Stopping Anxiety Medication Therapist Guide [2 ed.] 9780199713523, 9780195338546
Stopping Anxiety Medication Therapist Guide, Second Edition outlines a treatment program for individuals who have diffic
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Stopping Anxiety Medication
EDITOR-IN-CHIEF
David H. Barlow, PhD
SCIENTIFIC ADVISORY BOARD
Anne Marie Albano, PhD Gillian Butler, PhD David M. Clark, PhD Edna B. Foa, PhD Paul J. Frick, PhD Jack M. Gorman, MD Kirk Heilbrun, PhD Robert J. McMahon, PhD Peter E. Nathan, PhD Christine Maguth Nezu, PhD Matthew K. Nock, PhD Paul Salkovskis, PhD Bonnie Spring, PhD Gail Steketee, PhD John R. Weisz, PhD G. Terence Wilson, PhD
Stopping Anxiety Medication SECOND EDITION
Therapist Guide Michael W. Otto • Mark H. Pollack
1 2009
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 © 2009 by Oxford University Press, Inc. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 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 Otto, Michael W. Stopping anxiety medication : therapist guide / Michael W. Otto, Mark H. Pollack. — 2nd ed. p. cm. Includes bibliographical references. ISBN 978-0-19-533854-6 1. Panic disorders—Treatment. 2. Benzodiazepines. 3. Drugs— Dosage—Reduction. 4. Tranquilizing drugs. I. Pollack, Mark H. II. Title. RC535.S76 2009 616.85 22306—dc22 2008043384
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Printed in the United States of America on acid-free paper
About TreatmentsThatWorkTM
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, such that we have reduced threats to internal and external validity, making the outcomes more directly applicable to clinical situations. Third, governments around the world and healthcare systems and policymakers 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, 2004; Institute of Medicine, 2001). 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
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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 make that possible. The second edition of this guide updates an evidence-based program for stopping anxiety medication. The program is specifically designed for the successful discontinuation of benzodiazepines for the treatment of panic disorder; however, it can also apply to the discontinuation of other types of medication for the management of anxiety. The clinician coordinates with the prescribing physician to ensure the patient follows a recommended slow-taper schedule for the safe discontinuation of medication. Many patients have difficulty with discontinuation due to medication-withdrawal symptoms and fears of relapse of panic disorder. Therefore the program targets the management of symptoms and treatment of the underlying disorder through exposure and cognitivebehavioral techniques. Clinicians will find this guide an invaluable resource for helping patients effectively reach their goal of stopping anxiety medication and remaining panic-free over time. David H. Barlow, Editor-in-Chief, TreatmentsThatWorkTM Boston, MA
References Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59, 869–878. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
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MWO: To my son Jackson, for his enthusiasm and joy MHP: To Patty, Josh, and JJ, for all of it
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Acknowledgments
The second edition of the Stopping Anxiety Medication therapist guide and patient workbook was designed to help individuals with panic and other anxiety disorders successfully discontinue their antianxiety medication. These works provide a wealth of information and step-by-step clinical strategies for this goal. These strategies were shaped by our research and clinical practice and by our close collaboration with our research colleagues. Most notably we would like to thank the authors of the previous edition of these works, Drs. David H. Barlow, Jennifer C. Jones, and Michelle G. Craske, for their contributions in shaping our work and the manual versions you see here. We would also like to thank our patients, who trusted us with their care, shared their perspectives with us, and contributed to the care of others by participating in research.
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Contents
Chapter 1
Introductory Information for Therapists
Chapter 2
The Taper Schedule
Chapter 3
Session 1
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Chapter 4
Session 2
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Chapter 5
Session 3
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Chapter 6
Session 4
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Chapter 7
Session 5
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Chapter 8
Session 6
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Chapter 9
Session 7
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Chapter 10
Session 8
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Chapter 11
Booster Sessions: Sessions 9–11
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Appendix A Response to Relaxation-Induced Anxiety
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Appendix B Responses to Anxiety Attacks Induced by Interoceptive Exposure 167 References
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About the Authors
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Chapter 1
Introductory Information for Therapists
Background Information and Purpose of This Program This treatment program is designed to aid individuals who have panic disorder with the task of discontinuing medication treatment. The goal is to facilitate successful medication discontinuation while also providing patients with the skills for eliminating the underlying panic disorder. Although this treatment program was built around the unique difficulties faced by patients who are tapering benzodiazepine medication, it has also been applied successfully to the task of antidepressant discontinuation (Whittal, Otto, & Hong, 2001). This program has also been applied clinically to difficulties discontinuing medication treatment for other anxiety disorders, including benzodiazepine medication use for generalized anxiety disorder and post-traumatic stress disorder. The principles underlying this treatment program are fully consistent with cognitive-behavioral models of panic disorder that emphasize fears of internal sensations of anxiety as well as the fears of the external situations where these feelings have been elicited (e.g., Barlow, 2002; Clark, 1986; McNally, 1990). Because of its focus on treating panic disorder as well as aiding medication discontinuation, this manualized program has been applied in studies as a primary intervention for panic disorder in patients who have failed to respond to medication treatments (e.g., Heldt et al., 2003, 2006; Otto, Pollack, Penava, & Zucker, 1999). In these applications, the medication discontinuation components have been treated as optional, depending on the goals of the individual patient (e.g., Otto, Pollack, & Sabatino, 1996).
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This therapist guide for stopping anxiety medication (SAM) is written for mental health professionals with experience in the treatment of panic disorder. It provides session-by-session instructions for exposure-based cognitive-behavioral therapy (CBT) that can be presented in either an individual or group format. The program consists of eight regular sessions and three booster sessions. This program represents the minimal level of intervention we recommend for benzodiazepine discontinuation. Patients having particular difficulties with panic symptoms may require additional booster sessions. The initial session requires 90 minutes, with subsequent sessions requiring 60–90 minutes according to whether the sessions are delivered in individual or group format, respectively. In addition to this therapist-directed program, a patient workbook is available to help patients better guide and monitor their own progress. This guide devotes a separate chapter to each regular session and one to the three booster sessions. Each of the regular-session chapters begins with a list of materials needed and an outline providing an overview of the session elements and goals. The chapter then provides a detailed account of the interventions, their order of presentation, and a clinical style for delivering the interventions. Commonplace examples and analogies are frequently used to facilitate the patient’s acquisition of this treatment information. Group treatment should be conducted in a room equipped with a whiteboard or other display materials, which allows visual as well as oral presentation of treatment information. For individual treatment, the therapist may present the visual information by writing in a notebook, by presenting printed information directly from the figures and tables in this guide, or by referring to the many figures and worksheets provided in the corresponding patient workbook. Benzodiazepine discontinuation requires coordination of care with the prescribing physician. In general, it is useful to provide the prescribing physician with an overview of this CBT program and its potential for helping patients successfully discontinue benzodiazepine treatment and remain off medication long term (potentially at a lower level of distress). The patient’s reasons for discontinuation should be reviewed, and full approval to proceed with medication taper should reflect a joint decision by the patient, prescribing physician, and the CBT therapist. In all cases,
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the taper rate and medical clearance for taper should be approved by the prescribing physician. In addition to the interventions described here, regular monitoring of discontinuation symptoms must be conducted. This monitoring may be performed by the prescribing physician, but it should also be done by the CBT therapist. For this monitoring, we recommend the use of a clinician-rated scale. The Medication-Taper Symptom Checklist is provided in Chapter 2 and in the patient workbook. Alternatively, therapists may want to consider using the Physician Withdrawal Checklist (Rickels, Schweizer, Case, & Greenblatt, 1990) or the Benzodiazepine Withdrawal Checklist (Pecknold, McClure, Fleuri, & Chang, 1982). To allow a comparison of emergent symptoms to those characterizing the disorder prior to discontinuation, the monitoring clinician should establish a 2-week baseline level of symptoms prior to starting discontinuation. This baseline time period is easily achieved in the context of this manualized program because the initiation of medication taper does not begin until after the third treatment session. Before the initiation of CBT, patients should have received a full psychiatric assessment and a medical evaluation of physical health. The medical evaluation is completed to ensure that patients are in adequate health to complete the physical exercises necessary for the interoceptive exposure. Because some women may be seeking to discontinue their benzodiazepine treatment due to pregnancy, it is important for these patients’ internists or obstetricians to approve interoceptive exposure procedures (e.g., hyperventilation or stair climbing). In our experience, the interoceptive exposure procedures have been approved in almost every case, notably because these procedures are helpful for both medication discontinuation and elimination of a greater physical stressor—the repeated panic episodes. Before the first session, patients should also be oriented to the program with the following information: (a) During treatment, information is presented about common behavioral patterns in panic disorder, and, at times, elements of a session may feel classroomlike; (b) training in specific skills for the control of panic disorder is provided, and patients will be expected to practice these skills outside of sessions; (c) treatment will
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involve graduated exposure to the somatic sensations of anxiety to help patients learn to respond to these sensations without fear; (d) regular attendance and practice are essential for progress.
Focus of SAM This manualized treatment program is designed for individuals with a primary diagnosis of panic disorder who have failed at previous attempts to discontinue their benzodiazepine treatment (or antidepressant treatment for anxiety) or who are reluctant to attempt discontinuation without adjunctive interventions. Patients usually have a variety of motivations for discontinuing their medication treatment. Common reasons include concerns about drug dependency, a general desire to control the panic disorder without medications, medical recommendations for discontinuation (e.g., before a planned pregnancy), and a marginal response to current treatment combined with a desire to try alternative treatment. Although patients seeking to discontinue their medication will represent a variety of levels of severity, we (Otto et al., 1993) found that severity of the panic disorder was not a predictor of discontinuation success and that the majority of participants in the program successfully discontinued medication despite a moderate level of panic symptoms. Also, comorbid anxiety or affective diagnoses are common in patients with panic disorder. These comorbid conditions do not preclude discontinuation success as long as the primary diagnosis is panic disorder. Moreover, CBT for panic disorder has been shown to be effective despite the presence of a variety of comorbid anxiety and mood disorders (see Otto, Powers, Stathopoulou, & Hofmann, 2008; Tsao, Lewin, & Craske, 2002). Nonetheless, because this program specifically targets the treatment of patterns underlying panic disorder, patients with comorbid mood or anxiety disorders may require additional cognitive-behavioral interventions if these patterns persist.
