettes

Case Vignette 1 C: Is it best to say to myself that I don’t need to worry about feeling anxious? T: In a way, that is correct, but it is much more effective to be as specific as you can. Rather than simply telling yourself to be less anxious, iden-

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Changing Your Perspective Negative thought: I might faint in the shopping mall. Will this pass, and will I survive? I guess people have fainted before and managed to go on; my life would go on; my embarrassment will not last forever. Ways of coping: I would wake up and feel disoriented; I assume that someone walking by would have come over to help me—maybe a bunch of people. They would probably want to help me. I might ask them to help me get up and call my husband; I would sit there for a while and just wait for my husband; then we would go home; I would probably call my doctor: I would want to check if there is anything wrong that may have caused me to faint. I would probably go back to work the next day, assuming I felt okay. Figure 10.2.

Example of completed Changing Your Perspective form

tify specific predictions that you are making. What is the worst thing you can imagine happening if you become anxious? C: Maybe I’ll look really weird to other people. I can imagine being in a crowd of people, with everyone staring at me as they walk by and thinking I’m crazy. T: Who are these people? C: Just anyone shopping in a mall or people on the street. T: So, if these strangers were walking past you thinking, “There is a crazy woman,” what would happen? C: I’d feel really embarrassed. T: So, let us think about how bad it is to be embarrassed and of ways in which to cope with that embarrassment.

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Case Vignette 2 C: What if I fainted? T: Well, let us think about that. Let us say that you are in the grocery store, and as you are waiting in the checkout line, you faint. C: That scares me to think about. T: The fact that it scares you is a really good reason for us to continue to face it head-on. What would happen? There you are, down on the floor, and. . . ? C: And I would regain consciousness. T: And then what? C: I guess someone would help me get up. T: And then what? C: I would find a place to sit and wait until I felt okay, and then I would go home. T: And what would happen the next day, and the next week, and the next month? C: I guess I would go back to doing the things that I normally do.

Case Vignette 3 C: Sometimes, it is difficult for me to know what I am thinking at the time that I’m panicking. What should I do then? T: Are you able to identify the feeling as a panic attack? C: Yes. T: So, at the very least, you can recognize what the feeling is. That is, you could tell yourself that you are experiencing a panic attack. With that in mind, what can you do with that information?

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C: Well, I suppose I can tell myself that this is a panic attack, and as with all my previous panic attacks, it will pass quickly, and what is the worst that can happen? T: That is right.

Atypical and Problematic Responses Occasionally, problems arise because clients view their escape behaviors as out of control, dangerous, or both. For example, one client became frightened when driving on a highway because she could no longer see her friend in a car behind. Hence, she pulled over onto the median strip in the middle of the highway and began to back up. Another client would try to control panic attacks that occurred in the middle of the night by jumping into her car and driving at very fast (e.g.,  mph) speeds. A different client would hit his head to control the feeling of panic. In each case, the behavior is designed to escape from the feelings of panic and is therefore motivated by physiological arousal, urges to escape, and thoughts of danger. Furthermore, the escape behavior is a logical action at the time because it is directed at achieving safety. In other words, the escape behavior is logical and driven by perceptions of danger and safety. Thus, it is not an out-of-control or irrational action, given the beliefs operating at the time. The real problem is the misappraisal of danger which led to the behavior. In these cases, one should use cognitive restructuring— by examining the data or putting things back into perspective—to address the negative thinking that motivated the escape behavior in the first place. The real danger associated with these types of escape behaviors (e.g., high-speed driving), however, must be addressed, because they do have the potential for causing harm. Finally, the expectation that thinking skills will immediately decrease physical symptoms is problematic and misdirected. It is also likely to lead to more misappraisals and symptoms due to thoughts such as, “The dizziness did not go away, so something must be wrong with me.”

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Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

✎ The client should use the Changing Your Perspective form for each example of blowing things out of proportion from the Negative Thoughts list.

✎ Instruct the client to complete either a Changing Your Odds or a Changing Your Perspective form for any panic attacks that occur over the next week.

SECTION 4

Review of Thinking Skills

Outline ■ Review thinking skills ■ Have clients recall and evaluate their worst panic attack by using a step-by-step analysis

Therapist Behaviors As in prior sections, therapists should avoid giving direct reassurance and instead ask questions or pose juxtapositions that lead clients to recognize the distortions in their thinking. Give corrective feedback on the Changing Your Odds and Changing Your Perspective forms that the client completed over the last week, especially when the records lack specificity (e.g., clients who record that what they are most worried about is panicking should be encouraged to

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detail what it is about panicking that worries them) or indicate a style of blanket reassurance (e.g., clients who record that everything will be okay as their evidence or ways of coping should be encouraged to list the evidence or to generate actual coping steps). Guide clients as they revisit their worst panic attack, and help clients evaluate the sequence of events, with special emphasis on mistaken negative thoughts that lead to increased arousal or behaviors of escape that, in turn, increase anxiety.

Recalling One’s Worst Panic Attack By recalling their worst panic as a “lucky escape” or something that they would never want to go through again, clients are maintaining the perceived threat associated with panic. A successful, matter-of-fact analysis of the components and processes involved in the worst panic is stressed. Furthermore, an ability to understand previous worst panics in an objective fashion means less anticipation of future panic attacks. Occasionally, clients attribute their survival to external safety objects. For example, “I survived only because my husband arrived just in time to take me to the hospital.” Getting clients to appreciate that they would have been safe even without the external safety object is an essential component of understanding worst panic attacks.

Case Vignette C: I can’t imagine ever going through another panic attack like that one three years ago. T: Let us think about that panic attack to get a better handle on why it felt so bad and why you think you could not tolerate it happening again. Using our step-by-step method, describe what happened. C: I was rushing to an appointment with my mother’s surgeon (she was about to have heart surgery), felt pain in my chest and numbness in

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my arm, and was convinced that I was having a heart attack. So, I panicked and drove to the closest ER. T: So, you have described the thoughts, feelings, and behaviors very well. Obviously, you were very scared at the time because you thought that you might die. What would you think now if you felt chest pain and numbness in your arm? C: Probably, I would realize that I was tense or maybe that my breathing was off. I know I am healthy and not at risk for a heart attack, at least not at my age. T: That is a very good examination of the evidence. Now, what about the idea of going through an intense panic attack? What is the evidence that you could not survive it? C: Well, actually, I suppose that I could survive it, because I have before.

Atypical and Problematic Responses As before, it is not uncommon for clients to begin to use their thinking skills as a safety signal, that is, as a way of immediately reducing symptoms or anxiety. In this case, the therapist can reiterate the purpose of the thinking skills. In addition, therapists might consider shifting to a paradoxical intention approach—at least for a short period of time—to illustrate whether clients think about being unlikely to be harmed and being able to cope with whatever happens (i.e., thinking skills), or whether they think about the worst-case scenario to a ridiculous extreme (e.g., sweating so profusely that everyone around is laughing and actually slipping in the sweat). In either situation, the outcome is the same. Some clients may show high levels of distress when asked to think about their worst panic. Alternatively, they may slip into rigid negative thinking patterns: for example, “That was horrible—I was really out of control.” In either case, continue with the practice in session and through homework assignments so that the emotional reactivity eventually decreases over days of repeated practice and so that alternative narratives of the experience are developed.

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Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

✎ The client should continue to complete either a Changing Your Odds or a Changing Your Perspective form for any panic attacks that occur over the next week.

✎ The client should practice a step-by-step analysis of a worst panic attack.

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Chapter 11 Facing Agoraphobia Situations

(Corresponds to chapter  of the workbook)

This chapter is divided into three sections.

Materials Needed for All Sections ■ Facing Agoraphobia Situations form ■ Facing Symptoms and Agoraphobia Situations form

SECTION 1

Planning for Exposure

Therapist Behaviors Note: If the client was not able to generate a Hierarchy of Agoraphobia Situations (see chapter  in the workbook), and if the therapist is convinced that there is neither agoraphobia nor reliance on safety behaviors or safety signals in everyday functioning, then this chapter may be skipped. Therapist guidance for in vivo exposure to agoraphobia situations is not outlined in the workbook. However, it is conceivable that a therapist accompanies the client on some occasions to provide corrective feedback, to provide participant modeling, and to facilitate the client’s toleration of fear and anxiety in the agoraphobia situation. When such therapistdirected exposure is conducted, it should immediately be followed by self-directed exposure; for example, the therapist may accompany the client

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on a walk, and then the client should immediately repeat the walk on his or her own to enhance self-directed practice over the following week. Otherwise, the therapist’s role is to guide the client in setting goals, designing practices, and giving corrective feedback, especially with management of escapes or avoidance. Essential throughout all aspects of in vivo exposure is for the therapist to be directive and confident and to encourage clients to continue despite high levels of anxiety. To suggest to clients that a particular situation may be too difficult or too distressing, or to overempathize with clients’ distress during in vivo exposure practices, will only reinforce their inability to tolerate anxiety. On the other hand, therapists should not push clients blindly into agoraphobia situations but, rather, should spend time preparing clients for an exposure practice that will help them learn what they need to learn (e.g., “I can drive four exits on the freeway feeling hot and sweaty and not lose control of the car”; or, “I can shop in the crowded shopping mall for one hour even though I feel weak in my legs”; or, “I can walk around the park, and even though I am anxious the entire time, I do not faint”), discussing ways of managing acute distress in the midst of the practice with the client, dismantling reasons for premature escapes from an exposure practice, and providing encouragement to get right back into it.

In Vivo Exposure As mentioned in previous chapters, the goal of exposure therapy is not immediate reduction in fear and anxiety; rather, the goal is for the client to learn something new as a result of exposure. Exposure is best structured in a way that permits new learning. This means that clarification of what it is that clients are most worried about as they face their feared objects, situations, and physical sensations; clarification of the conditions that will best help clients to learn that what they are most worried about never or rarely happens; and clarification of the fact that they can cope with the phobic stimulus and tolerate anxiety are essential for effective exposure. If what the client is most worried about is that fear and anxiety will remain elevated for the entire duration of the practice, then the corrective learning is about the client’s toleration of sustained anxiety.

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There are right ways and wrong ways to conduct in vivo exposure. The latter probably accounts for the lack of success that clients have had previously when they have attempted to expose themselves to fear-provoking situations. The information in the workbook on “reasons why past attempts may have failed” is intended to demystify in vivo exposure and to elevate its credibility for those whose prior experiences have been negative. These reasons include failure to recognize the differences between difficult or negative one-time experiences and repeated systematic exposure practice; too much time between practices; insufficient duration of practices, so that corrective learning (that anticipated negative consequences rarely or never occur or that one can cope with the phobic stimulus and tolerate the anxiety) is mitigated; and subtle avoidance, safety signals, and distraction strategies used during practices. The danger of facing a situation one time only is that the relief felt on exiting the situation may overpower the learning that takes place. For example, consider the woman who is afraid of walking around the block. As she leaves her house to walk around the block, her anxiety rises until she turns the last corner toward home when she feels better because her safe place (her home) is visible, and therefore, the sense of danger lessens. As she reaches the door of her home, she feels a great sense of relief and goes inside to feel even more comfortable. What this practice has done in essence is to reinforce the sense of safety of her home and to magnify the sense of danger of being away from it. As she walks in the door, her thoughts might be, “I just made it. I couldn’t do it again. I was lucky.” In contrast, the goal of exposure therapy is to end a practice with thoughts such as, “It wasn’t so bad after all. Nothing happened to me. It’s really not that dangerous. I could do it again.” These latter types of thoughts develop or grow in number through repeated experience. This would mean that the client would benefit most by walking around the block several times before returning to the house. As stated previously, too much emphasis on fear reduction within an exposure trial is at odds with the latest research, which indicates that fears and anxiety disorders may be partly generated by overly rigid attempts to avoid the emotional experience of fear and anxiety. Toleration of fear and anxiety is a critical learning goal. In general, the principle emphasized throughout the treatment is that exposure and cognitive restructuring serve to develop a new set of non-