Development of This Treatment Program and Evidence Base Although benzodiazepine treatment has been found to be effective for the control of panic disorder, it is not uncommon for patients
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to have significant difficulties when discontinuing medication. The return of panic symptoms at levels as bad as, or worse than, those before treatment is common, and many patients with panic disorder find themselves unable to discontinue their medication successfully (Fyer et al., 1987; Noyes, Gamey, Cook, & Suelzer, 1991; Pecknold, Swinson, Kuch, & Lewis, 1988). These difficulties occur with both short and long half-life benzodiazepines and continue despite the use of slow-taper strategies (Denis, Fatséas, Lavie, & Auriacombe, 2006; Schweizer, Rickels, Case, & Greenblatt, 1990). The SAM program was devised in response to this problem with medication discontinuation. The purpose of this program is to facilitate successful medication discontinuation and to provide patients with skills for the management of panic disorder over the long term. This program is based on aspects of the panic control therapy (PCT) program developed and validated by Barlow and associates (e.g., Barlow, Craske, Cerny, & Klosko, 1989; Barlow, Gorman, Shear, & Woods, 2000; Craske, Brown, & Barlow, 1991), but has been modified to target problems encountered during medication discontinuation. As compared to PCT, the SAM program strengthens the interoceptive exposure (stepwise exposure to feared internal sensations) component of treatment. Interoceptive exposure is introduced far earlier in this treatment than in PCT and is viewed as a much more central feature of the therapeutic change process for both the treatment of panic disorder and helping patients be resilient in the face of withdrawal sensations. Interoceptive exposure is used to help individuals reacquire a sense of safety in response to emotional and somatic sensations of anxiety as well as benzodiazepine taper-related sensations. Elimination of the amplification of anxiety sensations, as well as elimination of anxiogenic and catastrophic responses to symptoms of medication withdrawal, is at the core of this program. Notably, it is also this feature of interoceptive exposure that is gaining new applications for aiding with withdrawal and emotion-based craving of licit and illicit drugs (Otto, in press; Otto, Safren, & Pollack, 2004; Zvolensky, Yartz, Gregor, Gonzalez, & Bernstein, in press). We first evaluated the SAM program in a controlled trial of 34 patients with panic disorder seeking to discontinue their benzodiazepine medication (Otto et al., 1993). Patients taking alprazolam or clonazepam
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and having difficulties in discontinuing their medication on their own were randomly selected to participate in either a slow medication-taper program alone or a slow-taper program in conjunction with SAM treatment delivered in a group format. The slow-taper with SAM program included weekly monitoring and supportive visits with the prescribing psychiatrist. One patient in the slow-taper-alone program refused to initiate the taper, and therefore results were limited to 33 patients. Of the patients in the slow-taper-alone program, only 25% successfully discontinued their medication. In contrast, 76% of patients in the SAM program successfully achieved discontinuation. An examination of patterns of distress indicated that levels of distress decreased during the SAM program despite the discontinuation of medication. An evaluation 3 months after the discontinuation period indicated that 77% of the patients in the SAM program remained benzodiazepine-free, with a trend toward decreased severity of illness relative to the pretaper assessment in these patients. In a second evaluation of this treatment, we used a three-group design comparing the relative efficacy of (1) this program, along with physician support and a slow taper, (2) a relaxation training program combined with physician support and a slow taper, and (3) physician support and a slow taper alone. The relaxation treatment condition was used to control for nonspecific aspects of treatment and to provide a better comparison of the value of the acceptance-based strategies inherent in interoceptive exposure programs and the value of the coping-based approach that is inherent to the use of muscle relaxation programs designed to control symptom severity. At our site, a total of 47 patients were randomized to these treatment groups and started treatment (see Otto, Hong, & Safren, 2002). At the end of acute treatment, 56.3% of patients treated with CBT had achieved a benzodiazepine-free status, as compared to 31.3% in the taper support plus relaxation training condition, and 40% in the taper-support-only condition. Differences between groups continued to be evident over a 6-month follow-up period, with a 62.5% benzodiazepine-free rate in the full SAM program, 12.5% when the taper support program was combined with relaxation training, and a 26.7% rate in the physician-support-only program. Also, in support of the elements of the SAM program, we found a significant positive correlation between adherence to the treatment manual (as
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judged by taped ratings of therapy content) and the outcome achieved in the SAM treatment. Together the results suggest that it is the active, rather than nonspecific, elements of treatment of the SAM program that may underlie these beneficial treatment outcomes. Moreover, the results supported the benefits of the focus of the SAM treatment on the elimination of fears of anxiety sensations using interoceptive exposure and cognitive restructuring rather than reliance on attempts to cope with these sensations using relaxation strategies. In addition to being used to discontinue benzodiazepine medication, the SAM program has been used to aid discontinuation of antidepressant medication. In a case series of eight patients with panic disorder, Whittal et al. (2001) reported that all patients successfully discontinued their treatment with selective serotonin reuptake inhibitors (SSRIs), while demonstrating further clinical improvement from a group program of CBT based on the SAM manual. It is important to note that beneficial outcomes have been achieved with other programs of CBT that applied similar informational, cognitive restructuring, and interoceptive exposure interventions to the task of benzodiazepine and antidepressant discontinuation in patients with panic disorder (Hegel, Ravaris, & Ahles, 1994; Schmidt, WollawayBickel, Trakowski, Santiago, & Vasey, 2002; Spiegel, Bruce, Gregg, & Nuzzarello, 1994). For example, in an open trial, Hegel et al. (1994) reported high rates of successful benzodiazepine discontinuation (80%) following 12 sessions of CBT and found high panic-free rates at 1 year follow-up. In a randomized trial, Spiegel et al. (1994) compared a program of CBT to physician-support alone for helping outpatients with panic disorder discontinue their benzodiazepine medication. Both studies provided evidence of superior achievement or maintenance of benzodiazepine-free status with the CBT program relative to the control condition. Of particular interest was the ultra-slow-taper program used in the study by Spiegel and associates. Using this very slow benzodiazepine taper, a majority of patients were able to acutely discontinue benzodiazepines, regardless of the presence of CBT. However, patients who did not receive CBT relapsed quickly (after 6 months, only half of the patients in the taper-alone group were able to stay benzodiazepinefree, compared with 100% of the patients who received the CBT program). Hence, whereas a very slow taper may be used to reduce the
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intensity of withdrawal symptoms, it appears that treatment of the core fears underlying panic disorder is crucial for helping individuals stay benzodiazepine- and panic-free over the longer term.
Cognitive-Behavioral Model of Panic Disorder The SAM treatment program is based on a cognitive-behavioral model of panic disorder positing that panic attacks are maintained because an individual develops fear of the somatic sensations associated with the experience of panic attacks. Initial panic attacks are viewed in the context of a stress-diathesis model and are relatively common. The development of recurrent panic attacks represents the activation of the protective fight–flight reaction under conditions in which no objective, but a wealth of subjectively perceived, danger is present. The subjective danger is instantiated by the imagined consequences of panic sensations and commonly includes feared outcomes such as passing out, dying, losing control, going crazy, or being humiliated. Accordingly, panic attacks in the context of panic disorder are viewed as phobic-like reactions to salient somatic sensations of arousal. Anxious apprehension about the possibility of a future attack, combined with avoidance and escape from events or situations where feared sensations are elicited, create the dramatic disability associated with this disorder (Candilis et al., 1999; Carrera et al., 2006; Cramer, Torgersen, & Kringlen, 2005). Individuals in states of anxious apprehension are vigilant for potential danger (i.e., sensations and situations that may signal an impending panic attack). This readiness accounts for a chronically high, generalized arousal and the sensitivity to a wide variety of cues capable of eliciting the next panic attack. The combination of anxious apprehension and panic attacks represents a self-perpetuating cycle that characterizes the disorder (see Figure 1.1). CBT that emphasizes information, cognitive restructuring, and interoceptive and in vivo exposure can eliminate these patterns (e.g., Smits, Powers, Cho, & Telch, 2004) and provide acute benefit with strong maintenance of treatment gains (Furukawa, Watanabe, & Churchill, 2006; Gould, Otto, & Pollack, 1995). As such, relative to pharmacologic alternatives, it is a particularly cost-effective treatment for panic disorder (McHugh et al., 2007).
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Stress Biological Diathesis
Alarm Reaction Rapid heart rate, heart palpitations Shortness of breath, smothering sensations Chest pain or discomfort, Numbness or tingling
Increased anxiety and fear
Conditioned Fear of Somatic Sensations
Catastrophic Misinterpretaions of Symptoms
Hypervigilance to symptoms Anticipatory anxiety
Figure 1.1
Cognitive-Behavioral Model of Panic Disorder
Problems Associated With Benzodiazepine Taper Patients who have experienced partial or full control of their panic disorder with benzodiazepine medications face a number of potential difficulties upon taper and discontinuation of these medications. Despite the physiological blockade of aspects of panic attacks and anxious apprehension, fears of somatic sensations may persist. Discontinuation of benzodiazepines, even with a slow taper, is associated with the emergence of withdrawal symptoms that may include mood disruption (anxiety, irritability, dysphoria), motor and somatic symptoms (muscle aches, stiffness, headaches, weakness, lack of energy, restlessness, muscular cramps, decreased sexual interest, flulike symptoms, tinnitus), gastrointestinal symptoms (loss of appetite, indigestion, diarrhea), sensory disturbances (increased sensory acuity, increased pain sensitivity, paresthesias, metallic taste, light sensitivity, perceptual distortions), sleep disruption (insomnia, nightmares), and cognitive disturbances (trouble concentrating, difficulties in verbal expression, derealization, confusion) (Roy-Byrne & Hommer, 1988; Tyrer, Murphy, & Riley, 1990).
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The emergence of these symptoms is associated with difficulties in completing the taper process even in patients without a history of panic disorder. Patients with panic disorder may face additional difficulties because the withdrawal symptoms closely mimic the symptoms of panic attack and because the withdrawal symptoms accompanying the taper process increase the likelihood that feared somatic sensations will be experienced. These sensations emerge at a time when patients are more likely to be vigilant to the possible return of their disorder and may be especially prone to respond to sensations of withdrawal with increased arousal and catastrophic interpretations that often culminate in panic attacks. For many patients, benzodiazepine discontinuation removes a conditioned safety signal: the expectation that a panic-free period will follow each dose of medication. Hence, these patients face the additional difficulty of increased expectancies of anxiety and panic when a dose is missed. This reaction has been termed pseudowithdrawal and may itself increase anxious apprehension and vigilance to somatic sensations, thereby hastening the return of panic episodes (Winokur & Rickels, 1981). All of these difficulties can be subsumed under the terms withdrawal reactions and rebound anxiety. Rebound anxiety refers to an increase in anxiety above the patient’s typical levels resulting from the withdrawal of medication; it may hasten and exacerbate relapse. In addition to these difficulties, patients may face a return of their panic disorder independent of the acute withdrawal period. This relapse presumably reflects the absence of treatment of the basic pathological processes of panic disorder (i.e., anxious apprehension and fear of somatic sensations). In summary, a cognitive-behavioral model of the difficulties encountered during benzodiazepine discontinuation emphasizes the exposure of patients to the panic-like sensations they fear during a time when they are vigilant to their occurrence and fear the return of the disorder (Otto, Pollack, Meltzer-Brody, & Rosenbaum, 1992). Figure 1.2 summarizes some of these effects. In view of these discontinuation difficulties, effective behavioral treatment must include a focus on (a) decreasing conditioned fears of somatic sensations, (b) providing patients with skills for managing the severity of panic sensations, and (c) providing patients with skills for minimizing withdrawal symptoms. Because benzodiazepine withdrawal symptoms mimic the anxiety and panic
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Benzodiazepine taper
Anxiety and somatic symptoms associated with panic
Removal of a conditioned safety cue (the medication)
Increased anxiety and panic episodes
Vigilance to the possible return of the disorder Misinterpretation of symptoms and catastrophic cognitions Conditioned fear of somatic sensations
Figure 1.2
Cognitive-Behavioral Model of Difficulties Associated With Benzodiazepine Taper
sensations feared by panic patients (fears that are compounded by the vigilance to the possible return of the panic disorder at the time of medication taper), we have conceptualized the process of benzodiazepine discontinuation as a biological provocation procedure delivered to vulnerable individuals (Otto et al., 1992). The SAM treatment program incorporates four interrelated classes of interventions: interoceptive exposure, cognitive restructuring skills, exposure to avoided situations (in vivo exposure), and select somatic management skills (diaphragmatic breathing and relaxation training). We use this interrelated set of interventions in the SAM program to treat the underlying panic disorder while preparing patients to respond more adaptively to the somatic sensations they may experience as part of benzodiazepine withdrawal.
Alternative Treatments A range of pharmacologic strategies have been evaluated in clinical trials as an aid to benzodiazepine taper. A gradual taper rather than abrupt discontinuation is safer and associated with less distress and increased likelihood of successful discontinuation; switching from a short– to a long–half-life agent may well shift the time course of taper sensations, but does not appear to eliminate these sensations (Denis et al., 2006;
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Otto et al., 1993). Although augmentation with a variety of pharmacologic agents has been suggested as potentially effective to ameliorate distress associated with benzodiazepine discontinuation in panic disorder, support from systematic controlled study is relatively sparse, with mixed evidence for the potential utility of the anticonvulsant carbamazepine (Denis et al., 2006) and data from one trial in patients with generalized anxiety disorder showing benefit for the tricyclic antidepressant imipramine (Rickels et al., 2000). Overall, in terms of the available research on this topic, cognitive-behavioral programs have the most consistent support for aiding benzodiazepine withdrawal (for review, see Otto et al., 2002).
Risks and Benefits of This Treatment Program Many patients elect to continue long-term treatment with benzodiazepine medications (Worthington et al., 1998), and this is a strategy for continued control of panic disorder that should be discussed with patients as part of a decision to pursue a medication-taper program. In addition, many patients elect to combine a number of pharmacologic treatments to try to maximize treatment of their panic disorder (Bruce et al., 2005). The present treatment program represents an alternative to these strategies, where CBT is used to replace medication treatment while trying to maximize control of the panic disorder. Patients entering this treatment should know that benzodiazepine discontinuation is associated with a range of bothersome symptoms. Slow taper can be expected to reduce the intensity of these sensations, but likely will not eliminate them. As such, patients need training in strategies for responding to these symptoms. This treatment manual provides such training, while also providing core treatment interventions for the underlying panic disorder. Any decision to pursue medication taper should be made in conjunction with the prescribing physician, and patients should be explicitly informed that rapid discontinuation of benzodiazepines can be dangerous and that an approved slow-taper program is part of good medical care. Research indicates that not all patients successfully complete their scheduled taper program (see Otto et al., 2002), and hence stopping
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or slowing the taper, while continuing to develop skills in CBT, is an option for helping patients who are having difficulties. The overall aim of the SAM program is to help patients achieve their goals of being both benzodiazepine- and panic-free. Clinicians and patients should work together to determine an appropriate timeline for this goal if the taper schedules outlined in this program are too challenging.
The Role of Medications Information on the benzodiazepine, antidepressant, and additional treatments for panic disorder is provided in Chapter 2. Chapter 2 also provides guidance on a taper schedule that balances clinical safety and the minimization of taper symptoms with a desire to complete the taper and therapy process in a reasonable time frame. As is evident in Chapter 2, differences in the half life of medications may lead to different profiles in the emergence of withdrawal symptoms. It is the job of the treating clinician to work with the patient and the prescribing physician to choose a taper schedule that allows preparation of the patient for the symptoms that may be induced by the taper program.
Outline of This Treatment Program The SAM treatment program includes interventions that are designed (a) to decrease the distress that typically accompanies benzodiazepine (or antidepressant) discontinuation and (b) to treat the underlying panic disorder in order to increase the likelihood that recipients will maintain a medication-free status. Four core treatment components are detailed in this guide: (1)
Information, education, and cognitive restructuring are designed to correct misinformation and to eliminate the catastrophic misinterpretations of panic-like sensations (e.g., equating a racing heart with an impending heart attack).
(2)
Interoceptive exposure (systematic exposure to feared bodily sensations) is used to increase an individual’s tolerance of, and
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comfort with, somatic sensations associated with both benzodiazepine taper and panic disorder. (3) In vivo exposure to feared or avoided situations is provided to help ensure that fears of somatic sensations do not continue to be active in avoided situations and to help patients return to their full role functioning. (4) Training in diaphragmatic breathing and progressive muscle relaxation is designed to reduce the contribution of general somatic arousal and hyperventilatory symptoms to patient distress during the taper program.
SAM Program Interventions Cognitive Interventions The cognitive interventions include information, education, and cognitive restructuring. Starting with Session 1, patients are provided with a cognitive-behavioral model of panic disorder. This model, the fear-of-fear cycle, serves as the foundation for all subsequent material introduced in the SAM treatment program and provides patients with a framework for understanding the changes they are seeking to make in their anxiety and panic patterns. In addition to this model, patients are given detailed information about the physiological changes that accompany anxiety and panic attacks and are taught about the large impact cognitive misinterpretations have on the fear-of-fear cycle. Two specific types of misinterpretations are discussed: probability overestimation and catastrophizing. Probability overestimation refers to an individual’s tendency to overestimate the likelihood that a panic attack will be associated with a negative event. Catastrophizing refers to the person’s tendency to perceive an event or outcome as intolerable, unmanageable, or catastrophic. The message to patients is that such thoughts can increase the intensity of panic attacks and help maintain the panic disorder. The patients’ catastrophic thoughts and probability overestimations are identified, and strategies for countering such cognitive distortions are taught. The methods used to elicit such cognitive errors involve basic questioning techniques. For example, patients are asked, “What is the worst
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that could happen if you were to have a panic attack in this situation?” As specific concerns are identified, the initial question is followed by such questions as, “What would happen then?” and, “What would be so bad about that happening?” The goal is to help patients think through their thoughts far enough to identify the core prediction or catastrophe fueling the fear. During this process, patients learn to distinguish the somatic sensations of anxious arousal and panic from the imagined catastrophic consequences of these feelings. Cognitive interventions for probability overestimations involve having patients (a) identify the core prediction underlying their fears of each symptom cluster (e.g., “If I panic I will have a heart attack”), (b) treat the prediction as a hypothesis (guess about the world) rather than as a fact, and (c) evaluate critically the available evidence that supports and refutes this hypothesis. In this fashion, patients can arrive at a more realistic assessment of the probability that their feared predictions will eventuate. In addition to arriving at this more accurate probability estimate, patients are encouraged to examine alternative explanations for a given event (e.g., “The chest pain may be due to heartburn”). It is most important for patients to understand that the focus of this intervention is not on the probability of feeling panicky or anxious; rather, the focus is on the probability that a specific consequence will follow the experience of anxiety. Cognitive interventions for catastrophic cognitions entail a similar multistep process. First, patients must identify the precise nature of the imagined catastrophe. Second, patients must identify the worst-case scenario and imagine that it could actually happen. Third, patients are encouraged to evaluate critically the actual severity of this event. That is, patients are asked whether the event is really as bad as they imagined and whether they could cope if it occurred. Finally, patients are encouraged to remember that, even if the worst were to occur, anxiety and its effects are time limited and manageable and that most catastrophic events are very unlikely to occur. Some cognitions lend themselves better to one type of countering strategy than to another. For example, it might be difficult to decatastrophize having a heart attack as a consequence of a panic attack. Such a misinterpretation is better dealt with as a probability overestimation.
15
Likewise, the realistic probability of experiencing embarrassment if one were to faint in public may be quite high. However, most people, at some point in their lives, have demonstrated the ability to cope with embarrassment. The consequence of embarrassment can be more easily decatastrophized. In addition, these countering procedures can be integrated by having patients focus on their ability to cope with negative events, if they do arise. For example, fainting in a supermarket as a consequence of panic is very unlikely, although the patient could cope if she were to faint. In-session and home-based practice of these cognitive strategies is essential. In the early stages of the treatment program, these cognitive strategies are used to target fears associated with the medication taper. This component includes specific examples of how misinterpretations of anticipated withdrawal symptoms may cause patients to reenter the fear-of-fear panic-disorder cycle. In Session 4, after patients have begun the taper process, misinterpretations related to actual withdrawal symptoms are addressed with the aforementioned strategies. Finally, panic-related fears are addressed as one strategy for preventing reentry into the fear-of-fear cycle. Exposure to such thoughts is conducted in session and is designed to decrease the automatic, visceral reaction these thoughts invoke. The program provides further training in later sessions by exposing patients to these thoughts in the context of interoceptive exposure. Because the goal is to decrease the emotional reaction to such thoughts, the presence of concomitant, panic-related sensations is believed to facilitate this process. Patients are also provided with a specific cognitive strategy designed for use with withdrawal symptoms. This cognitive strategy entails the labeling of symptoms as the “benzodiazepine flu,” utilizes patients’ ability to cope with flu symptoms, and encourages them to apply the same strategy to symptoms that arise as part of the medication taper. For example, patients are reminded that they have coped with flu symptoms several times in their lives, even though the experiences were not pleasant. When confronted with such symptoms, patients typically do not respond with catastrophic cognitions or increased anxiety. Instead, they
16
tolerate the symptoms of illness until the symptoms remit. Patients are encouraged to apply this approach to the somatic sensations associated with medication taper. The approach is used in conjunction with other panic-control strategies to help patients manage taper-related sensations in a way that does not engage the fear-of-fear cycle. Overall, the cognitive interventions used in the SAM program are designed to help provide patients with a new framework for understanding and interpreting their symptoms of anxiety and panic. Accurate interpretation of the meaning of symptoms aids both the introduction of interoceptive exposure techniques and the accurate post-induction processing of these symptoms. In short, cognitive interventions are used to enhance the cognitive flexibility of patients for their interpretation of symptoms, and then interoceptive and in vivo exposure techniques are used to provide the corrective experiences for eliminating fears of these sensations.