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fearful associations between stimulus (e.g., height), response (e.g., dizziness), and meaning (e.g., “I will fall”). The new set of associations (e.g., height, dizziness, “I will not fall”) gradually becomes more salient than the old fearful associations, which, through disuse, are less and less likely to guide emotions at any given time. Nonetheless, the old fearful associations are likely to remain intact, and although dormant immediately after treatment, they are vulnerable to reactivation under certain conditions, such as contexts that are salient reminders of when panic was first acquired. In the moment of fear, clients are encouraged to use their breathing and thinking skills to encourage completion of the assigned task; the coping skills are not intended as means for reducing fear and anxiety but, rather, for tolerating fear and anxiety. If escapes do happen, the goal is to learn from them rather than to regard them as failures. Recognition of the precipitant to escape is very important, because the urge to escape is usually based on the prediction that continued endurance will result in some kind of danger. For example, clients may predict that the sensations will become intense and lead to an out-of-control reaction. This prediction can be discussed in terms of jumping to conclusions and blowing things out of proportion. At the same time, escape itself need not be viewed catastrophically (i.e., embarrassment or a sign of failure). Agoraphobia situations may not directly elicit physical sensations of panic, but in some way, they have become associated with panic attacks. That is, panic attacks are anticipated to occur in those situations. Usually, these are situations from which escape is difficult or embarrassing, such as driving on a highway where exits are few or being in the middle of a crowd from which escape would be obvious to others. Nevertheless, sensations play an important role in the level of anxiety or fear experienced while in the situation. Also, the point at which clients want to escape from the agoraphobia situation is likely to be related to the experience of certain sensations. Eventually, the goal is to face both the situation and the symptoms in the situation by deliberately inducing the sensations. This is described in section . In vivo exposure to situations can proceed in either a graduated or intense form. The choice is left to the client. Evidence to date is largely based

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on a graduated approach to exposure, although some studies have indicated success with flooding therapy, in which clients go directly to the most intensely anxiety-provoking situations. The risk for the intense approach is that clients are not adequately prepared to tolerate intense distress, and therefore, they escape in the midst of intense distress and do not return to the exposure task for some time. This escape behavior is very likely to lead to sensitization and increased distress. Thus, a graduated approach is usually recommended. Each practice is to be delineated as concretely as possible (e.g., driving past two exits only rather than driving until too panicky to go on). Before attempting to face an agoraphobia situation, the client will clearly understand exactly what the practice will entail (e.g., “I will walk around inside of mall for  minutes by myself ”). In this way, there is no uncertainty about whether the practice was conducted correctly. Without such concrete details, clients may decide that they have failed. Also, the practice should not be ended because of anxiety (e.g., “I will continue driving on the freeway until I feel anxious”) because then the exposure practice reinforces avoidance of anxiety. Clients are encouraged to maintain a regular schedule of repeated in vivo exposure practices and to conduct these practices regardless of internal (e.g., having a bad day, feeling ill) or external (e.g., inclement weather, busy schedules) factors that may prompt postponement of practices.

Practicing In Vivo Exposure Instruct the client to choose one of the least anxiety-producing items from the Hierarchy of Agoraphobia Situations with which to begin in vivo exposure (starting with items rated as  or higher). The steps for in vivo exposure to agoraphobia situations are as follows: identifying what one is most worried about in the situation; establishing the most effective conditions for providing disconfirmatory experience for that worry; establishing gradual or direct exposure to those conditions; envisioning ways of managing moments of fear during the exposure; planning ways of managing escapes from the exposure; and evaluating what was learned following the exposure.

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The client should complete a Facing Agoraphobia Situations form for each exposure completed. A blank form is included in the workbook, and multiple copies can be downloaded from the TreatmentsThatWork™ website (http://www.oup.com/us/ttw). An example of a completed Facing Agoraphobia Situations form is shown on page .

Case Vignettes

Case Vignette 1 C: I really don’t want to face these situations because I know I’ll get very anxious. I haven’t driven on my own for any distance for many, many years, and now you’re asking me to do it. T: Of course, you might expect to feel anxious or panicky the first time that you attempt the situations you have been avoiding. On the other hand, remember that through repetition, the exposures will get easier. Also, you have a different set of skills than you had before, which will most likely help you when you begin your driving. Would it help to break down the task into a series of small steps and to perform each one a number of times to feel more comfortable before proceeding to the next step?

Case Vignette 2 C: I have so many situations that I need to practice that this is going to take me forever. How long will it take? T: The best procedure is to practice every situation you are currently avoiding. It may take some time. However, with each task that you accomplish or master, you will probably find that many of the other tasks become a lot easier. Therefore, even though it seems overwhelming right now, it will get easier as you go on.

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Facing Agoraphobia Situations Date: 2/12/06 Situation: Driving from home to work on the freeway. End Goals (excluding superstitious objects, safety signals, safety behaviors, and distractions): Drive the entire distance without medication bottle, and in the middle lane. Today’s Goals: Drive halfway, with medication bottle, and the in right lane. Negative Thought (i.e., whatever it is you are most worried about happening): I will become lost in feelings of unreality and lose control of the car. How many times has it happened? Zero. What is the evidence? I have had those feelings many, many times and yet have never lost control of my actions. What are the real odds? (–) 5 Ways of coping: When I feel those feelings, I will recognize that the chances of me losing control are very slim; if I ever get to a point of not being able to physically control the car, I will pull over. Did what I most worried about occur? (Yes/No) No Maximal anxiety (–): 8 ---------------------------------------------------------------------- None

Mild

Moderate

Strong

Extreme

Figure 11.1.

Example of completed Facing Agoraphobia Situations form

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Case Vignette 3 C: What I am most worried about in these situations is that I’ll panic, and I do panic each time I go into them, so I really am being accurate in thinking that. T: What are you imagining will happen if you panic in these situations? C: Mostly that I’ll pass out, and sometimes, that I’ll just really embarrass myself because everyone will know that something is wrong with me. T: Then those are the thoughts to examine. How many times have you actually passed out from panic? How many times have people noticed that you panic? What if they do notice?

Case Vignette 4 C: My fear is of losing control of the car when I feel dizzy. The risk is too great, so I’ve always pulled off the road. I still think that I could lose control of the car if I continue to drive. T: At the moment, you do not have enough evidence to know. Once we begin actually facing these situations, this is likely to change. Maybe in planning for the exposures, we could come up with driving situations that you consider safer, such as driving with someone or driving in an empty parking lot. Once you have had some experience driving, you will be in a better position to evaluate the accuracy of your thoughts.

Case Vignette 5 C: I’ve been avoiding malls for so long that I can’t even remember what my original fear was—just how anxious it felt. T: Can you imagine yourself in a mall now? C: All I can imagine is running out of the mall. T: What do you imagine happening if you do not run out of the mall?

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C: Oh, it’s all coming back to me now. I feel terrified that I’ll never find an exit, and I’ll just keep panicking and go crazy.

Atypical and Problematic Responses Because much of this section of the program is self-directed, compliance with exposure assignments can become problematic. The therapist’s role at this point is to emphasize the value of repeated exposure and the necessity of facing agoraphobia situations for further improvement. Occasionally, as clients make changes in their typical daily patterns, family members may be affected. Discussion of ways in which to incorporate, or at least inform, significant others is useful under such conditions (see chapter  in the workbook). As reflected in the case vignettes, many clients doubt the value of repeated exposure. These doubts stem from their own history with exposure, whether the exposure was a deliberate attempt to overcome fear or was forced on them by circumstances. In most cases, these doubts are at least partially quelled by reviewing the section on why in vivo exposure has not worked in the past. Having clients describe a recent exposure attempt, with emphasis on providing specific details, may reveal differences between their attempts and therapeutic exposure. If the client has difficulty providing these details, prompting questions (e.g., “What was going on right before you got in the car? Why did you choose to drive this time? What was the very first symptom you noticed? What was the first thought? How did you respond to these?”) usually manage to draw out sufficient details. Because of the empirical support for exposure-based treatment, ask clients who continue to have doubts to attempt the treatment despite their doubts and to forestall judgments until they have some experience with the treatment.

Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

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✎ At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

✎ The client should continue to complete either a Changing Your Odds or a Changing Your Perspective form for any panic attacks that occur over the next week.

✎ The client should practice facing a situation from the Hierarchy of Agoraphobia Situations at least three times over the next week.

SECTION 2

Review of In Vivo Exposure Practices

Outline ■ Review in vivo exposure practices conducted by the client over the past week ■ Work with the client to design the next set of exposures

Therapist Behaviors The therapist behaviors are the same as in section . Also, the therapist will judge the number of sessions to spend on in vivo exposure to agoraphobia situations, with the aim of having the client repeatedly practice most (if not all) items on their Hierarchy of Agoraphobia Situations.

Review of the Past Week The main goal of this section is to reinforce corrective learning from the in vivo practices conducted over the past week and to design the next set of in vivo practices. The objective evaluation of performance after each trial of exposure is considered necessary to offset subjective and damaging self-evaluations. As demonstrated in experimental literature on learning and condition-

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ing, appraisals of aversive events after they have occurred can influence anxiety about future encounters with the same types of aversive events. Any practice that is terminated prematurely should be reviewed carefully for contributing factors, which should then be incorporated into subsequent trials of facing situations. Escapes (i.e., leaving a situation before the specific goals for the day had been accomplished) are likely to be motivated by specific sensations or misappraisals. Escapes can therefore be useful learning experiences to the degree that fears of sensations or misappraisals are identified and subjected to evidence-based analyses (i.e., thinking skills). Also, clients are encouraged to use their breathing and thinking skills to remain in the situation until the specified duration or task has been completed, despite uncomfortable sensations. It is important for clients to recognize that the goal is to repeatedly face situations despite anxiety, not to achieve a total absence of anxiety. Toleration of fear rather than immediate fear reduction is the goal for each exposure practice; this approach will lead to an eventual fear reduction. Troubleshooting is part of the objective, matter-of-fact approach that underlies the entire treatment: to identify obstacles to success and find ways of problem-solving as opposed to resigning oneself to failure. It is unrealistic to expect progress to be on a linear, upward trend. Clients should not become discouraged by fluctuations in anxiety or avoidance but, rather, should use these as cues to continue facing situations. As noted earlier, reviewing practices that did not go well can lead clients to a greater understanding of the factors contributing to their anxiety, which can then be incorporated into future practices. Anxiety that does not decline over repeated days of in vivo exposure may result from too much emphasis being placed on fear and anxiety reduction; that is, trying too hard or wishing too much for anxiety to decline typically maintains anxiety. Discussion of the impact of context specificity on “return of fear” is intended to encourage clients to practice in highly significant contexts, such as those in which they experienced their first or their worst panic attacks. If these salient contexts are not mastered, clients are at greater risk for the return of fear.

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Case Vignettes

Case Vignette 1 C: One of my situations is driving. I know you said to design driving practices around distance, but it can vary so much. Sometimes, two exits on the highway seem really easy, and other times, I’m terrified with the idea of just one exit. Wouldn’t it make more sense to just keep driving as long as I can? T: Say you tried it that way, and, instead of stopping at two exits, you drove until you panicked. What would you be teaching yourself then? C: Well, I’d know that I could drive up to the point at which I panicked. T: So, what you are actually doing in that kind of practice is teaching yourself that at some point, you will still panic and have to stop driving. If you forced yourself to drive a certain distance, regardless of how easy or hard it was, what do you think would happen? C: I guess if it was really easy each time, I’d increase the distance for my next practice. But if it was hard, and I did it anyway, I’d probably learn that I could get through it, even if I did feel anxious. So, I shouldn’t say I’ll practice till I panic, because I’ll always be setting myself up for failure by stopping each time due to anxiety. T: That is right.