Interoceptive Exposure
Interoceptive exposure is used to elicit, in a systematic, controlled fashion, the physical sensations that trigger increased apprehension and anxiety in patients with panic disorder. The purpose of these procedures is to decrease patients’ fear of bodily sensations. Through repeated exposure to the sensations and concomitant rehearsal of cognitive and relaxation strategies, patients strive to reach the following goals: (a) decreased fear of anxiety and panic-like sensations that is part of the withdrawal reaction to benzodiazepine discontinuation, (b) elimination of the fear of somatic sensations that is part of the panic disorder (this goal is important because the panic disorder may reemerge or worsen as patients decrease their benzodiazepine medication), and (c) improved tolerance of sensations previously viewed as dangerous or intolerable. Interoceptive exposure procedures also provide patients with additional opportunities to practice cognitive strategies and to facilitate the application of these strategies to sensations that arise due to medication withdrawal and naturally occurring anxiety and panic. Patients are introduced to the rationale for interoceptive exposure when the cognitive-behavioral model of panic disorder is presented. As stated
17
previously, this model emphasizes the anxiogenic effect of misinterpreting the somatic sensations of panic. In subsequent sessions, patients receive additional information regarding the purposes of interoceptive exposure. Specifically, patients learn that through conditioning (repeated associations), feared sensations acquire the ability to trigger a panic reaction automatically. Therefore, an important component of treatment is to decrease this automatic reaction. Patients accomplish this, in part, by repeatedly experiencing the feared sensations in a controlled fashion. This procedure enables patients to separate the experience of the sensations from the experience of anxiety and to learn that their feared consequences do not eventuate. Before each new exercise, patients are told what sensations they are likely to experience and that these sensations are a natural result of the exercise. This information helps patients successfully complete, rather than escape, the interoceptive exposure procedures. Successful completion of initial interoceptive exposure exercises is viewed as especially important in a discontinuation program because patients are moving from a state of relative comfort (freedom from panic in some cases) to a state of discomfort as sensations are induced by interoceptive exposure or medication taper. Hence, initial interoceptive trials emphasize the use of cognitive strategies to help patients best recognize and tolerate the induced symptoms. These procedures meet the primary goal of a coping and exposure-based treatment rather than that of a distraction-based model of treatment and provide the basis for tolerating sensations induced by medication taper. Repeated exposure to these sensations facilitates extinction; hence, patients are encouraged to stop all attempts at avoiding the sensations (including distraction) as well as activities and situations that elicit sensations (e.g., phobic situations or exercise). The interoceptive exposure portion of the treatment program includes a variety of exercises such as head rolling, chair spinning, tube breathing, and so on (see Chapter 7 on Session 5 for a complete list). These exercises were chosen because they elicit a variety of somatic sensations and mimic those arising from anxiety, panic, and benzodiazepine discontinuation. Patients should be exposed to each of the specified exercises even if the sensations elicited are not characteristic of their panic attacks. This practice is important because novel sensations may arise as a result
18
of medication taper, and one goal of the exposure is to prepare patients for these new sensations. Specific exercises for each patient should take into account the physical condition of the patient and are chosen at the discretion of the therapist. Interoceptive exposure is introduced early (in Session 2) and is emphasized strongly in the SAM program. Patients are introduced to each exercise in session and then are asked to continue exposure at home. The model of exposure used in the program incorporates decreasing levels of safety cues. Patients achieve initial comfort with an interoceptive exposure procedure in the office setting under the supervision of the therapist. Patients then complete the exercise at home, working to increase their ability to induce sensations without fear. After patients achieve relative comfort with the interoceptive sensations at home, they complete, in later sessions, interoceptive exercises away from home. As patients complete successful exposure in a variety of situations, they learn that they can proceed without fear even if sensations should arise in these situations in the future. Because of the programmed practice in these situations, the interoceptive exposure has provided patients with direct evidence that these sensations can be managed without fear, panic, or catastrophic consequences. Interoceptive exposure, conducted in a variety of circumstances and under a variety of conditions (including times when patients may be relatively sleep deprived or may be experiencing varying levels of psychosocial stress or taper-related symptoms), helps ensure that patients will fully learn that the sensations are “safe,” rather than learning that the sensations are safe only under selected circumstances (e.g., safe because the therapist is present, safe when feeling well, or safe when induced at home). Indeed, recent evidence suggests that the presence of safety cues can interfere with the beneficial effects of exposure (Wells et al., 1995). In the SAM program, a stepwise reduction of safety cues is provided as part of a natural progression from interoceptive exposure conducted with varying intensities in the therapist’s office to more challenging homework assignments conducted away from the therapist. As illustrated in Figure 1.3, the goal of interoceptive exposure is to fundamentally change how patients respond to sensations of anxious arousal regardless of the source of these sensations.
19
Somatic sensations of anxiety
Panic-inducing response Uh-oh!!! What if I ... die? ... lose control?? Catastrophic memories Hurry up/tense up/control
Comfort-inducing response “Relax” with the sensations Note exactly what the sensations feel like Use coping thoughts and coping memories Remember you don’t have to do anything about the sensations
Figure 1.3
Retraining to Choose Coping Responses to the Body’s Alarm Reaction
The goal is to help patients stop anxiogenic patterns of trying to avoid, distract, or relax away anxiety sensations and instead to help patients to appropriately attend to, accept, and decatastrophize their own experience of anxiety (Otto et al., 2004). In the earliest stages of the SAM program, this is done to help “inoculate” patients against fear responses to benzodiazepine-taper sensations. As treatment progresses, interoceptive exposure is applied more broadly to help eliminate anxiogenic patterns underlying panic disorder so that anxiety and related sensations no longer provoke panic attacks, anticipatory anxiety, and avoidance.
Naturalistic and In Vivo Exposure
As part of a natural progression toward more difficult homework assignments, patients are encouraged to engage in naturalistic and in vivo exposure. Naturalistic exposure involves having patients engage in activities that naturally elicit sensations associated with panic, such as physical exertion, certain bodily movements, watching emotionally laden films, and drinking caffeinated beverages. Exposure to such activities helps patients learn to cope with sensations that may be less predictable or controllable. Naturalistic exposure is also designed
20
to decrease the apprehension with which patients view novel activities or situations during which sensations may arise. Likewise, in vivo exposure provides opportunities for patients to approach and enter situations in which panic is anticipated. Both types of exposure provide patients with opportunities to apply the panic management strategies in more natural, rather than contrived, circumstances. In addition, engaging in approach behavior as opposed to avoidance or escape allows patients to learn that their feared consequences do not occur and emphasizes the planning of daily activities around desired events rather than around harm avoidance. Finally, naturalistic exposure helps patients learn that sensations are safe not only when induced by a specific exercise but also when induced by a variety of life circumstances.
Somatic Management Strategies
We believe the least important element of the SAM program is the inclusion of training in somatic management skills, specifically, diaphragmatic breathing retraining and muscle relaxation training. Research suggests that deletion of these elements of treatment does not reduce the benefit of similar treatment programs for panic disorder (Craske et al., 1991; Schmidt et al., 2000). We are concerned that strategies to try to “control” anxious arousal may lead patients into desperate attempts to relax that may actually cue panic episodes. Instead, most of the SAM program of treatment is focused on helping patients respond differently to anxiety sensations (e.g., “how can I be comfortable with these sensations”) rather than focusing on eliminating the symptoms with somatic management techniques. Nonetheless, muscle tension is a regularly evoked symptom during benzodiazepine taper, and we wanted to provide patients with strategies to reduce both the intensity and annoyance of these chronic (during the taper period) symptoms. For these reasons, we continue to provide training in diaphragmatic breathing and muscle relaxation during this program, but are careful to introduce these strategies as ways to manage taper-related symptoms rather than core techniques for treating panic disorder.
21
Use of the Patient Workbook The patient workbook for the SAM program aids therapists in their role of helping patients to complete benzodiazepine discontinuation successfully and to remain panic free. It provides patients with information on panic disorder, medication treatment, discontinuation symptoms, and the elements of the SAM program and includes all of the necessary forms, homework assignments, and practice reminders to help ensure patients’ smooth progress through treatment. Initial chapters of the workbook provide patients with a wealth of information, allowing them to read and review the informational component of treatment between sessions. In addition, the self-assessment, cognitive, and exposure exercises included in the workbook help ensure that patients take an active role in guiding their own interventions and in practicing treatment skills independent of their time with their treating clinicians. The patient workbook also has a section on spousal involvement. Spouses or other significant individuals in patients’ lives are encouraged to read the patient workbook. Patients are also encouraged to involve their spouses in selected treatment exercises such as interoceptive exposure.
Individual Versus Group Treatment The SAM treatment program can be administered in either an individual or a group setting. Although the original, controlled treatment trial supporting its efficacy (Otto et al., 1993) was conducted in a group format, the SAM program has been applied most frequently in clinical practice in an individual format. The group program offers patients effective treatment at a generally lower cost and provides the opportunity to learn from others in the group. The group format, however, requires that patients defer their benzodiazepine taper until a full group of patients can be evaluated and scheduled; hence, in most settings, timely treatment can be provided more easily in an individual format. The effectiveness of an individual format is also supported by other
22
applications of CBT to benzodiazepine discontinuation (Hegel et al., 1994; Spiegel et al., 1994).
Other Applications of the SAM Program As noted, the SAM program has been applied successfully to the treatment of panic disorder in the absence of the goal of medication taper. In particular, it has been applied to the treatment of individuals who have failed to respond adequately to pharmacotherapy. For these individuals, group treatment has shown not only strong acute efficacy, but long-term maintenance of treatment gains in the context of medication discontinuation over time (Heldt et al., 2003). Principles from the SAM program have also been applied to the treatment of illicit drug use. In particular, the focus on exposure to emotional and somatic sensations associated with drug use has been used by us in the treatment of continued illicit drug use among opiate-dependent patients in a methadone maintenance program (Otto et al., 2004; Pollack et al., 2002). In this illicit drug treatment program, internal (primarily emotional) and external cues for illicit drug use are identified, alternative (adaptive) behaviors in response to these cues are discussed, then the relevant emotional cues are induced in session in an exposure model and followed by practice of acceptance of emotional sensations in conjunction with rehearsal of one or more nondrug responses to the cues. Interoceptive exposure-based strategies have also been incorporated in novel treatment programs for smoking. In smoking, fears of anxiety symptoms are a risk factor for failure in smoking cessation attempts (e.g., Brown, Kahler, Zvolensky, Lejuez, & Ramsey, 2001; Zvolensky, Bonn-Miller, Bernstein, & Marshall, 2006), and accordingly interoceptive exposure, as applied as part of a smoking cessation program, appears to enhance the longer-term success of quit attempts (Zvolensky et al., in press). Overall, these programs are consistent with the goal of using interoceptive exposure to “inoculate” patients to the sensations that may otherwise push them toward drug use. In the case of the SAM program, it is to inoculate them against having to resume prescribed benzodiazepine treatment due to intolerance of somatic sensations of arousal
23
or feared withdrawal sensations. In treatments of drug-use disorders, interoceptive exposure is similarly applied to inoculate patients against emotions that may enhance craving for their addictive substance. In all programs, patients in treatment presumably learn from interoceptive exposure a much broader repertoire for responding to avoided or feared negative emotions.