Case Vignette 2 C: I haven’t even started yet, and I get anxious just planning my practices! T: What happens when you plan to face agoraphobia situations? C: I think of all the things that could go wrong, how awful I’ll feel if I have to leave, and how I’ll never get over this problem. T: So, you are really giving yourself a lot of negative information when you think about these practices. So, it is no wonder that the prepara-

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tion upsets you. Using your skills, think over what you just said and how you might think differently. C: Well, for the things that I think could go wrong, those are my typical panic fears: that I’ll pass out in the store or run out screaming, and everyone will look at me and think that I’m crazy. And I already know that won’t really happen, because it’s never happened before; I guess if I really have to leave before the practice is over, it’s not the end of the world. I’ll just have to try it again and, maybe, break that item down a little to make it easier at first. And I really don’t have any evidence yet that I’ll never get over this. I’ve made a lot of progress so far, but it was a lot of work, and I suppose I felt at times that I’d never get this far. So, I guess I’ll just keep trying.

Case Vignette 3 C: I stayed at the mall the entire time that I was supposed to, but I was terrified the whole time! T: That is great! C: How is that great? I felt awful! I hate being that anxious. T: Remember, the point of confronting these situations is not to be able to do it without any fear. In fact, each situation you practice was chosen specifically because it scares you, so it would be unrealistic not to have any anxiety. The important point here is that despite your anxiety, you stayed for your entire practice. And as we have discussed, it is likely that by continuing to go to the mall, the fear will gradually begin to decrease.

Atypical and Problematic Responses Most problems that arise during in vivo exposure can be resolved through perseverance. One of the most frequent complaints is that the anxiety does not decrease quickly enough on a given occasion or that even when it does decrease, it is still present on the next occasion. Re-

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member that what is most important is for fear levels to gradually decline from one exposure practice to the next, but the amount of fear reduction within a session is not as important. Therapists play two important roles here. First, by reviewing clients’ practices, they can provide corrective feedback on aspects that may be contributing to the lack of anxiety reduction over time, such as continued unhelpful coping styles. (A particularly important maladaptive coping style is to cling to safety signals.) Second, therapists can be a source of great support and encouragement as clients work through their hierarchies. For clients who have extensive or long-standing avoidance patterns, overcoming agoraphobia can take a considerable amount of time, and discouragement and frustration are likely to arise. Reminding clients of their progress to date, even specifically pointing out strategies that they have successfully used in previous exposures and earlier periods of frustration, can serve as a needed boost to help them continue facing their fears. As mentioned in the previous section, the therapist is to prepare clients for their exposure practice, so that the learning is optimal. Be confident and directive, so that clients are encouraged to learn that they can tolerate anxiety and distress. If fear and anxiety are not decreasing over days of exposure, consider whether the client is holding on to safety behaviors or safety signals. Take the example of the person who is facing a fear of heights by practicing on balconies but who does so with one foot far back from the balcony and his or her body weight away from the railing. The situation is being faced but with a great deal of caution, as if the person still believes that it is not safe to lean against the railing for fear of losing control and falling over. This is self-defeating since the situation is being faced under the assumption that danger is present. Fighting anxiety—when clients do everything that they can to prevent themselves from becoming anxious in the situation or are entering the situation with the hope of not becoming anxious—is another reason why the situation may remain anxiety provoking over many repetitions. Remind clients that it is more beneficial to invite anxiety rather than to fight it and that the more they try to resist internal events, the stronger they will become. Give the example of attempting to suppress laughter in a solemn setting (such as a religious ceremony) or of attempting to

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suppress an inappropriate fantasy; usually, such urges increase. Similarly, by trying desperately not to be anxious, clients are likely to increase anxiety. Examples of inviting anxiety would be statements such as, “Let us see how anxious I can get”; “I want to feel the shakiest I have ever felt”; or, “I want my heart to race faster than ever before.”

Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

✎ The client should continue to complete either a Changing your Odds or a Changing Your Perspective form for any panic attacks that occur over the next week.

✎ The client should practice facing a situation from the Hierarchy of Agoraphobia Situations at least three times over the next week.

SECTION 3

Facing Physical Symptoms in Agoraphobia Situations

Outline ■ Work with the client to deliberately induce feared physical sensations during exposure exercises

Therapist Behaviors Therapist behaviors are the same as in section .

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Facing Physical Symptoms in Agoraphobia Situations The notion of deliberately inducing feared bodily symptoms within the context of feared agoraphobia situations derives from evidence that the compound relationships between external and internal cues can be the most potent anxiogenic agent. That is, it is not just the situation, nor is it just the bodily sensation that triggers distress; rather, it is the combination of the bodily sensation in the situation which is most distressing. Thus, effective exposure targets both types of cues. Otherwise, clients run the risk of later return of fear. For example, repeatedly practicing walking through a shopping mall without feeling dizzy does not adequately prepare clients for occasions on which they feel dizzy walking through a shopping mall, and without such preparation, clients may be likely to panic and escape should they feel dizzy in this or similar situations in the future. Have the client choose an item from the Hierarchy of Agoraphobia Situations, either one already completed or a new item, and choose which symptom to induce and ways of inducing that symptom in that situation. The client will record this practice using the Facing Symptoms and Agoraphobia Situations form in the workbook. This form differs from the Facing Agoraphobia Situations form in that a section called Symptom Exaggeration has been added. Clients use this section to record the symptom that will be deliberately induced in the in vivo exposure practice and the way in which it will be induced. In addition, the negative thoughts are tied to the situation and to the symptoms in the situation. A blank form is included in the workbook, and multiple copies can be downloaded from the TreatmentsThatWork™ website (http://www.oup .com/us/ttw). An example of a completed Facing Symptoms and Agoraphobia Situations form is shown on page .

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Facing Symptoms and Agoraphobia Situations Date: 3/24/06 Situation: Shopping in a crowded mall. Symptom Exaggeration: Wearing a woolen sweater to increase body heat and sweating. End Goals (excluding superstitious objects, safety signals, safety behaviors, and distractions): To shop in a crowded mall for two hours, staying mainly in the center of the mall, away from the exits. Today’s Goals: To shop in a crowded mall for two hours, staying in the center of the mall for one hour while wearing a heavy sweater. Negative Thought (i.e., whatever it is you are most worried about happening, with the symptoms in the situation): I will pass out. 0

How many times has it happened?

What is the evidence? I have become hot and sweaty many, many times before and yet have never fainted. What are the real odds? (–)

2

Ways of coping: If I faint, I will wake up and get help. Did what I most worried about occur? (Yes/No) No. Maximal anxiety (–):

6

---------------------------------------------------------------------- None

Mild

Moderate

Strong

Extreme

Figure 11.2.

Example of completed Facing Symptoms and Agoraphobia Situations form

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Case Vignettes

Case Vignette 1 C: I was doing really well for a while, facing each situation on my hierarchy. Then, the other day, I had a panic attack for the first time in ages. Now I’m really afraid to go back to the same situations. T: What did you do when you panicked? C: At first, I was just so scared and so mad that it was happening again, and then I remembered to look at my thinking. When I realized that I was blowing things out of proportion, it got better. T: So, it sounds like you actually did well. What would stop you from continuing to face your situations? C: When I panicked this time, I was in a mall, so it was still pretty safe. But what if it happened again while I was driving? T: What if it did? How would that be different? C: It wouldn’t really, I guess. It would be harder to use my skills, but I had to do that when I first started to face my fears, and it did get easier. It’s more frustrating, because I thought I was really over that, but looking back, I know I’ve handled worse panics before.

Case Vignette 2 C: I am so discouraged. I just want to feel normal again. I don’t want to have to be on guard every time I leave my house. T: What is it that you are on guard against? C: The possibility of panicking. T: Why do you feel the need to protect yourself against panicking? What are your thoughts about what could happen if you panicked? C: The same old things—that I will die.

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T: So, it sounds like we need to revisit the ways of looking at the evidence and developing realistic probabilities.

Case Vignette 3 C: I haven’t taken any medication in ages, but I still like knowing that it’s there if I need it. T: What do you mean by “need it”? C: You know, if I start to panic. T: When we have reviewed your exposures, it seemed as if there were several occasions when you panicked, but you still finished the task anyway, even without the medication. C: That’s true. But I’ve always known that I had it available. T: It sounds like you have been using the availability of medication as a safety signal. Maybe it is time to address this more directly by weaning you from carrying medication with you in the same way by which you weaned yourself from carrying a paper bag with you. C: I guess that makes sense. It really is more superstitious than anything else, because I never actually take the medication anymore.

Case Vignette 4 C: Do you really think I am ready to drink coffee and go to the movies? T: What worries you about the combination of coffee and the movie theater? C: Well, I’ve practiced in movie theaters a lot, so that feels pretty good, but the coffee is going to make me feel very anxious. T: And if you feel very anxious in the movie theater, then what? C: Then, I don’t know what. Maybe I will get those old feelings again, like I have to get out.

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T: Based on everything that you have learned, how can you manage those feelings? C: Well, I guess my number-one rule is never to leave a situation because I am feeling anxious. I will stick it out no matter what. T: That sounds great. It means that you are accepting the anxiety and taking the opportunity to learn that you can tolerate it. What else? C: I can ask myself what is the worst that can happen. I know that I am not going to die or go insane. I will probably feel my heart rate going pretty fast because of the coffee. T: And if your heart rate goes fast, what does that mean? C: I guess it just means that my heart rate will go fast. T: This will be a really good way for you to learn that you can tolerate the anxiety and the symptoms of a racing heart.

Atypical and Problematic Responses The ups and downs of practicing can sometimes be discouraging to clients. That is, they may feel as if they have conquered a particular situation and then experience an unexpected panic on the next occasion of entering the same situation. In these cases, remind clients that learning is rarely linear but, more importantly, that recurrences of panic and anxiety provide excellent opportunities to learn the most critical thing for them to learn—that is, to learn that they can tolerate anxiety and that anxiety and the symptoms of panic are not harmful. In this way, recurrences of panic and anxiety are seen as excellent learning opportunities. Again, the goal of this treatment is for clients to be less anxious about panic and anxiety—the goal is not to prevent fear and anxiety.

Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

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✎ At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

✎ Instruct the client to continue completing either a Changing Your Odds or a Changing Your Perspective form for any panic attacks that occur over the next week.

✎ The client should practice facing a situation from the Hierarchy of Agoraphobia Situations at least three times over the next week until all the items are completed.

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Chapter 12 Involving Others

(Corresponds to chapter  of the workbook)

Materials Needed There are no materials needed.

Outline ■ Discuss and plan ways for clients to involve significant others in their treatment

Therapist Behaviors Therapists can assist in this collaboration by role-playing the part of coach and by reviewing practices in which one or both parties felt misunderstood, pushed, or otherwise distressed.

Involving Significant Others Significant others frequently have a big impact on agoraphobia and its treatment, even when they are not directly involved in a treatment program. For example, agoraphobia avoidance behavior generally leads to increased dependence on significant others, which is likely to change the dynamics of the interpersonal relationship. The behavior and attitudes of significant others also can have strong effects, both positive and negative, on the client’s anxiety and avoidance. For these and other reasons,

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involving significant others in treatment can be quite beneficial, a suggestion that has been supported by empirical research. Significant others can play both positive and negative roles in the development and maintenance of agoraphobia and also in its treatment. It is important that this information is conveyed both to clients and to significant others in such a way that blame and recrimination are minimized and that all parties approach treatment with as collaborative an attitude as possible. A large part of this chapter consists of ways in which this communication might be facilitated, primarily through increasing others’ understanding of the anxiety difficulties and the methods of treatment. A major step in involving significant others in treatment is to help them to understand panic and agoraphobia, as well as the treatment program. In this way, the reasons for seemingly irrational fear and avoidance will be made clearer, and the difficulty of the treatment program will be more greatly appreciated. Communication with significant others is crucial. First, discussion with significant others is critical in helping them to learn more about how the client’s agoraphobia has been maintained by inadvertent reinforcement and how agoraphobic behavior has affected the relationship. Second, before others begin assisting with in vivo exposure, everyone involved must have the same clear understanding of what each person’s roles and responsibilities are and how various concepts and feelings are to be communicated during the height of anxiety, so that the practices do not end in misunderstandings or animosity.