Principles Versus Protocols of Treatment In closing, an important feature of the session-by-session format of the SAM program is the description of the goals, defined in terms of patients’ skills (“learning elements”), to be achieved in each session. This is provided to help therapists judge the success of each session, not by completion of a checklist of interventions, but by attending to the therapeutic learning that the interventions are designed to achieve. We hope this approach will help therapists attend to the principles underlying the treatment interventions and to apply the wealth of their skills in therapeutic problem solving and the “art” of therapy in helping patients move toward their treatment goals.
24
Chapter 2
The Taper Schedule
Prescribing the taper schedule for benzodiazepine discontinuation is ultimately the choice of the treating physician, but it will be important for you to ensure good communication between you, the patient, and the prescriber around the goals and rate of medication taper (including sharing taper information from this chapter). Rapid discontinuation of benzodiazepines is dangerous, and hence, a slow taper has the benefit of maximizing both safety and the likelihood of success of the discontinuation attempt. Taper Schedule for Benzodiazepines It is common to make more rapid reductions at higher dosage levels and then to slow the rate of taper when low doses are reached. In a study by Otto et al. (1993), the slow-taper program for alprazolam (Xanax® ) represented a reduction of the daily dose by 0.25 mg every 2 days for doses above 2.0 mg and a reduction by 0.125 mg every 2 days once a dose of 2.0 mg or less was reached. A taper according to this schedule lasts approximately 5 weeks for patients taking a daily dose of 2 mg. For patients taking 4 mg per day, the taper period lasts 7 weeks. To reduce the interdose rebound that may occur with alprazolam treatment, daily doses are often prescribed on a four-times-daily schedule. Taper schedules for other benzodiazepine agents can be calculated according to dose-equivalent conversions (see Table 2.1). For example, for the approximate 2:1 difference in potency for clonazepam (Klonopin® ) relative to alprazolam, patients taking more than 1.0 mg of clonazepam would decrease their dose by 0.25 mg every 4 days and then by 0.125 mg every 4 days for doses of 1.0 mg or less. At present, 0.25 mg tablets of clonazepam are not readily available. Instead, reductions can be made by
25
Table 2.1 Benzodiazepines Commonly Used to Treat Anxiety and Panic Medication
Alprazolam (Xanax® ) Clonazepam (Klonopin® ) Lorazepam (Ativana® ) Clorazepate∗ (Tranxene® ) Diazepam∗ (Valium® ) Chlordiazepoxide∗ (Librium® ) ∗ Not
Dose Equivalent Half Life (in hours) Speed of Onset (in mg)
1.0
12–15
Intermediate–Fast
0.5
15–50
Intermediate
2.0
10–20
Intermediate
15.0
30–200
Fast
10.0
20–100
Fast
20.0
5–30
Intermediate
typically prescribed for panic disorder.
0.25 mg (half of the available 0.5 mg tablet) every 8 days for the last 1 mg of the taper. The taper schedule for clonazepam included in Table 2.2 and the patient workbook corresponds to the 0.5 mg tablets now available. A taper schedule for alprazolam is provided in Table 2.3. As can be noted, the sample schedule includes zero-dose days, which allows the clinician to continue monitoring after discontinuation. We recommend the use of printed taper schedules (such as those in the patient workbook) to make patients aware of the planned taper schedule and to help ensure that they take an active role in monitoring their progress. The schedule should provide written information about the total dose to be taken each day and the dosing schedule for that day. In addition, space should be provided for the patient to record the actual amount of medication taken. This record provides the monitoring physician and the patient with a means of tracking the use of as-needed doses and the patient’s ability or inability to maintain the planned dose reductions. In all cases, we follow recommendations to allow occasional as-needed (prn) doses, while emphasizing a slow reduction in medication use. The patient who falls behind the scheduled dose reduction should be encouraged to continue planned slow taper if possible, without attempts to catch up to scheduled reductions.
26
Table 2.2 Sample Taper Schedule for Clonazepam Week/Day
Dosage (in mg)
Total for day
Morning
Noon
Evening
Bedtime
Expected: 0.75
Expected: 0.00
Expected: 0.50
Expected: 0.00
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.75
Expected: 0.00
Expected: 0.50
Expected: 0.00
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Week 1 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Expected: 0.75
Expected: 0.00
Expected: 0.50
Expected: 0.00
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.75
Expected: 0.00
Expected: 0.50
Expected: 0.00
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.50
Expected: 0.00
Expected: 0.50
Expected: 0.00
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.50
Expected: 0.00
Expected: 0.50
Expected: 0.00
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.50
Expected: 0.00
Expected: 0.50
Expected: 0.00
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.50
Expected: 0.00
Expected: 0.50
Expected: 0.00
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.50
Expected: 0.00
Expected: 0.50
Expected: 0.00
Actual: _____
Actual: _____
Actual: _____
Actual: _____
1.25 1.25 1.25 1.25 1.00 1.00 1.00
Week 2 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Expected: 0.50
Expected: 0.00
Expected: 0.50
Expected: 0.00
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.50
Expected: 0.00
Expected: 0.50
Expected: 0.00
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.50
Expected: 0.00
Expected: 0.50
Expected: 0.00
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.50
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.50
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: _____
Actual: _____
Actual: _____
Actual: _____
1.00 1.00 1.00 1.00 1.00 0.75 0.75 continued
27
Table 2.2 Sample Taper Schedule for Clonazepam continued Week/Day
Dosage (in mg)
Total for day
Morning
Noon
Evening
Bedtime
Expected: 0.50
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.50
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Week 3 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Expected: 0.50
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.50
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.50
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.50
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
0.75 0.75 0.75 0.75 0.75 0.75 0.50
Week 4 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Expected: 0.25
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.00
Expected: 0.25
Expected: 0.00
Actual: ______
Actual: ____
Actual: ____
Actual: ____
0.50 0.50 0.50 0.50 0.50 0.50 0.50 continued
28
Table 2.2 Sample Taper Schedule for Clonazepam continued Week/Day
Dosage (in mg)
Total for day
Morning
Noon
Evening
Bedtime
Expected: 0.25
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Week 5 Day I Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Expected: 0.25
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ___
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ___
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.00
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
0.25 0.25 0.25 0.25 0.25 0.25 0.25
Week 6 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Expected: 0.00
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.00
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.00
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.00
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.00
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
0.25 0.00 0.00 0.00 0.00 0.00 0.00
29
Table 2.3 Sample Taper Schedule for Alprazolam Week/Day
Dosage (in mg)
Total for day
Morning
Noon
Evening
Bedtime
Expected: 0.75
Expected: 0.5
Expected: 0.75
Expected: 0.5
Actual:_____
Actual: ____
Actual: _____
Actual: _____
Expected: 0.75
Expected: 0.5
Expected: 0.75
Expected: 0.5
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.75
Expected: 0.5
Expected: 0.5
Expected: 0.5
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Week 1 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Week 2 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Expected: 0.75
Expected: 0.5
Expected: 0.5
Expected: 0.5
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.5
Expected: 0.5
Expected: 0.5
Expected: 0.5
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.5
Expected: 0.5
Expected: 0.5
Expected: 0.5
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.5
Expected: 0.5
Expected: 0.5
Expected: 0.375
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.5
Expected: 0.5
Expected: 0.5
Expected: 0.375
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.5
Expected: 0.375
Expected: 0.5
Expected: 0.375
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.5
Expected: 0.375
Expected: 0.5
Expected: 0.375
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.5
Expected: 0.375
Expected: 0.375
Expected: 0.375
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.5
Expected: 0.375
Expected: 0.375
Expected: 0.375
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.375
Expected: 0.375
Expected: 0.375
Expected: 0.375
Actual: _____
Actual: _____
Actual: _____
Actual: _____
Expected: 0.375
Expected: 0.375
Expected: 0.375
Expected: 0.375
Actual: _____
Actual: _____
Actual: _____
Actual: _____
2.5 2.5 2.25 2.25 2.0 2.0 1.875
1.875 1.75 1.75 1.625 1.625 1.5 1.5 continued
30
Table 2.3 Sample Taper Schedule for Alprazolam continued Week/Day
Dosage (in mg)
Total for day
Morning
Noon
Evening
Bedtime
Expected: 0.375
Expected: 0.375
Expected: 0.375
Expected: 0.25
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.375
Expected: 0.375
Expected: : 0.375
Expected: 0.25
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Week 3 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Expected: 0.375
Expected: 0.25
Expected: 0.375
Expected: 0.25
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.375
Expected: 0.25
Expected: 0.375
Expected: 0.25
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.375
Expected: 0.25
Expected: 0.25
Expected: 0.25
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.375
Expected: 0.25
Expected: 0.25
Expected: 0.25
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.25
Expected: 0.25
Expected: 0.25
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.25
Expected: 0.25
Expected: 0.25
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.25
Expected: 0.25
Expected: 0.125
Actual: ____
Actual: ____
Actual: ____
Actual: ____
1.375 1.375 1.25 1.25 1.125 1.125 1.00
Week 4 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Expected: 0.25
Expected: 0.25
Expected: 0.25
Expected: 0.125
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.125
Expected: 0.25
Expected: 0.125
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.125
Expected: 0.25
Expected: 0.125
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.125
Expected: 0.125
Expected: 0.125
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.25
Expected: 0.125
Expected: 0.125
Expected: 0.125
Actual: ______
Actual: ____
Actual: ____
Actual: ____
1.00 0.875 0.875 0.75 0.75 0.625 0.625 continued
31
Table 2.3 Sample Taper Schedule for Alprazolam continued Week/Day
Dosage (in mg)
Total for day
Morning
Noon
Evening
Bedtime
Expected: 0.125
Expected: 0.125
Expected: 0.125
Expected: 0.125
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.125
Expected: 0.125
Expected: 0.125
Expected: 0.125
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Week 5 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Week 6 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
32
Expected: 0.125
Expected: 0.125
Expected: 0.125
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.125
Expected: 0.125
Expected: 0.125
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.125
Expected: 0.00
Expected: 0.125
Expected: 0.00
Actual: ____
Actual: ___
Actual: ____
Actual: ____
Expected: 0.125
Expected: 0.00
Expected: 0.125
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.125
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ___
Actual: ____
Actual: ____
Expected: 0.125
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.00
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.00
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.00
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.00
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.00
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
Expected: 0.00
Expected: 0.00
Expected: 0.00
Expected: 0.00
Actual: ____
Actual: ____
Actual: ____
Actual: ____
0.5 0.5 0.375 0.375 0.25 0.25 0.125
0.125 0.00 0.00 0.00 0.00 0.00 0.00
Taper Schedule for Antidepressants The same general principles apply to the discontinuation of antidepressants. In order to facilitate the withdrawal process, these agents should be tapered gradually, with a more rapid reduction rate at higher dosage levels and then a slower taper rate when low doses are reached. For example, for patients on paroxetine at a dose of 40 mg per day, the dose should generally be reduced by no more than 10 mg every 2 weeks down to 20 mg per day and then down to 10 mg per day over the next month prior to discontinuation. Similarly, sertraline 200 mg per day can be gradually decreased by 50 mg every 2 weeks down to 50 mg per day and then decreased to 25 mg per day for 2 weeks prior to discontinuation. Venlafaxine should be decreased by no more than 75 mg every 2 weeks down to 75 mg per day and then down to 37.5 mg per day for at least 2 weeks prior to discontinuation. More gradual rates of taper may be necessary if prominent withdrawal symptoms such as dizziness emerge.
Monitoring of Discontinuation Symptoms Regular monitoring of discontinuation symptoms must be conducted. We recommend using a clinician-rated scale, such as the MedicationTaper Symptom Checklist provided in this chapter and in the patient workbook. The Physician Withdrawal Checklist (Rickels, Schweizer, Case, & Greenblatt, 1990) and the Benzodiazepine Withdrawal Checklist (Pecknold, McClure, Fleuri, & Chang, 1982) are other options. A 2-week baseline level of symptoms prior to starting discontinuation should be established to allow a comparison of emergent symptoms to those characterizing the disorder prior to discontinuation. The baseline time period is incorporated into this treatment, as the initiation of medication taper does not begin until after the third session.
33
Medication-Taper Symptom Checklist Number of full (four or more symptoms) panic attacks in the last week: Number of limited symptoms panic attacks in the last week: For the following items, rate (CIRCLE) only symptoms that were present when you were not having a panic attack. Please rate each item for its occurrence/intensity over the last week using the following scale 0 1 2 3 Not Present
Rarely Present
Present/ Moderately Bothersome
Very Bothersome
Anxiety
0 1 2 3
Low appetite
0 1 2 3
Irritability
0 1 2 3
Indigestion
0 1 2 3
Sadness
0 1 2 3
Stomach cramps or bloating
0 1 2 3
Difficulties concentrating or expressing yourself
0 1 2 3
Nausea or vomiting
0 1 2 3
Derealization or depersonalization (Feeling unreal or detached)
0 1 2 3
Diarrhea
0 1 2 3
Confusion
0 1 2 3
Dizziness
0 1 2 3
Difficulties sitting still
0 1 2 3
Light-headedness
0 1 2 3
Headache
0 1 2 3
Sweating
0 1 2 3
Pain behind the eyes
0 1 2 3
Shaking or trembling
0 1 2 3
Muscle stiffness
0 1 2 3
Elevated mood
0 1 2 3
Muscle cramps or aches
0 1 2 3
Panic attacks
0 1 2 3
Muscle twitching
0 1 2 3
Tearfulness
0 1 2 3
Weakness or low energy
0 1 2 3
Agitation
0 1 2 3
Flu-like symptoms
0 1 2 3
Memory problems
0 1 2 3
Ringing in the ears (tinnitus)
0 1 2 3
Mood swings
0 1 2 3
Metallic or unusual tastes or smells
0 1 2 3
Unsteady gait or clumsiness
0 1 2 3
Light sensitivity
0 1 2 3
Problems with speech
0 1 2 3
Sound sensitivity
0 1 2 3
Increased saliva
0 1 2 3
Blurred vision or perceptual distortions
0 1 2 3
Runny nose
0 1 2 3
Tingling, numbness, or burning
0 1 2 3
Shortness of breath
0 1 2 3
Difficulties falling or staying asleep
0 1 2 3
Chills
0 1 2 3
Nightmares
0 1 2 3
Fever
0 1 2 3
Decreased sexual interest
0 1 2 3
Other:
0 1 2 3
34
Chapter 3
Session 1
(Corresponds to chapters 1–6 of the workbook)
Materials Needed ■
Stopping Anxiety Medication workbook
■
White board
■
Diaphragmatic Breathing Practice Log
■
Medication-Taper Symptom Checklist
■
Orient the patient to therapy and relevant issues
■
Describe a behavioral model of panic disorder
■
Discuss anxiolytic and antipanic mechanisms of pharmacological treatments
■
Discuss emergence of symptoms associated with medication discontinuation
■
Discuss the specific treatment interventions and their rationale
■
Instruct patient on keeping track of symptoms
■
Teach diaphragmatic breathing skills
■
Discuss the results of provocation studies (Note: This treatment component is ideally presented in Session 2, but often arises as part of a patient’s questions in Session 1 and, hence, may be presented here.)
Outline
35
■
Address questions about the onset of panic disorder (Note: This treatment component may be presented in any of the first five sessions when these questions are asked by the patient.)
■
Assign homework
Overview of Session Goals The goal of this session is to orient the patient to a cognitive-behavioral model for panic disorder and its treatment. Care needs to be taken in this process. The patient is coming for treatment for medication discontinuation and hence is entering this treatment informed by the model of the disorder provided by a previous care provider. In its weak form, this model may be that medications are a preferred method for treating panic disorder. In its strong form, this model may include the belief that medications are required to fix biochemical abnormalities that underlie panic disorder. Moreover, in starting CBT for panic disorder, the patient will need to shift from a relatively passive treatment orientation (taking a pill) to an active role that requires monitoring of the elements of the fear-of-fear cycle and rehearsal of new responses to these elements. In helping the patient make this shift, care needs to be taken in respecting her earlier treatment orientation and in helping the patient shift to a cognitive-behavioral model. The model presented in this session is designed to help patients differentiate episodes of panic cycles into component parts, understanding the self-perpetuating nature of fear-of-fear responses. The strategy for this intervention is to elicit patient involvement while organizing the patient’s report of symptoms in the fear-of-fear cycle. The session also includes diaphragmatic breathing training. By including breathing retraining in the first session, the therapist signals to the patient that the treatment is focused on the acquisition of new skills, not just the acquisition of information. The following learning elements characterize a successful Session 1: ■
36
Patients have the ability to identify somatic symptoms of panic independently of fears of these symptoms.
■
Patients (at least tentatively) can view panic symptoms as symptoms of arousal (elements of the fight–flight response).
■
Patients have an ability to emotionally and logically understand the role of catastrophic misinterpretations of panic symptoms.
■
Patients are oriented toward classifying the elements of the fear-of-fear cycle and the nature of the thoughts that accompany panic attacks.
■
Patients have some ability to shift breathing styles.
Orientation to Treatment Confidentiality Orientation to treatment should include introductions between the patient and the therapist and a discussion of confidentiality. Confidentiality and limits to confidentiality (including the type of progress notes to be kept) should be discussed with the patient.
Involving Significant Others To help ensure that treatment efforts take into account the patient’s social context—the demands, disappointments, and changing roles brought by the disorder and now by treatment—efforts are made to engage the patient’s spouse or partner in the treatment process. The patient should be encouraged to inform the spouse or the partner about the nature of panic disorder and its treatment. The patient may be referred to Chapter 4 of the workbook, which provides material to be read by the patient’s spouse or partner. In addition, the advantages of having the spouse or partner assist in completing homework assignments and practice exercises should be addressed. These benefits include helping the spouse or partner understand panic sensations first hand (which may well increase empathy for the patient’s experiences) and normalizing the experience of symptom induction for the patient (by showing that the spouse or partner also experiences symptoms in response to the induction procedures).
37
Behavioral Model of Panic Disorder Orientation to Alarm Reactions The informational material presented in Session 1 starts with what the patient knows best—the phenomenology of panic episodes. The goals of the initial discussion are to have the patient identify the many somatic sensations of panic and to have her understand the difference between somatic sensations and the cognitive and behavioral events that accompany them. Initiate this discussion by asking the patient to list the somatic symptoms of her panic attacks. As symptoms are mentioned, write each on the board. If the patient has difficulties starting the list of symptoms, cue the discussion by writing “Increased heart rate” and “Increased breathing rate.” Then ask the patient to generate additional items by remembering what she felt during the panic episodes. The list may include many of the following symptoms (see Figure 3.1): rapid or pounding heart, rapid breathing, difficulty catching the breath or breathlessness, dizziness or light-headedness, trembling, sweating, choking, tight or painful chest, other muscle tension, nausea or urge to use the bathroom, unreality, blurred vision, numbness or tingling, heavy legs, and hot or cold flashes. To provide a full presentation of panic symptoms, add to the patient’s list the remaining symptoms of a panic attack by noting, “Sometimes other patients report . . . ,” and then
Alarm reaction Heart pounding Rapid breathing Sweating Nausea/ gastrointestinal distress Numbness/ tingling/crawling sensations Dizziness/ light-headedness
Figure 3.1
Somatic Symptoms of Alarm Reaction
38
Muscle tension/ tight chest Bright vision/ unreality Choking/ lump in throat Heavy legs/ weak knees Hot or cold flashes
suggesting additional panic symptoms. In this way, you and the patient can identify the range of symptoms that may emerge during the discontinuation process when panic episodes and generalized anxiety may briefly recur. Review the list with the patient and ask if all the panic sensations have been captured. If the patient mentions specific fears such as fear of dying, going crazy, or losing control, write these fears to the right of the list and specify the difference between sensations (physical feelings) and fears (the cognitive interpretation of these symptoms). Help the patient focus only on the physical sensations during this part of the session. After the patient has agreed that the list is complete, redefine the sum of sensations as an “alarm reaction.” Subsequently, explain that the alarm reaction is the body’s natural reaction to fear and danger. The goals of this discussion are (a) to provide the patient with some understanding of the source and adaptive significance of the physiological changes that produce the symptoms and (b) to help the patient discriminate somatic sensations from the many cognitive and behavioral reactions that accompany them. To aid the patient’s acquisition of the information, all material is presented in both oral and written (diagrammatic) form. Define the symptoms as part of the body’s alarm response to danger. To the left of the “Alarm reaction” column, write “Fear/danger” and draw an arrow from the “Fear/danger” column to the “Alarm reaction” column as indicated in Figure 3.2. Explain that the body automatically
Alarm reaction
Fear/danger (Lions, tigers, bears)
Heart pounding Rapid breathing Sweating Nausea/ gastrointestinal distress Numbness/ tingling/crawling sensations Dizziness/ light-headedness
Muscle tension/ tight chest Bright vision/ unreality Choking/ lump in throat Heavy legs/ weak knees Hot or cold flashes
Figure 3.2
Alarm Reactions Trigged by Fear or Danger 39
responds to fear with physiological changes that produce the sensations listed. As part of this discussion, communicate that the somatic symptoms experienced during a panic attack are part of the body’s protective defense system and have survival value. When explaining the etiology and significance of sensations, include discussion on how the patient has experienced the sensations. The goal is to ensure that the discussion is directly relevant to the patient’s experience of panic, and that each symptom is considered in its own right as a reasonable response to true threat.