Involving Significant Others in Exposure Exercises Significant others take on several roles in assisting with exposure practices. Providing support is one key role, because overcoming agoraphobia can be very stressful. Acting as a coach before, during, and after practices is also important. Involving significant others as coaches encourages a supportive team approach. However, in order to avoid a dependency on the significant other,

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clients are informed that exposures with significant others must be followed by exposure practices without the aid of significant others.

Case Vignettes

Case Vignette 1 C: My boyfriend and I have gotten into so many fights about my canceling plans to go out that I’m afraid to ask him to practice with me. It’ll just make things worse. T: That is one possibility. Are there other ways in which he might react? C: Well, he might be so relieved that I’m finally getting over this that he’d want to help me so we could go out more. Or he could do it because it’s important to me. T: Do you have any evidence that any of these possibilities are more likely than the others? C: I guess I do. He’s been pretty supportive of my treatment so far. He drives me here, even though he gets annoyed about it sometimes. And I know he’s proud of me for working so hard. Maybe when he learns more about it, it’ll be even easier.

Case Vignette 2 C: Our practices together have been going pretty well, and I’m really starting to feel confident. But sometimes, I almost wish that I wasn’t doing as well, because it’s not as okay anymore to tell my wife I don’t feel like going out. T: So, in some ways, the avoidance served some useful purposes for you. C: Sort of; I mean, I never planned for it, but sometimes, it’s just nice to know my wife will help me when things feel difficult or will understand if I want to stay home.

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T: It sounds like this might be a good time for the two of you to discuss how your becoming more independent might affect your relationship, both good and bad, and maybe to come up with other ways to communicate the desire for wanting to be taken care of that we all feel sometimes.

Case Vignette 3 (Note: “P” stands for “Partner” in the following vignette.) P: Most of the time, we work really well together, but sometimes, I get really frustrated when she hesitates because I know she’s been able to do this before. She’ll get mad at me for pushing too hard, and we end up in a fight. T: Have the two of you come up with a way of communicating when you are out doing the exposures? C: We did at the beginning, but, as I worked more and more on my own, we didn’t really need to use them as much, so we kind of stopped. T: So, one solution would certainly be to get back in that habit, if it worked well for you before. It sounds like there have also been some disagreements about the responsibilities each of you have here. How does each one of you see your roles in this? P: Mine is to try to be supportive and to help Sally when she doesn’t remember to use all of her skills. Isn’t it? C: Yes, but not to push me all the time. It’s my responsibility, ultimately, and if I don’t want to practice, or if I want to end early, I need you to understand that also. Sometimes, I feel too anxious, and you’re really helpful then, but other times, I’m just too worn out, and it would be worse to keep going. T: So, it sounds almost like you need Tom to read your mind to know when to push and when to stop. C: When you put it that way, it sounds like I’ve been pretty unfair. But it seems so obvious to me at the time.

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T: Maybe the two of you can come up with some ways by which to let each other know how you are feeling during the practices, so each of you can know very clearly what you are looking for from the other. Let’s role play them here.

Atypical and Problematic Responses For clients who are not involved in intimate relationships or whose partners are unable or unwilling to become involved in treatment, close friends can be equally useful. This is especially true if the friend lives with or has very frequent contact with the client, because some of the reinforcements discussed earlier are likely occur within that relationship, too. Some clients might even prefer to involve a friend rather than a partner. Clients who have been especially secretive about their anxiety are sometimes uncomfortable with the level of communication needed to fully use another person as a coach. Role-playing in the therapist’s office can be helpful here, as can a guided discussion regarding everyone’s expectations for treatment and for specific in vivo exposures. In some cases, the client’s agoraphobia avoidance was instrumental in maintaining the relationship, and increasing independence can seriously disrupt the relationship. For some, discussion of these issues during treatment may suffice. In other cases, however, these issues may reflect much greater relationship problems that have perhaps been masked by the anxiety and avoidance. Such issues would be better dealt with through couples’ therapy that focuses on issues separate from agoraphobia. However, it is noteworthy that most studies report increased marital satisfaction from the effective treatment of agoraphobia.

Homework

✎ Instruct the client to return to chapter  of the workbook and to continue planning and practicing exposures to agoraphobia situations, either with or without the help of a significant other.

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Chapter 13 Facing Physical Symptoms

(Corresponds to chapter  of the workbook)

This chapter is divided into four sections.

Materials Needed for All Sections ■ Symptom Assessment form ■ Facing Symptoms form ■ Activities Hierarchy ■ Facing Activities form

SECTION 1

Facing Physical Symptoms

Outline ■ Work with the client in order to conduct symptom exercises

Therapist Behaviors Participant modeling procedures are used to arrive at a hierarchy of anxietyproducing symptom exercises (i.e., the therapist models each exercise, and then the client copies the therapist), followed by therapist-guided, repeated exposures. Self-directed exposure is assigned for practice between sessions. For the in-session practice, therapists are to encourage clients to induce the sensations, to tolerate them for specified periods of time, and

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to focus on the sensations in an objective (rather than an affective or subjective) manner. Following completion of the exercise, clients are encouraged to use their breathing and thinking skills. The therapist then provides corrective feedback. As with exposures to feared situations, therapists are to be directive, confident, and encouraging of clients to continue the exercises despite anxiety, fear, or symptoms. To be overly hesitant with clients will only reinforce their sense of inability to handle the anxiety and the symptoms. Also, while cognitive preparation is very helpful (i.e., helping clients to recognize that they are unlikely to be harmed by the symptoms, etc.), be wary of spending too much time on the cognitive preparation, as it may actually become a form of avoidance of the exercises. It is essential to allocate a good portion of the session just to the symptom exercises (e.g.,  minutes).

Fear of Physical Symptoms Facing fear of symptoms means to be deliberately exposed to the feared sensations that trigger panic attacks. Typically, these types of sensations are avoided. Subtle avoidance includes distracting oneself from thoughts about physical sensations. Obvious avoidance includes avoiding activities, such as arguments or sexual relations, which elicit strong sensations. Avoidance precludes relearning and instead maintains the vigilance for and acute sensitivity to such sensations. Hence, an essential component of treatment is to confront repeatedly the feared sensations, so that clients learn they can tolerate the sensations and associated anxiety and that the sensations are not harmful. After a number of such practices, anxiety over the symptoms eventually declines. This process begins by inducing sensations by using a set of standardized and artificial exercises, such as spinning and hyperventilating. The client’s response to these exercises is first assessed so that they can be ranked in order from least- to most-anxiety producing using the Symptom Assessment form shown on page . Clients’ own repeated experiences of physical sensations are very different from systematically facing feared sensations. Their own exposures to the sensations have been associated with fear and avoidance. In contrast, the exposure exercises prevent avoidance. Through repeated exposures,

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Symptom Assessment ---------------------------------------------------------------------- None

Mild

Exercise

Moderate

Symptoms

Strong Anxiety Level 1–10

Extreme Similarity 1–10

Run in place

Spinning

Overbreathing

Drinking-straw breathing

Stare at self in mirror

Lift head quickly

Tense body

Other

Other

Figure 13.1.

Blank Symptom Assessment form

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clients learn that they are not harmed by the sensations and thus achieve increased confidence in their ability to tolerate symptoms. Hence, the sensations become less salient or meaningful. Consequently, vigilance for these sensations decreases, as does general anxiety about the sensations and panic attacks.

Symptom Exercises The symptom-induction exercises are designed to elicit the sensations most relevant to the client. The exercises are to be performed in a way that elicits sensations as strongly as possible. Although clients may be able to persist for only a short time initially, the length of exposure gradually can be extended. However, even with the first exposure trial, it is important to induce the sensations fully and to continue the exercise beyond the point at which the sensations are first noticed. To terminate the exercise on first noticing distressing symptoms will reinforce fear of the symptoms. Also, instruct clients to focus on the sensations during the exercises, not to distract from them. Also, breathing and thinking skills are to be implemented only after finishing the symptom-induction exercise. All obvious and subtle forms of avoidance (e.g., distraction, minimal symptom induction) should be prevented in order to obtain the most benefit from these exposures. Similarly, all safety behaviors and safety signals (e.g., holding on for support, remaining in close proximity to an exit, etc.) should be eliminated. After clients perform each exercise, they will rate the intensity of the symptoms, fear of the symptoms, and similarity of the symptoms to those that occur during panic attacks using the Symptom Assessment Form in the workbook. From these ratings, a hierarchy is developed, from least- to most-feared exercise (of the exercises that elicit sensations that are at least mildly similar to those experienced during panic attacks).

Repeated Exposures Clients proceed up their own hierarchy of anxiety-provoking symptom exercises in order of increasing intensity. In addition, within each exer-

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cise, the duration of exposure to sensations gradually can be lengthened. Through repeated exposure, the intensity of sensations should either remain the same or increase. The sensations rarely decrease markedly, although the level of fear eventually decreases, and the ability to endure sensations increases.

Facing Symptoms Date: 3/26/06 Symptom exercise: Hyperventilation Negative thought (i.e., whatever it is you are most worried about happening): I will not be able to function—I will not be able to talk or walk. First Exercise

Did what I most worried about occur? (Yes/No) Maximal anxiety (–):

No.

8

Second Exercise

Did what I most worried about occur? (Yes/No) Maximal anxiety (–):

No.

8

Third Exercise

Did what I most worried about occur? (Yes/No) Maximal anxiety (–):

No.

6

---------------------------------------------------------------------- None

Mild

Moderate

Strong

Extreme

Figure 13.2.

Example of completed Facing Symptoms form

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At the end of each repetition, the client will complete a Facing Symptoms form. A blank form is included in the workbook, and multiple copies can be downloaded from the TreatmentsThatWork™ website (http://www .oup.com/us/ttw). An example of a completed Facing Symptoms form is shown on page .

Case Vignettes

Case Vignette 1 C: You said it was important not to distract when I feel the sensations. Should I concentrate on how awful I feel? T: The point is not to concentrate on feeling awful but to allow yourself to experience fully the sensations. By giving yourself permission to feel these sensations, you are giving yourself the chance to appreciate fully the fact that you can handle the sensations and that they are not harmful.

Case Vignette 2 C: So this means that for the week before my menstrual period, I should always expect to panic more because of the hormonal changes going on, and it’s the hormones that cause my panic attacks? T: When did you begin to experience panic attacks? C: Two years ago. T: When did you begin to menstruate? C: Twenty years ago. T: Why do you think that you did not panic in the first  years of your menstrual cycle? C: I don’t know. I never even thought about panicking up until  years ago.

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T: This highlights the fact that panic is not the direct result of certain physical sensations becoming apparent, whether due to hormonal fluctuations or other reasons. Rather, panic occurs as the result of a complex interaction between physical sensations and fear of those sensations. The panics that you experience just prior to menstruating may indeed be triggered by physiological sensations arising from hormonal fluctuations, but the panic attack only occurs if you are afraid of the sensations. C: I see what you mean. So as long as I can learn not to be scared of the feelings, I shouldn’t panic. T: That is right. In turn, by being less afraid of these physical sensations, you will be less attentive to them, less anxious overall, and less vulnerable to experiencing the symptoms in the first place. Nevertheless, you might always notice some physical symptoms before menstruating.

Case Vignette 3 C: Why do I think this way? Is it part of my personality to be afraid of physical symptoms? T: It seems that the way in which we interpret different events in our lives is strongly influenced by our whole history of learning experiences. So, if through a series of experiences, you have learned to associate physical symptoms with danger, then it would make sense for you to respond to benign physical symptoms with a sense of potential danger. For example, being very sickly as a child, or seeing someone else go through a serious illness, may lead you to be more likely than someone who has not had such experiences to view bodily sensations as potentially risky. The good news is that we can structure learning experiences to change the ways in which we think. In fact, that is what this treatment is about: using experience to develop new ways of thinking about physical symptoms.