Rapid Heartbeat and Rapid Breathing
Rapid heartbeat and rapid breathing are the body’s method of preparing the body for action, making sure that enough blood and oxygen are supplied to all the muscle groups and essential organs that need them. Therefore, rapid, deep breathing is necessary to provide increased oxygen, and the heart must beat faster and harder to circulate the oxygen in the blood supply.
Sweating
Sweating is common during times of fear. One of the primary functions of sweating is to cool the body. Another effect of sweating is to make the skin more slippery. This effect may have adaptive significance: In times of danger, a slippery body is much more difficult for an attacking animal or person to grasp.
Nausea or Stomach Upset
During times of danger, the body naturally shuts down the systems and processes it does not need. This shutdown allows the organism to direct energy to functions crucial for survival. Digestion is one of the processes that are not needed in times of danger, and in many people, stomach motility or acidity may change, resulting in sensations of stomach upset. These sensations are also related to the primordial reaction of defecation
40
in times of danger. Remind patients that many animals (such as dogs or mice) will defecate in times of fear. Note that humans are animals also, and it is not unusual that they have a component of this reaction; hence, in times of fear, many people may experience nausea and diarrhea.
Numbness and Tingling
Numbness and tingling may have two common sources. One source is hyperventilation, the common effects of which include feelings of numbness and tingling. People often experience these sensations in only one arm or leg, in a masklike area around the mouth, or across the scalp. Explain that hyperventilation may simply be an exaggeration of trying to breathe rapidly as part of the preparation to fight or flee in the face of danger. A second source of numbness and tingling, or at least a “skin crawling” sensation, is piloerection: Under conditions of danger, the hairs on the arms, legs, and scalp will often stand up. The adaptive significance of this reaction is increased sensitivity to touch or movement. However, this action of the hair follicles can leave the skin feeling odd.
Dizziness or Light-Headedness
Dizziness or light-headedness may result from hyperventilation. Another effect of hyperventilation is that certain areas of the body become less oxygenated. This effect is not enough to be dangerous but is enough to produce strange sensations. The brain is one area that receives less oxygen, the effect of which can cause dizziness, light-headedness, visual disturbances, or feelings of unreality.
Tight or Painful Chest
A tight or painful chest is part of more general muscular tension. Patients may also experience muscle tension in the form of a throbbing headache that may arise during or after a panic episode. Increased muscle tension is part of the body’s preparation for danger and subsequent
41
action. Sensations of chest tightness, especially in the sternum area, are actually fairly easy to recreate. These sensations seem to arise in part from the person trying to take very large breaths, during which the chest is thrown outward at the same time that the chest muscles are tense. (Illustrate this point by taking several chest breaths while pressing down with your hand on your chest, noting that chest breathing while anxious is tantamount to breathing against muscle resistance.) Note that this particular sensation is further illustrated when diaphragmatic breathing is discussed. Unreality or Bright Vision
One aspect of unreality may be that the environment looks brighter or fuzzier during a panic attack. One of the effects of the alarm reaction, and likely an indirect effect of hyperventilation, is dilation of the pupils. Dilation occurs under conditions of danger, perhaps as a reaction to try to let in more light and to have adequate vision at a time when defense is necessary. This effect is especially applicable when defense is necessary at night. To illustrate this change in vision, ask patients to remember what vision was like after their eyes were dilated during a visit to the optometrist or ophthalmologist; objects might have appeared to be extra bright or glowing. Choking Sensations
Choking sensations may be either (a) a function of increased muscle tension, which also affects some of the musculature around the neck and esophagus; or (b) a sensation derived from chest breathing and from rapidly moving air in and out, thereby drying the throat.
Heavy Legs
The sensation of heavy legs may arise in part from the muscles tensing as part of a preparation for action. Discuss the relatively common example of the experience of heavy legs that may arise before an athletic competition. Ask patients to try to remember how their muscles felt just before preparing to race (as in a running or swimming competition),
42
with particular attention to how the muscles might have felt just before the starting gun was fired. Note that similar sensations may occur as the body prepares for danger.
Hot or Cold Flashes
Hot or cold flashes often arise from the dual action of increased perspiration on the skin and constriction of the blood vessels in the upper skin layer. This effect also has adaptive significance: A cut or other injury will bleed less when the vessels are constricted. However, the combination of perspiration and decreased blood flow to the skin can lead to sensations of hot or cold flashes. Hot-flash sensations are a common result of hyperventilation. In discussing all of these sensations, emphasize that these symptoms are natural and adaptive under conditions of realistic danger.
Cognitive Reactions With the definition of the alarm reaction and its adaptive significance established, the next step is to discuss the cognitive reaction to the alarm. This discussion provides further discrimination between somatic symptoms and cognitive and behavioral reactions to these symptoms. Begin by describing common reactions to actual dangerous events. Namely, under conditions of actual danger, the alarm reaction may not be especially noticed because attention is riveted to the source of actual danger. Illustrate this point by asking the patient to recall times when she might have come close to having a car accident or was exposed to some other realistic danger. The driver is often unaware of the somatic changes that took place at the time of the near accident (e.g., pounding heart, muscle tension, and heavy legs), at least until some time after the event. Help the patient conclude that when exposed to actual danger, a person often focuses her attention on that danger and does not notice bodily responses that are usually regarded as normal under these circumstances. Explain that a very different cognitive reaction can occur if the alarm reaction fires when no danger is readily apparent. Again, the person
43
rivets attention to the source of danger, but because no external, dangerous event exists, attention turns inward. Under these conditions, the sensations themselves can become the source of concern in what can be called an “uh-oh” reaction. Write the following examples below the “Alarm reaction” column on the board, while explaining that they are among the most common uh-oh reactions reported by patients with panic disorder: ■
What is happening?
■
I am having a heart attack (stroke)!!!
■
What if others notice?
■
What if I fall down?
■
What if it gets worse?
■
What if I go crazy?
■
What if I lose control?
The process of presenting these statements should be the same as used for the alarm reaction. That is, elicit these statements from the patient, but if the patient is slow to respond, present these common fears. As they are presented, ask the patient to elaborate on each one to the extent that it is applicable. With the list complete, take time to emphasize how frightening these thoughts are. This presentation should include the statement, “Anyone, not just patients with panic disorder, but anyone who has thoughts like these and believes them will become frightened.” Note with some emphasis that these are among the most frightening thoughts a person can think. These are thoughts of losing control, enduring social embarrassment, and dying. Ask the patient, “What could be worse than these fears?”
Emphasis on the Self-Perpetuating Cycle With the somatic and cognitive reactions defined, discuss the selfperpetuating nature of the panic cycle. This discussion should start with the following review:
44
(a) The alarm reaction is supposed to fire when one is frightened or threatened. (b) When the alarm reaction occurs “out of the blue,” it is usually very frightening in its own right and is followed by anxiety-provoking thoughts and self-focused attention. (c) The natural reaction to such anxiety-provoking thoughts is an increase in the sensations and experience of anxiety. (d) These patterns make up the essence of a fear-of-fear, or more exactly, panic-in-response-to fears-about-anxiety cycle. Because this material is emphasized verbally, the fear-of-fear cycle should be completed on the board, as depicted in Figure 3.3. Overall, emphasize how frightening the thoughts are and review the model demonstrating the self-perpetuating nature of panic. Alarm reaction Heart pounding
Muscle tension/ tight chest
Rapid breathing Fear/danger (Lions, tigers, bears)
Bright vision/ unreality
Sweating Nausea/ gastrointestinal distress Numbness/ tingling/crawling sensations
Choking/ lump in throat Heavy legs/ weak kness
Dizziness/ light-headedness
Hot or cold flashes
Uh-oh reaction What is happening?
What if I fall down?
I am having a heart attack (stroke)!!!
What if it gets worse?
What if others notice?
What if I lose control?
What if I go crazy?
(Memories of past attacks)
Figure 3.3
Fear of Fear: Cognitive Reaction
45
The following presentation is used to demonstrate how physical sensations and cognitive interpretations may feed off each other and fuel the panic cycle. (An active theatrical style is recommended for this presentation.) I would like to tell you about the way I think about some of the core patterns in panic disorder. For this model, I oversimplify the brain down to only two component parts: the limbic system and the cortex. The limbic system is a very old part of the brain. It is involved with primitive emotional and survival systems, and is part of providing you with enough arousal to be vigilant to danger and defend yourself. Its job is to prepare for that danger by turning up body systems, helping the body become more aroused so that it is ready to react to the danger. This is the limbic system. I picture that part of the brain as strong and powerful, but dumb. The other part is the thinking part of the brain, the cortex. The cortex helps you do problem solving, in part by reasoning about what may happen next. It asks “What if . . . ?” and comments on what it’s worried about. The cortex and the limbic system work together like this: When you enter a situation where you previously had a panic attack or where you worried about having a panic attack, the thinking part of the brain points this out by saying, “I hope I don’t panic here, I hope nothing happens.” The other part of the brain is listening and says, “What? Something bad may happen here? Well, I guess we should prepare a little bit.” And your heart beats a little faster. Then, the thinking part says, “Oh my gosh, my heart is beating faster. I hope it doesn’t keep going; I hope something more doesn’t happen. If it keeps going, I might panic.” The other part of the brain responds by saying, “What? Something more may happen? Well, we’d better get ready for it.” And then sweating increases, breathing increases, and the heart quickens. The thought is then, “Oh my gosh! It’s happening now, my heart is beating way too fast, something bad is going to happen!” The other part says, “What? Something bad is going to happen???? Let’s get ready for the worst; let’s get some adrenaline in there.” Then the thought is, “Oh my gosh, it’s happening! I’m dizzy; I’m going to fall down. What if I have a heart attack?” The other part of the brain says, “Oh my gosh, a heart attack! Let’s prepare!” And in this way, the two parts of the brain can feed off each other.
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Over time, both these brain regions get really good at this pattern. With enough practice of this pattern, all it takes is a quickening of the heart rate, and the limbic system kicks in by immediately signaling the need for defense. We need to retrain both the limbic system and the cortex out of this pattern. For the cortex, we will do this with some logical evaluation of your thinking patterns, but for that powerful yet dumb limbic system, treatment will have to involve some regular practice with experiencing initial anxiety symptoms to teach the limbic system not to react to these sensations.