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Atypical and Problematic Responses Occasionally, clients continue to be perplexed by the experience of somatic sensations that occur for no apparent reason. It is useful to reiterate several main points as follows: “First, if you are generally anxious or worried (e.g., about experiencing panic), your level of physical arousal will be ‘up a notch.’ Therefore, you will be more susceptible to experiencing physical symptoms that are by-products of heightened arousal, such as sweating or shaking. Second, if you worry a lot about panicking, you will be very attentive to signals of impending panic—the physical symptoms.” An occasional problem with the interoceptive exposure procedure is the failure to experience anxiety due to perceived safety, predictability, and controllability. That is, in the context of the exercises conducted in session with a therapist, the level of anxiety about the symptoms is mitigated by knowing where the symptoms come from, that they will end, and that they are safe. In contrast, the same symptoms elicit much more anxiety if they occur for no apparent reason in the client’s daily life. Discussion of the thinking that leads to more or less fear of sensations under different conditions is very helpful. This discussion highlights the significance of anxious thoughts—the symptoms are the same, but the thoughts are different. Also, even though the symptoms are thought about differently in different circumstances, the actual risk associated with the symptoms has not changed. Occasionally, clients report difficulty performing the symptom exercises at home. This difficulty is most often associated with the sense of danger in the event that they panic or that “something happens.” In addition to putting things back into perspective (i.e., “What is the worst that can happen?”), a graduated approach can be employed. Initially, clients may practice in the presence of a friend or family member, or even in the therapist’s office with the therapist out of the room. The next step is to practice when alone. In a similar vein, clients may perform the exercises but with limited symptom exposure. That is, clients may terminate the exercise as soon as sensations are felt or may not perform the exercise with the intensity needed to experience the sensations fully. Full benefit is unlikely to be achieved under these conditions. Therapists should address such avoid-

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ance behavior and help clients to modify their anxious beliefs about what would happen if they were to experience the symptoms.

Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

✎ The client should continue to complete either a Changing Your Odds or Changing Your Perspective form for any panic attacks that occur over the next week.

✎ The client should practice symptom exercises three times each day.

SECTION 2

Review of Symptom Exercises

Outline ■ Review the client’s symptom exercises from the past week ■ Encourage the client to continue symptom exercises

Therapist Behaviors Therapist behaviors are the same as in section .

Review The main goal of this section is to review what was learned as a result of the between-session practices; to continue therapist-directed, in-session, symptom-induction practices; and to encourage continued betweensession practices.

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Case Vignettes

Case Vignette 1 C: Spinning in the chair makes me dizzy and nauseous no matter how many times I do it. Should I keep spinning? T: Do you feel anxious or afraid when you become dizzy or nauseous? C: Not anymore. I did the first couple of times, but now it’s just an uncomfortable feeling of dizziness and nausea. T: If you are no longer afraid of the sensations, there is no need to continue with the exercise. The exercises are not designed to eliminate the sensations but to lessen the fear and avoidance of those sensations.

Case Vignette 2 C: I’m only afraid of the sensations produced by these exercises when I’m in certain situations, like being in a crowded shopping mall or on a bus. T: Later, we will work on confronting the symptoms in these types of situations. For now, let us examine what kind of thoughts make the symptoms more anxious in those situations because, in reality, the symptoms are no more harmful in a crowded shopping mall than they are here.

Case Vignette 3 C: After all of my aerobic exercise over the last few weeks, I’ve certainly learned not to be afraid of my heart racing. But in the last week, I’ve noticed a weakness in my arms, and now, that symptom scares me. Does this mean that I’ll always be anxious about one or another symptom? T: The fact that you have become frightened of a new symptom may indicate a continuing tendency to misinterpret bodily sensations as dangerous in some way. You can apply the same procedures as you did for

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the racing heart. With time, the general tendency to view symptoms in a threatening way will decrease.

Case Vignette 4 C: Every time I breathe through the drinking straw, it feels as if I’m suffocating, and I have to stop. It never gets any easier. T: Since you know that this practice will not really suffocate you, it is best to continue with the repeated exposures. If it is difficult to continue for  seconds beyond the point at which you begin to feel like you cannot breathe, cut it back to five seconds, and do that enough times until you feel comfortable. Then, gradually go up to  seconds, and so on.

Case Vignette 5 C: I tried hyperventilating on my own. However, I wasn’t very successful because I felt too scared, and I stopped it as soon as I noticed the strange feelings. T: What did you think would happen if the sensations became more intense? C: I thought the feelings would get worse and worse and worse and just overwhelm me. I didn’t want to have that feeling of panic again. T: If you did become overwhelmed, what would happen to you then? C: Then I’d feel really terrible. T: And if you felt really terrible? C: Well, nothing. I’d just feel terrible. T: The word “terrible” carries a lot of meaning. Let us see if we can pin down your anxious thoughts, which make the feelings so terrible. C: I just can’t tolerate the feeling. T: What tells you that you cannot tolerate it? How do you know that you cannot tolerate it?

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Atypical and Problematic Responses As with exposures to agoraphobia situations, fear and anxiety about the symptoms may fail to decline over repeated days of exposure practice. In this case, look for examples of safety behaviors or safety signals that may be inadvertently contributing to the anxiety. In addition, assist clients in looking at the realistic odds or changing their perspective (i.e., thinking skills) for whatever it is that they are most worried about happening, and help them to appreciate the value of learning to tolerate anxiety and its symptoms. Occasionally, clients report that they ended the exercises because they were producing long-lasting symptoms. For example, practicing spinning in a chair was reported by one of our clients to induce dizziness for one entire week. Assuming that there are not true medical explanations (e.g., vertigo), this protracted symptomatology is likely due to misappraisals of the symptoms as being harmful or indicative of something wrong; attempts or desires to get rid of the symptoms; or safety behaviors. In these cases, help clients to conduct a step-by-step analysis of the week’s worth of symptoms, and practice the exercise in session with the instruction to make the symptoms as intense as possible. It is also possible to arrange for clients to engage in normal daily routines and tasks immediately after the exercises or after they leave the office so as to reinforce their abilities to tolerate the symptoms. For example, a client can be encouraged to go to the store, make a phone call, or ask someone for directions despite the presence of dizziness or lightheadedness immediately following the treatment session. In other words, encourage continued approach behavior and minimize safety behaviors following each session involving interoceptive exposure.

Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

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✎ The client should continue to complete either a Changing Your Odds or Changing Your Perspective form for any panic attacks that occur over the next week.

✎ The client should continue to practice symptom exercises three times a day.

SECTION 3

Facing Symptoms in Activities

Outline ■ Extend symptom exercises to activities that are common in day-today life ■ Have the client choose items to practice from the Activities Hierarchy in the workbook

Therapist Behaviors Exposure to certain activities can be conducted in session, with therapist feedback and participant modeling. For example, drinking coffee or eating chocolate is very suitable for in-session exposure. Between sessions, self-directed exposure is essential in order to facilitate generalization and to lessen the reliance on safety signals (i.e., presence of others). Therapists are to review clients’ practices over the prior week, brainstorm complications such as procrastination or escape, and help clients design their next between-session practices. As with exposure to feared situations, the therapist is to be directive and confident and to encourage clients to persist despite anxiety.

Facing Activities Exercises Naturalistic activities are now used in the same way that symptom exercises were used to induce relevant feared sensations. Examples of these activities include aerobic activity, sexual arousal, high excitement, watch-

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ing suspenseful movies, anger, being in hot or stuffy conditions, and so forth. Although the activities may result in sensations that are not easily stopped (e.g., as in the case of drinking coffee), the sensations should not be viewed as more dangerous. Like the symptom exercises, the activity exercises are designed to be systematically graduated and repetitive. Clients may apply the breathing and thinking skills while the activity is ongoing. This is in contrast to the symptom-induction exercises, where coping skills are used only after completion of the symptom exercises. This is because the activities often are considerably longer than the symptom-induction exercises. Nevertheless, clients are encouraged to focus on the sensations and to experience them fully throughout the activity, while not using the coping skills to prevent the onset of sensations. A multitude of behaviors are designed to avoid certain physical sensations. Very subtle avoidance can occur without full awareness. For example, being unwilling to place oneself in stressful situations or confrontational encounters with other people could reflect anxiety about experiencing panic-like sensations. Similarly, hesitation about walking in the open (in contrast to staying close to a structure or another person) may reflect anticipation of intense sensations. Best results come from combining interoceptive exposure (to the symptom exercises or to activities like drinking coffee) with elimination of the excessive safety behaviors. The activities that elicit panic-like sensations are different from typical agoraphobia situations. Agoraphobia situations are those in which panic is expected because of previous experiences of panic in similar situations. For example, highway driving may be avoided because of a history of panic in that situation. On the other hand, the activities described in this section directly elicit sensations (e.g., drinking coffee induces sensations in everyone, not just those fearful of panicking), although the intensity of the sensations is likely to be stronger when the sensations are feared. For practice, the client should choose activities from the Activities Hierarchy included in the workbook. At the end of each practice, the client

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will complete a Facing Activities form. A blank form is included in the workbook, and multiple copies can be downloaded from the Treatments ThatWork™ website (http://www.oup.com/us/ttw). An example of a completed Facing Activities form is shown below.

Facing Activities Date: Activity: Jogging End Goals (excluding superstitious objects, safety signals, safety behaviors, and distractions): Jog for 20 mins, alone. Today’s Goals: Jog for five minutes, with running group. Negative Thought (i.e., whatever it is you are most worried about happening): I will become breathless and stop breathing. How many times has it happened? None. What is the evidence? Even though I feel breathless, I am healthy and unlikely to stop breathing. What are the real odds? (–) Zero. Ways of coping: I will go slowly and remind myself that breathlessness is not dangerous. Did what I most worried about occur? (Yes/No) No. Maximal anxiety (–): 5 ---------------------------------------------------------------------- None

Mild

Moderate

Strong

Extreme

Figure 13.3.

Example of completed Facing Activities form

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Case Vignettes

Case Vignette 1 C: What if I go to an aerobics class, get really anxious, and have to leave? T: Remember, you can do this in graduated steps. For example, you initially could decide to attend an aerobics class for  minutes; and then, the next time, you could go for  minutes, and so on. Also, if you feel like you have to leave in the midst of an aerobics class, think about what it is that you are most worried about happening, and then consider the realistic odds or ways of coping. If that is not possible in the class, step outside to give yourself time to think things through, and then return to the class.

Case Vignette 2 C: One of the things that I’m going to do is to walk at a vigorous pace while carrying weights. But I haven’t done exercise for so long that I wonder if it might be too much. T: Indeed, you need to consider what is reasonable. For anyone who has not exercised for a long time, it is unwise to jump immediately into very vigorous exercise. Let us start slowly and then build up to more strenuous workouts.

Atypical and Problematic Responses Occasionally, clients report that their level of fear does not reduce across repeated exposure trials. Sometimes, this occurs because clients continue to hope that the sensations do not become intense, and they try to eliminate the sensations as soon as possible after the exercise or activity is terminated. In such cases, the breathing skills in particular tend to become safety crutches rather than adaptive strategies. In addition to putting things back into perspective (e.g., “So what if my heart races?”), it is helpful to practice the symptom exercises and activities without subsequent use of breathing. Instead, instruct the client to make the sensa-

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tions last as long as possible. A paradoxical intentional approach can be used also (i.e., make the sensations as intense as possible). Sometimes, a client’s reluctance is expressed in the view that “I never drink coffee, so why should I start now? Even if I wasn’t scared, I would not drink coffee”; or, “Who wants to feel sick from a fairground ride?” Here, you need to help clients to realize that, sometimes, exposure hierarchies go beyond what is “normally done” or what is preferred in order to instill a strong sense of mastery and control. Therefore, even though they would not typically engage in certain activities, there is value in carrying them out. Failing to complete the top hierarchy items could leave the client susceptible to a return of fear at some later time.

Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

✎ The client should continue to complete either a Changing Your Odds or Changing Your Perspective form for any panic attacks that occur over the next week.

✎ The client should practice activity exercises at least three times a week, until the client’s anxiety reading on a given day is no more than a score of two.

SECTION 4

Review of Activity Exercises

Outline ■ Review the client’s activity exercises from the past week ■ Discuss with the client what has been learned and ways of managing escape behaviors

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Therapist Behaviors Therapist behaviors are the same as in section .

Review The exposure principles are the same as in the previous sections, although now, more attention is given to reinforcement of progress, brainstorming of problems with exposure, and creativity in generating exposures.

Case Vignettes

Case Vignette 1 C: I’m going to eat certain foods that I’ve avoided in the past because they made my stomach feel very heavy, which always signals to me the possibility of choking. However, I never like to eat alone, not because I’m scared, but because I just prefer to eat with other people. Will that be okay? T: For the purposes of the exposure, it will be more useful for you to eat alone despite your preference for eating with other people. Eating alone would allow the fullest exposure in which you will learn to be less afraid of the sensation of fullness in your stomach. That is, you will learn that you do not need the safety of the presence of others.

Case Vignette 2 C: If I drink a cup of coffee, I know it’s going to make me feel really agitated and jumpy. Then I won’t be able to concentrate or function at work. Do you really want me to drink a cup of coffee? T: Again, you can use a graduated approach. For example, you could drink a small amount first. Alternatively, you could drink coffee on the

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weekends so as to allow yourself to become more comfortable with the sensations and then drink on days that you go to work. Also, remember that poor concentration is probably due to being too attentive to the sensations that will also interfere with your concentration on other tasks. Learning to be less anxious about the symptoms will cause you to be less attentive to them and, thus, better able to concentrate on other things around you.

Case Vignette 3 C: One of my practices is to drive my car with the heater on and the windows closed. That is complicated by the fact that I don’t like to drive long distances away from home. How should I design my practice? T: You could choose from among a number of different options. You could practice driving longer distances with the heater off, and then you could do so with the heater on. Or, you could practice driving the same distance with the heater on, then drive a longer distance with the heater off; and finally, you could drive the longer distance with the heater on. Which way makes most sense to you?

Atypical and Problematic Responses The activities often are more difficult than the symptom exercises. For example, they sometimes are conducted in public places; the duration of the sensations is difficult to control; and they take more time overall. For this reason, clients sometimes find these exercises to be more anxiety provoking and may be less compliant with them. In other cases, reluctance to face these activities stems from the increased fear associated with the unpredictability and uncontrollability of these exposures. Unlike the symptom exercises, in which the sensations usually end shortly after stopping the exercise, clients often have no control over the onset or offset of symptoms resulting from naturalistic activities. For example, once the coffee has been ingested, the client can neither stop the exposure nor predict exactly when the effects of the caffeine will end. Clients should be reminded of any errors in thinking which

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may lead them to view these symptoms as being more dangerous rather than as merely more unpredictable and uncontrollable.

Homework

✎ The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

✎ The client should continue to complete either a Changing Your Odds or Changing Your Perspective form for any panic attacks that occur over the next week.

✎ The client should practice activity exercises at least three times a week, until the client’s anxiety reading on a given day is no more than a score of two.

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Chapter 14 Medications

(Corresponds to chapter  of the workbook)

Materials Needed There are no materials needed.

Outline ■ To teach clients about medications for anxiety and panic ■ To teach clients about ways of weaning themselves off medications ■ To show clients how medication can be combined with this treatment program

Therapist Behaviors This chapter is primarily didactic in orientation, and it places medications, side effects, and withdrawal symptoms within the psychobiological conceptual model of the treatment. The therapist’s role is to be informed, to able to answer questions, and to provide clarifications, where necessary.

Medications for Anxiety and Panic Medication is not described as a more or less effective form of treatment in comparison to cognitive behavioral therapy (CBT ) but as a more or less appropriate treatment dependent on different beliefs and life circumstances.

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Medications are described, so that clients may understand their effectiveness, side effects, and withdrawal problems.

Weaning Off Medications A program to help wean clients from medication is described in the workbook. In this program, withdrawal effects from medication, particularly benzodiazepines, are managed using the skills taught in the workbook. The withdrawal effects are conceptualized as an opportunity to face fears of symptoms.

Combining Medications With This Treatment Program The issue of combining medications with CBT of the sort outlined in this guide and the corresponding workbook is complicated, and it has been alluded to in previous chapters with reference to the use of anxiolytics when facing fears of symptoms and fears of agoraphobia situations. Data concerning medications in combination with CBT for panic and agoraphobia are presented in the first few chapters of this therapist guide. There is some evidence that benzodiazepines combine least well with CBT, and there is some evidence that, overall, the combination of medications with CBT is less efficacious in the long term than is CBT alone. However, long-term data are sparse. Furthermore, it is believed that the detrimental impact of adding medications to CBT can be overcome in part by encouraging continued exposure to feared stimuli as medications are withdrawn, by removing the reliance on medications as safety signals, and by encouraging an attribution of therapeutic improvement to oneself as opposed solely to medications. These issues are outlined in more detail in the workbook.

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Case Vignettes

Case Vignette 1 C: What if I panic when I come off the medication? T: Why do you think you would panic? C: Because all those old feelings would come back again. T: What feelings are you talking about? C: I’m sure I’d get scared, because my heart would be racing, and I’d feel sweaty and shaky, just like before—just like it was before I started the medication. T: Based on what you have learned from this treatment program, how could you react differently to those feelings? C: I would think about the fact that the feelings are not harmful, I would think of the worst that could possibly happen, and I would put things into perspective. Even if the symptoms didn’t go away, I’d realize that they’re just physical symptoms.

Case Vignette 2 C: I always thought that the medication was controlling a chemical imbalance. T: To date, there is no clear evidence for a specific chemical imbalance that causes panic attacks. However, medications seem to work on the chemical neurotransmission in a way that lessens distress.

Case Vignette 3 C: I don’t think I can drive, or be alone, without my medications. It makes me really anxious to think of not having any more medication. T: What do you think will happen if the medication is not available?

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C: That I will panic and not be able to control the panic. T: How do you think that the medication is stopping you from panicking? C: It gives me reassurance that I can stop the feelings. T: And what would happen if you were not able to stop the feelings? C: I guess that they would get so intense and out of control that I would lose it completely. T: So, it sounds as if you see the medication as preventing a catastrophic outcome. Let us evaluate that catastrophic outcome by examining the evidence, and we will see if it is at all likely. How do you know that you will “lose it” completely?

Atypical and Problematic Responses Letting go of the safety of medication is sometimes very difficult in terms of both physical and psychological dependency. In addition to a process of gradual weaning away from higher dosages (under the supervision of the prescribing physician), weaning a client from psychological dependence can be facilitated by the client’s gaining further and further autonomy over the medication bottle. For example, clients may practice by giving their medication to a companion, leaving it in the glove box of their car, or leaving it at home. In addition, correction of misinterpretations about what the medication is supposedly doing is helpful. Many times, clients mistakenly think that the medication is preventing catastrophic occurrences, and they feel vulnerable to dying, losing control, or going insane without the help of their medication. This kind of reasoning, of course, is very suitable for cognitive restructuring. The fact is that while medication may be effective in blocking panic attacks, it is not preventing the catastrophic consequences from happening, because those catastrophic consequences are unlikely to happen in the first place, with or without medication. A common misassumption related to this issue is that intense panic and anxiety increase the risk of catastrophic outcomes, and thus, the medication is valuable because it blocks intense anxiety and panic. In this case, use thinking

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skills to address the mistaken notion that catastrophic outcomes are more likely with more intense panic. It is likely that clients who have relied on medication to control their anxiety will be apprehensive about stopping their use of medication, even if they have stated a desire to do so. This anxiety may translate into doubts regarding their progress in the workbook programs and doubts about their ability to maintain or continue making gains if they cease medication use. In these cases, it is important to emphasize to clients, as in the first case vignette, that their own efforts have been effective beyond simple medication use. Incorporating medication use into an exposure hierarchy also can be helpful. Doing so brings medication use in line with other factors that make situations easier or harder to cope with, in a way that the client has become familiar with. This approach also addresses the very likely possibility that as clients decrease their medication, some anxiety will recur. Preparing for this recurrence in advance can forestall unnecessary anxiety while reaffirming to the client that they do in fact have control over even heightened levels of anxiety.

Homework

✎ Have the client speak with the prescribing physician if the client is currently taking medication and wishes to stop.

✎ The client should develop a step-by-step plan for dealing with any withdrawal symptoms by using the skills learned throughout this program.

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Chapter 15 Accomplishments, Maintenance, and Relapse Prevention (Corresponds to chapter  of the workbook)

Materials Needed ■ Progress Evaluation form ■ Practice Plan ■ Long-Term Goals form

Outline ■ Review the client’s progress up to this point ■ Encourage the client to continue to face fear and anxiety ■ Discuss ways of maintaining progress

Therapist Behaviors The therapist’s role is to assist clients in making objective statements regarding their progress to this point; perhaps reminding clients of improvements that they have not themselves noted. In addition, the therapist should assist clients in designating areas in need of further work for the Practice Plan.

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Evaluating Progress Instead of focusing on feelings in general, which is likely to be biased, progress is best evaluated by examination of objective data. Progress is indexed by improvement—not by reaching an absolute end goal of no panic, anxiety, or agoraphobia—and by skill development. Change or improvement is a continuing process, as is the case when learning any new set of responses or skills. Improvement can continue after the client completes the workbook because of the learning that has occurred, and results indicate that continued improvement is very typical. Reasons for lack of progress, such as insufficient practice, lack of understanding of the principles, the need for more time to implement the therapeutic strategies, and an initial error in diagnosis, all imply what type of action can be taken next in order for the client to progress. In other words, lack of progress is not presented as a hopeless outcome. Client can evaluate their own progress by completing the Progress Evaluation form in the workbook. If hesitations about approaching situations or physical symptoms occur in the future, these are not signs of the underlying problems resurfacing to uncontrollable levels or signs that the underlying problems were never treated effectively in the first place. Instead, it means that this is the temporary reappearance of old habits that can be treated in the same ways as learned through this workbook. The temporary resurgence of old habits is not a sign that treatment did not work. Stressful events are described as leading to increased emotional vulnerability and increased physiological arousal, which, in combination or alone, may increase susceptibility to old ways of reacting for a brief period of time.

Practice Plans If necessary, work with the client to identify areas for further practice. The client will use the Practice Plan in the workbook to list all of the things to be practiced over the next few weeks. A blank form is included

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Practice Plan Things to Practice

Description

More practice of returning fast, shallow breathing back to a

Breathing Skills

slow and abdominal pattern; go back to practice of 10 minutes, twice per day, in relaxing places. I am doing well with jumping to conclusions, but I need to do

Thinking Skills

more with my habit of blowing things out of proportion. Imagine scenarios of panicking in public, and think through facing the worst and putting things back into perspective Facing Agoraphobia Situations

I am ready to drive out to visit my brother.

Facing Symptoms

Push myself harder in exercise class since I am holding back too much.

Figure 15.1.

Example of completed Practice Plan

in the workbook, and multiple copies can be downloaded from the TreatmentsThatWork™ website (http://www.oup.com/us/ttw). An example of a completed Practice Plan is shown above.

Long-Term Goals Now that treatment is ending, the client may begin planning for things that he or she was previously unable to do because of panic and anxiety. Clients can use the Long-Term Goals form in the workbook to list their goals and the steps needed to reach those goals. A blank form is included

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Long-Term Goals Long-Term Goal

Career move into managerial position

Steps to Achieve Long-Term Goal

Talk to personnel staff. Look at courses being offered. Enroll in a course.

Develop new friendships

Join singles group at my church. Talk to others at my gym. Join associations and organizations.

Going back to school

Call admissions office. Get schedule of classes. Talk to others who have returned to school.

Figure 15.2.

Example of completed Long-Term Goals form

in the workbook, and multiple copies can be downloaded from the TreatmentsThatWork™ website (http://www.oup.com/us/ttw). An example of a completed Long-Term Goals form is shown above.

Ending Treatment Clients frequently express concerns about ending the program. It is therefore important to emphasize again that the treatment was designed to provide clients with the necessary skills for managing anxiety and that they now can take these skills to continue their progress.

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Case Vignettes

Case Vignette 1 C: Even though I’m doing most of the things I used to avoid, just the thought of driving on my own makes me anxious. Driving was always my biggest problem, and it looks like I’ll never get over it now. T: It sounds like you are separating driving from all the other items in your hierarchy because it is the hardest thing for you to face. How might you make the idea of driving less frightening? C: When the other situations seemed overwhelming at first, I broke them down into smaller steps. So I suppose that I could start with driving a tiny bit with someone in the car with me and then work up to longer distances gradually. It’s really not that different from the other situations, then.

Case Vignette 2 C: I really feel like I’m not ready to finish; I still have a lot of situations which I’m avoiding. T: How would you approach each of these situations? What procedures would you use to deal with them? C: Well, I would decide which one I’m going to do first, think about what I am most worried about, look at the odds and ways of coping, and practice facing each situation enough times, until I feel more comfortable. T: So, you know what principles to apply and how to approach the task of learning to be less afraid. C: Yes. T: Then you have successfully learned the principles of this workbook. Now it is up to you to apply them to whatever situations may cause you difficulty.

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Case Vignette 3 C: I thought I’d be “cured” by the end of treatment, but now it’s the last session, and I’m still not all better. How long will it take until I am? T: If by “cured” you mean never feeling anxious, remember that anxiety is an adaptive response and that the goal is not to eliminate it completely. Rather, treatment has focused on learning skills to control excessive anxiety and panic. Like any new set of skills, these must be practiced regularly, and this takes time. But the more that you practice, the more natural that these skills and these ways of thinking and behaving will become. How long it takes until these new responses feel natural varies from person to person, but it depends mostly on the amount of effort that you put into it.

Case Vignette 4 C: I’m afraid that once I stop coming here, I won’t get any better because I’ll have no one to review my progress with me or to give me feedback on how to do things differently. T: Do you mean you are not sure how to structure appropriate assignments on your own? C: Well, that’s part of it. I know what to do in general—to break down harder tasks into little steps until I feel comfortable with them and to face the sensations fully instead of distracting myself like I used to. So, while I’d like the security of hearing from you that I’m doing it right, it’s more that I’m not sure I have the discipline to make myself practice. T: In that case, it is more a question of coming up with ways to stay motivated. You might try asking a friend or family member to help at first, if you feel you must report back to someone. You could also schedule a time each week when you consider your progress and report back to yourself. Some people find that giving themselves little rewards for completing their practices works well, and after a while, the benefits from practicing become motivation enough.

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Case Vignette 5 C: I’ve finished my hierarchy, but I still feel nervous sometimes when I face a new situation. Are you sure I’m ready to end treatment? T: Do you mean that you should stay in treatment until you never feel anxious ever again? C: Well no, I know that’s unrealistic. But how do I know for sure that I can really cope with new situations on my own? T: I guess you can never know anything for sure until you try it. But how have you handled these new situations so far? C: The same way in which I did the ones on my hierarchy, by breaking them down into manageable steps, preparing to confront them, and using my skills to face them. I suppose that’s what I’ll keep doing.

Atypical and Problematic Responses Clients sometimes feel discouraged at this point because they still experience panic attacks or avoid situations on occasion. Frequently, these clients minimize the improvements they have made while magnifying the problems still experienced. It is helpful to review records kept from the beginning of treatment so that clients may accurately evaluate their levels of change. Point out instances of discounting positive changes in favor of dwelling on the negative (e.g., “Sure, I’ve gone to shopping malls and movies a lot, but I still get anxious driving long distances by myself, so I’m really no better”; or, “Even though I’m not panicking every day anymore, I’ve still had some panics recently”). Emphasize that even though there is still room for improvement, they have made great strides so far, have worked very hard to get to this point, and should allow themselves to feel proud of their accomplishments. When major life crises occur toward the end of treatment, a client may actually regress a bit and feel back at “square one.” In such cases, acknowledge the setback, but explain that a setback does not mean that all progress is lost. Reviewing records kept throughout treatment can be encouraging: The client made progress before and can certainly do so again.

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In addition, relearning skills is generally easier than learning them the first time. As in termination of any therapy program, many clients will feel uncertain of their ability to continue to progress or to maintain their progress once the treatment ends. Acknowledging that this uncertainty can feel frightening will assure clients that it is an expected and normal reaction. For clients who are more worried, explicitly pointing out the work that they have done on their own, such as practicing without the therapist present, can alleviate some of their fears. Planning together ways of confronting difficult situations that may arise in the future can also increase a client’s sense of readiness. Sometimes, scheduling one or two monthly “booster” sessions allows clients to experience the sense of being on their own while continuing to have the safety net of a scheduled therapy session. It is important to use these sessions to review the client’s independent progress, however, rather than to reassure or to work on new goals; otherwise, the therapist risks strengthening the belief that continuing in therapy is crucial for continued success.

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Chapter 16 Modification for Primary Care Settings

Panic disorder is prevalent and costly in primary care settings, making the need for effective interventions paramount. Community prevalence studies (Eaton, Romanoski, Anthony, & Nestadt, ; Kessler et al., ) indicate a current (in the last  months) prevalence rate for panic disorder of –% of the population, whereas estimates from primary care settings range from . to %, with a median of –% (e.g., Leon, Portera, & Weissman, ; Shear & Schulberg, ; Tiemans, Ormel, & Simon, ). Elevated prevalence in primary care settings may be due in part to the high comorbidity between Panic Disorder (PD) and unexplained physical symptoms and the tendency for patients to interpret panic-related symptoms as evidence of medical illness (e.g., Katerndahl & Realini, ; Katon & Roy-Byrne, ). Consequently, PD patients use primary care services at three times the rate of other patients (U.S. Department of Health and Human Services, ), exceeding that of depressed patients (Simon, ) and patients with other psychiatric disorders (Klerman, McGonagle, Zhao, Nelson, Hughes, Eschleman, et al., ). Unfortunately, PD is poorly recognized in primary care (e.g., see Fleet, Dupuis, Marchand, Burelle, Arsenault, & Beitman, ; Perez-Stable, Miranda, Munoz, & Ying, ; Spitzer, Williams, & Kroenke, ). Moreover, even when recognized by primary care physicians, PD and anxiety disorder appear to be inadequately treated (Katon et al., ; Meredith, Delaney, Horgan, Fisher, & Fraser, ; Young, Klap, Sherbourne, & Wells, ). According to one investigation (Roy-Byrne et al., ), of  primary care PD patients followed for – months, % did not receive any form of therapy, only % received liberally defined cognitive-behavioral therapy (CBT ), less than % received medications, and only % received an efficacious medication regimen.

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Thus, we modified panic control treatment (PCT ) for PD which is tailored to a primary care setting.

Length and Schedule of Treatment We shortened treatment relative to usual PCT, which typically lasts from  to  or more visits, so that the treatment would be more acceptable for primary care patients. Thus, we modified PCT to be delivered in six visits with a behavioral health specialist in the primary care clinic.

Treatment Setting We conducted the treatment sessions in the clinics because patients are more likely to accept mental health treatment when offered in the primary care setting. Also, it decreased the burden on patients, presented a more collaborative care model to patients, and facilitated communication with physicians. In some overcrowded clinics, space was at a premium, and behavioral health specialists met with patients at nonpeak periods or afterhours (e.g., early evening) clinic times.

Patient Eligibility Patient eligibility involved two stages. First, patients responded to a brief screening, beginning with two gating questions regarding the occurrence of anxiety attacks or unexplained paroxysms of physical symptoms (e.g., tachycardia). Those who responded affirmatively completed a subsequent three questions about the occurrence of attacks outside dangerous or performance situations, their frequency (in the last month), and the extent of worry about the recurrence of panic attacks. This simple screening is highly sensitive, although lacking in specificity (Stein, Roy-Byrne, McQuaid, Laffaye, Russo, McCahill, et al., ). Positive responses to the screening questions were followed by a lay-administered, structured composite diagnostic interview (World Health Organization, ; Wittchen, Zhao, Abelson, & Kessler, ) with follow-up questions asked of the patient by a psychiatrist in the event of diagnostic uncer-

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tainty. Patients were excluded if they had conditions that threatened life or participation in the study, including major medical illnesses, active suicidality, pregnancy, dementia, mental retardation, psychosis, and current substance abuse/dependence. Methods of screening and diagnosing are described in detail elsewhere (Roy-Byrne, Sherbourne, Miranda, Stein, Craske, Golinelli, et al., ).

Treatment Structure This treatment entails the same components as PCT, including psychoeducation and cognitive restructuring aimed at educating patients about the nature of anxiety and panic and correcting misconceptions about the physical symptoms of panic attacks and about medication and its side effects. A second component, breathing retraining, aims to educate patients about respiratory physiology and to teach respiratory regulation. The interoceptive exposure component aims to extinguish fears of bodily sensations by repeatedly inducing sensations and applying panic control strategies until fear is diminished. The in vivo exposure component aims to extinguish fears of agoraphobia situations by repeated and systematic confrontation with those situations until fear is diminished. Each component is tailored to the individual’s specific presentation and needs. For reasons of treatment acceptability and patient burden, we did not include the usual ongoing record-keeping of panic and anxiety, and we decreased the usual number of homework assignments (e.g., practice of interoceptive exposure). In addition, the primary care PCT included more discussion of medications, since this treatment was evaluated in a study in which PCT was combined with medications (Roy-Byrne, Craske, Stein, et al., ). The inclinic visits ended with the development of a relapse prevention plan that covered medication adherence and implementation of cognitivebehavioral strategies and the coordination of continued care with the primary care physician and other community resources. There were six phone contacts following the in-clinic visits which reinforced the relapse prevention plan, allowed ongoing symptom monitoring, and facilitated consultation in the event that panic worsened or was treatment resistant. Use of the telephone has been shown to be effective for delivering both primary medical care for various chronic illnesses (Wasson, Gaudette,

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Whaley, Sauvigne, Baribeau, & Welch, ) and psychological interventions in medically ill patients (Mermelstein & Holland, ). In fact, we found that improvement was correlated with the number of treatment sessions and the number of telephone contacts (Roy-Byrne, Sherbourne, et al., ). The specific structure of the workbook for primary care is as follows. Session : Education about panic and anxiety and medications. Session : Correction of myths about panic and medications; cognitive restructuring (labeling of jumping to conclusions and putting things into perspective); and breathing skills (slowed and diaphragmatic breathing). Session : Cognitive restructuring (changing your own odds and changing your perspective) and breathing skills (in distracting environments). Session : Breathing and thinking skills to cope with anxiety; interoceptive exposure to feared physical sensations. Session : Interoceptive exposure to feared physical sensations; extension of interoceptive exposure to naturalistic activities that produce feared physical sensations; and in vivo exposure to feared agoraphobia situations. Session : Instructions to continue to face feared sensations and situations; relapse prevention. Obviously, the six-session structure did not permit extensive practice with interoceptive exposure or in vivo exposure to feared situations, and so, in some ways, the primary care modification represents an introduction of PCT skills and principles which would then be continued by clients on their own. In our study, this approach to treatment was highly effective in comparison to treatment as usual within primary care settings (Roy-Byrne, Craske, et al., ), and the results were due primarily to the CBT rather than the medication (Craske & Mystkowski, ).

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Reiss, S., Peterson, R. A., Gursky, D. M., & McNally, R. J. (). Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behaviour Research & Therapy, , –. Richards, J. C., Klein, B., & Carlbring, P. (). Internet-based treatment for panic disorder. Cognitive Behaviour Therapy, , –. Rijken, H., Kraaimaat, F., De Ruiter, C., & Garssen, B. (). A follow-up study on short-term treatment of agoraphobia. Behaviour Research & Therapy, , –. Roy-Byrne, P. P., & Cowley, D. S. (). Pharmacological treatments for panic disorder, generalized anxiety disorder, specific phobia, and social anxiety disorder. In P. E. Nathan & J. M. Gorman (Eds.), A guide to treatments that work (nd ed., pp. –). New York: Oxford University Press. Roy-Byrne, P. P., Craske, M. G., Stein, M. B., Sullivan, G., Bystritsky, A., Katon, W. J., et al. (). A randomized effectiveness trial of cognitive behavior therapy and medication for primary care panic disorder. Archives of General Psychiatry, , –. Roy-Byrne, P., Sherbourne, C., Miranda, J., Stein, M., Craske, M., Golinelli, D., et al. (). Poverty and response to treatment among panic disorder patients in primary care. American Journal of Psychiatry, , –. Roy-Byrne, P. P., Stein, M. B., Russo, J., Mercier, E., Thomas, R., McQuaid, J., et al. (). Panic disorder in the primary care setting. Journal of Clinical Psychiatry, , –. Schmidt, N. B., Staab, J. P., Trakowski, J. H., & Sammons, M. (). Efficacy of a brief psychosocial treatment for panic disorder in an active duty sample: Implications for military readiness. Military Medicine, , –. Shear, M. K., & Schulberg, H. C. (). Anxiety disorders in primary care. Bulletin of the Menninger Clinic, , A–A. Simon, G. E. (). Psychiatric disorder and functional somatic symptoms as predictors of health care use. Psychiatric Medicine, , –. Spiegel, D. A., Brace, T. J., Gregg, S. F., & Nuzzarello, A. (). Does cognitive behavior therapy assist slow-taper alprazolam discontinuation in panic disorder? American Journal of Psychiatry, , –. Spitzer, R. L., Williams, J. B., Kroenke, K., et al. (). Utility of a new procedure for diagnosing mental disorders in primary care: The PRIME-MD  study. Journal of the American Medical Association, , –. Stein, M. B., Norton, G. R., Walker, J. R., Chartier, M. J., & Graham, R. (). Do selective serotonin re-uptake inhibitors enhance the efficacy of very brief cognitive behavioral therapy for panic disorder? A pilot study. Psychiatry Research, , –.

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Stein, M. B., Roy-Byrne, P. P., McQuaid, J. R., Laffaye, C., Russo, J., McCahill, M. E., et al. (). Development of a brief diagnostic screen for panic disorder in primary care. Psychosomatic Medicine, (), –. Street, L., Craske, M. G., & Barlow, D. H. (). Sensations, cognitions, and the perception of cues associated with expected and unexpected panic attacks. Behaviour Research & Therapy, , –. Tiemens, B. G., Ormel, J., & Simon, G. E. (). Occurrence, recognition, and outcome of psychological disorders in primary care. American Journal of Psychiatry, , –. Tsao, J. C., Lewin, M. R., & Craske, M. G. (). The effects of cognitivebehavioral therapy for panic disorder on comorbid conditions. Journal of Anxiety Disorders, , –. Tsao, J. C., Mystkowski, J., Zucker, B., & Craske, M. (). Effects of cognitive-behavior therapy for panic disorder on comorbid conditions: Replication and extension. Behavior Therapy, , –. Tsao, J. C. L., Mystkowski, J. L., Zucker, B. G., & Craske, M. G. (). Impact of cognitive behavioral therapy for panic disorder on comorbidity: A controlled investigation. Behaviour Research and Therapy,  (), –. van Balkom, A. J., de Beurs, E., Koele, P., Lange, A., & van Dyck, R. (). Long-term benzodiazepine use is associated with smaller treatment gain in panic disorder with agoraphobia. Journal of Nervous & Mental Disease, , –. van den Hout, M., Arntz, A., & Hoekstra, R. (). Exposure reduced agoraphobia but not panic, and cognitive therapy reduced panic but not agoraphobia. Behaviour Research & Therapy, , –. Wardle, J., Hayward, P., Higgitt, A., Stabl, M., Blizard, R., & Gray, J. (). Effects of concurrent diazepam treatment on the outcome of exposure therapy in agoraphobia. Behaviour Research & Therapy, , –. Wasson, J., Gaudette, C., Whaley, F., Sauvigne, A., Baribeau, P., & Welch, H. G. (). Telephone care as a substitute for routine clinical followup. Journal of the American Medical Association, , –. Westin, D., & Morrison, K. (). A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: An empirical examination of the status of empirically supported therapies. Journal of Consulting & Clinical Psychology, , –. Williams, K. E., & Chambless, D. L. (). The relationship between therapist characteristics and outcome of in vivo exposure treatment for agoraphobia. Behavior Therapy, , –.

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Williams, S. L. (). Perceived self-efficacy and phobic disability. In R. Schwarzer (Ed.), Self-efficacy: Thought control of action (pp. – ). Washington, DC: Hemisphere. Williams, S. L., & Falbo, J. (). Cognitive and performance-based treatments for panic attacks in people with varying degrees of agoraphobic disability. Behaviour Research & Therapy, , –. Wittchen, H. U., Reed, V., & Kessler, R. C. (). The relationship of agoraphobia and panic in a community sample of adolescents and young adults. Archives of General Psychiatry, , –. Wittchen, H. U., Zhao, S., Abelson, J. M., Abelson, J. L., & Kessler, R. C. (). Reliability and procedural validity of UM-CIDIDSM-III-R phobic disorders. Psychology in Medicine, , –. Wolpe, J. (). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press. Wolpe, J. (). The practice of behavior therapy (th ed.) (Pergamon General Psychology Series, ). Elmsford, NY: Pergamon. World Health Organization (). Composite International Diagnostic Interview. Geneva: WHO, Division of Mental Health. Young, A. S., Klap, R., Sherbourne, C. D., & Wells, K. B. (). The quality of care for depressive and anxiety disorders in the United States. Archives of General Psychiatry, , –.

Additional Readings Background reading that provides more extensive coverage of the theoretical basis of the program described in this guide, as well as empirical data supporting the efficacy of the treatment, can be obtained from the following. Barlow, D. H. (). Anxiety and its disorders: The nature and treatment of anxiety and panic (nd ed.). New York: Guilford. Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (). Cognitive behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. JAMA: Journal of the American Medical Association, , –. Craske, M. G. (). Anxiety disorders: Psychological approaches to theory and treatment. Boulder, CO: Basic/Westview. Craske, M. G., & Barlow, D. H. (in press). Panic disorder and agoraphobia. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders (th ed.). New York: Guilford.

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Craske, M. G., Lang, A. J., Aikins, D., & Mystkowski, J. (). Cognitive behavioral therapy for nocturnal panic. Behavior Therapy, , –. Craske, M. G., & Mystkowski, J. (). Exposure therapy and extinction: Clinical studies. In M. G. Craske, D. Hermans, & D. Vanstweegen (Eds.), Fear and learning: Basic science to clinical application. Washington, DC: American Psychological Association Books. Craske, M. G., Roy-Byrne, P., Stein, M. G., Donald-Sherbourne, C., Bystritsky, A., Katon, W., et al. (). Treating panic disorder in primary care: A collaborative care intervention. General Hospital Psychiatry, , –. Craske, M. G., & Tsao, J. C. I. (). Assessment and treatment of nocturnal panic attacks. Sleep Medicine Review, ,–. Roy-Byrne, P. P., Craske, M. G., Stein, M. B., Sherbourne, C., Bystritsky, A., Golinelli, D., et al. (). Cognitive behavior therapy and medication for primary care panic disorder: Sustained superiority for usual care. Archives of General Psychiatry, , –.

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About the Authors

David H. Barlow received his PhD from the University of Vermont in  and has published over  articles and chapters and almost  books and clinical workbooks, mostly in the areas of emotional disorders and clinical research methodology. The books and workbooks have been translated into over  languages, including Arabic, Mandarin, and Russian. He was formerly Professor of Psychiatry at the University of Mississippi Medical Center and Professor of Psychiatry and Psychology at Brown University and founded clinical psychology internships in both settings. He was also Distinguished Professor in the Department of Psychology at the University at Albany, State University of New York. Currently, he is Professor of Psychology, Research Professor of Psychiatry, and Director of the Center for Anxiety and Related Disorders at Boston University. Barlow is the recipient of the  American Psychological Association (APA) Distinguished Scientific Award for the Applications of Psychology. He is also the recipient of the First Annual Science Dissemination Award from the Society for a Science of Clinical Psychology of the APA and recipient of the  Distinguished Scientific Contribution Award from the Society of Clinical Psychology of the APA. He also received an award in appreciation of outstanding achievements from the General Hospital of the Chinese People’s Liberation Army, Beijing, China, with an appointment as Honorary Visiting Professor of Clinical Psychology. During the – academic year, he was Fritz Redlich Fellow at the Center for Advanced Study in Behavioral Sciences in Palo Alto, California. Other awards include Career Contribution Awards from the Massachusetts, California, and Connecticut Psychological Associations; the 

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C. Charles Burlingame Award from the Institute of Living in Hartford, Connecticut; the First Graduate Alumni Scholar Award from the Graduate College of the University of Vermont; the Masters and Johnson Award from the Society for Sex Therapy and Research; the G. Stanley Hall Lectureship, American Psychological Association; a certificate of appreciation for contributions to women in clinical psychology from Section IV of Division  of the APA, the Clinical Psychology of Women; and a MERIT award from the National Institute of Mental Health (NIMH) for long-term contributions to clinical research efforts. He is Past President of the Society of Clinical Psychology of the APA and the Association for the Advancement of Behavior Therapy, Past Editor of the journals Behavior Therapy, Journal of Applied Behavior Analysis, and Clinical Psychology: Science & Practice, and currently Editor-in-Chief of the TreatmentsThatWork™ series for Oxford University Press. He was Chair of the APA Task Force of Psychological Intervention Guidelines, was a member of the DSM-IV Task Force of the APA, and was a co-chair of the work group for revising the anxiety disorder categories. He is also a Diplomate in Clinical Psychology of the American Board of Professional Psychology and maintains a private practice. Michelle G. Craske received her PhD from the University of British Columbia in  and has published more than  articles and chapters in the area of anxiety disorders. She has written books on the topics of the etiology and treatment of anxiety disorders, gender differences in anxiety, and translation from the basic science of fear learning to the clinical application of understanding and treating phobias, in addition to several self-help books. In addition, she has been the recipient of continuous NIMH funding since  for research projects pertaining to risk factors for anxiety disorders and depression among children and adolescents, the cognitive and physiological aspects of anxiety and panic attacks, and the development and dissemination of treatments for anxiety and related disorders. She is Associate Editor for the Journal of Abnormal Psychology and Behaviour Research & Therapy, and she is a Scientific Board Member for the Anxiety Disorders Association of America. She was a member of the DSM-IV Anxiety Disorders Work Group Subcommittee for revision of the diagnostic criteria surrounding panic disorder and specific phobia. Craske has given invited keynote addresses at many international conferences and frequently is invited to present training

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workshops on the most recent advances in the cognitive behavioral treatment for anxiety disorders. She is currently a Professor in the Department of Psychology and Department of Psychiatry and Biobehavioral Sciences at the University of California, Los Angeles, and Director of the UCLA Anxiety Disorders Behavioral Research Program.

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