Agoraphobic Avoidance Emphasize that, as bad as this self-perpetuating cycle may be with just these elements, the discussion of the fear-of-fear cycle is not complete. Another element is avoidance. One strategy for helping patients develop a useful model for approaching agoraphobic avoidance uses an example of overlearned information distinct from panic patterns—the Monday morning phenomenon. For this metaphor, ask the patient about the most difficult (hardest to go to) morning of the work week for most people. The typical answer is Monday morning. Marvel at this reality; after only two days of being off work over the weekend, it becomes hard to go back to work. State that at least one reason that Monday mornings are difficult is that people get out of the habit of doing their jobs, and work is a bit more threatening to return to on Monday. One is not used to being “in the swing of things.” This effect is often more pronounced after a vacation. To personalize this process, provide a specific example from your own work patterns, or elicit an example from the patient. Next discuss how one feels when returning to work Monday morning after having had problems on Friday. Emphasize that this reaction is the same sort of event that can happen with avoidance of situations in which panic attacks have occurred, by saying, Naturally, when individuals reenter a situation where a panic attack occurred, they have memories that may trigger some of the uh-oh thoughts that are listed on the board. In addition, if they’ve avoided a situation for a while, not only do they face a bad memory of that situation, but they’re really out of practice; they are not used to it.
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Under those conditions, it’s unlikely that they will enter that situation without having some emotional arousal or anxiety. Unfortunately, people typically don’t think, “this is the Monday morning phenomenon; I am going to be anxious when I first reenter this situation but if I stay for a while, I am likely to get back in the swing of things and feel comfortable.” Instead, when they reenter the situation they tend to be vigilant to their emotional arousal and interpret it in terms of the panic cycle (“uh-oh, my panic is coming back”), and the fear-of-fear cycle may be activated and a panic attack may ensue.
Hurry-Up/Tense-Up/Control Response In addition to the avoidance of situations, discuss that many patients have a subtle reaction that combines an attempt to protect oneself with the attempt to avoid the situation. Many patients will hurry up, tense up, and avoid in response either to the thought or the experience of panic sensations or to a situation in which panic has occurred. The hurry-up/tense-up/control response entails a cognitive focus on avoiding or escaping and physically bracing oneself (e.g., through increased muscle tension) in an attempt to decrease the impact of the danger or to escape (e.g., by tensing up and hurrying up) as soon as is possible. Add this reaction to the fear-of-fear cycle diagram, as depicted in Figure 3.4. Be sure to emphasize how this reaction elicits more sensations of the alarm reaction (e.g., increased heart rate and muscle tension) and hence feeds into the fear-of-fear cycle.
Anxious Apprehension (Anticipatory Anxiety) The anticipation of recurrent panic attacks leaves patients in the position of being chronically tense and vigilant. Refer to this chronic tension, anxiety, and vigilance as anticipatory anxiety or anxious apprehension. Discuss how this reaction provides greater anxiety sensations and makes sure the person notices these sensations, which then become part of the fear-of-fear cycle.
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Alarm reaction Heart pounding
Muscle tension/ tight chest
Rapid breathing Sweating Nausea/ gastrointestinal distress
Fear/danger (Lions, tigers, bears)
Bright vision/ unreality Choking/ lump in throat
Numbness/ tingling/crawling sensations Dizziness/ light-headedness Symptoms increase
Heavy legs/ weak knees Hot or cold flashes
Fear of fear Uh-oh reaction
Increased anxiety (Hurry up/ tense up/ control)
What is happening?
What if I fall down?
I am having a heart attack (stroke)!!!
What if it gets worse?
What if others notice?
What if I lose control?
What if I go crazy?
(Memories of past attacks)
Figure 3.4
Fear-of-Fear Cycle
Summary of Fear-of-Fear Cycle The discussion of anxious apprehension and vigilance to bodily sensations completes the initial presentation of the fear-of-fear cycle. Questions about this cycle should be elicited and answered. Stylistically, we recommend eliciting a discussion by asking the patient, “Does any of this fear-of-fear cycle fit your pattern?” By deliberately undershooting your expectation of the relevance of the model, you provide the patient with a chance to step forward and accept the aspects of the model most relevant to her. This, after all, is the goal: To have the patient develop a
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broader model of panic disorder that makes sense to her and can help guide the treatment interventions to follow. One common question asked by patients concerns the difference between this behavioral model and a biological model of panic disorder. The answer to this question is delineated later in this chapter (see Review of Provocation Studies). If the question is not asked at this point, this discussion should be presented at the end of this first session or during Session 2.
Mechanisms of Pharmacological Treatments Pharmacological treatments (explain that common treatments include benzodiazepines such as alprazolam, clonazepam, and antidepressants such as imipramine, nortriptyline, or fluoxetine) tend to have several effects. First, these medications may make it harder for the body to fire a full alarm reaction. If using Figure 3.4 to review the model, illustrate this point by writing in “partial blockade” next to the “Alarm reaction” column. Second, these medications, particularly benzodiazepines, tend to reduce more general anxiety and arousal and thereby reduce the severity of daily anticipatory anxiety. Because these sensations of generalized anxiety and arousal are blocked, there are fewer anxiety sensations to become the focus of the fear-of-fear cycle. Finally, most medication treatments have an important psychological component. For many patients, anxiety decreases as soon as they know they have taken their medication. Explain that this reaction is a sort of safety signal that blocks many catastrophic thoughts; for example, “Ah—I’ve taken my Klonopin® . I think I’ll be okay now.” Illustrate how this thought replaces some of the catastrophic thoughts and therefore prevents them from fueling the fear-of-fear cycle. In addition, patients may also become less vigilant to symptoms after they have taken their medication. Patients should be reminded that this effect is an important one that they, rather than the medication, are having on their symptoms. It is also not uncommon for some patients to carry medication with them some time after they have stopped wanting to take it. Likewise,
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some patients will carry with them an empty pill bottle just because doing so helps them feel safer, and, because they feel safer, panic attacks are blocked.
Emergence of Symptoms With Medication Discontinuation One of the effects of discontinuation of benzodiazepine treatment is patients feeling more anxious for a period of time as the body adjusts. This reaction is analogous to having reined in horses for a period of time and then letting the reins back out. Horses generally run a bit faster. In the same way, the body has been “reined in” by the benzodiazepine medications, and as patients progress through the medication-taper process, the body may become revved up. Discuss that this reaction is one of the difficulties of the discontinuation process. As the medication is decreased, sensations of anxiety emerge. Remind patients that this reaction is a very natural part of the process. The complications occur when these sensations are interpreted in the context of the fearof-fear cycle. Illustrate, using the material drawn on the board, that this catastrophic interpretation can result in panic attacks. One explanation for this phenomenon is that the fear-of-fear cycle itself has never been directly treated. The inclusion of its treatment is part of the goal of this program, that is, providing an intervention for every component of the medication treatment that is being discontinued.
Treatment Interventions and Rationale Discuss the following treatment components. As part of this discussion, refer to the fear-of-fear cycle on the board (Figure 3.4) and the specific aspect of this cycle that is the target for the intervention.
Somatic Skills With this intervention, patients learn skills to shut down the alarm reaction itself. These skills include training in diaphragmatic breathing to help directly decrease the physical sensations. In addition, muscle
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relaxation techniques are taught to help patients decrease more general anxiety and tension. (Write in this intervention on the board, as shown in Figure 3.5.) Note that the purpose of both of these skills is to help patients rein in bodily arousal as the medication is tapered.
Cognitive Restructuring Treatment includes a cognitive component to help patients reinterpret catastrophic thoughts. The goal is for patients to gain control over the effects that these fearful thoughts have on them by substituting anxiolytic for anxiogenic cognitive coaching. In discussing this process, remind patients that this effect is one associated with medication use. That is, patients might have learned to say, “It’s okay. I don’t have to worry about panic now that I have taken my medication” (cognitive safety cue). Write this intervention on the board, as shown in Figure 3.5.
Alarm reaction Somatic skills to reduce the intensity of symptoms and to stop patterns that drive symptoms
Symptom reduction due to interventions
Interventions for fear of fear
Increased anxiety
Uh-oh reaction
Somatic skills Rehearsal of relaxation in response to somatic sensations and catastrophic thoughts
Cognitive restructuring to provide more accurate thoughts Interoceptive exposure to break the automatic fear response to anxiety sensations
Figure 3.5
Learned Interventions to Stop the Fear-of-Fear Cycle
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Interoceptive Exposure This intervention is designed to help patients reinterpret physical sensations in a nonfearful manner. This intervention comprises repeated exposure to feared sensations in conjunction with rehearsal of coping responses. Patients are afforded specific opportunities to experience the sensations and to learn to react differently. Consequently, the sensations will be less likely to evoke fear or discomfort. Write this intervention on the board, as shown in Figure 3.5. Emphasize that interoceptive exposure will occur in a graduated fashion.
Keeping Track of Symptoms Introduce the Medication-Taper Symptom Checklist, which is used to help track symptoms the patient may have during the taper attempt. Because benzodiazepine-taper symptoms may mimic anxiety symptoms, it is important for the patient to track her symptom levels for at least 2 weeks before starting the taper. Use the information from this form to help plan strategies to manage the patient’s symptoms during the medication taper program.
Diaphragmatic Breathing Training At the end of Session 1, patients receive initial training in diaphragmatic breathing skills. Training is begun by helping each patient discriminate between chest and diaphragmatic breathing. First, demonstrate chest breathing, exaggerating the chest movements. Emphasize that this breathing works well under many conditions but can be problematic under conditions of anxiety when the chest musculature may tighten. Next, demonstrate diaphragmatic breathing. Show the abdomen moving outward as you inhale and relaxing as you exhale. Have the patient note that as you breathe in this manner, the chest stays still. After providing this conceptual instruction, allow the patient to practice. Ask the patient to place one hand on the chest and one hand on the abdomen (just below the rib cage) and to take several chest breaths
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to observe the difference in chest breathing and diaphragmatic breathing. Emphasize the difference in the way the chest and abdomen move the resting hands, and provide individual feedback. Some patients may feel mildly light-headed or dizzy during the breathing practice due to hyperventilation. Make sure to explain to these patients that these sensations are natural symptoms of overbreathing that can occur as they learn a less effortful breathing procedure. One method of emphasizing the difference between chest and diaphragmatic breathing is with the following somatic example. Demonstrate this exercise prior to asking the patient to participate. Have the patient clasp hands behind the head with elbows spread apart. This position causes increased tightness across the chest and leads to increased chest pressure or mild discomfort when full breaths are attempted. These sensations may occur when the patient chest breathes during a panic attack. During this exercise, encourage the patient to attend to the feelings of chest tightness that come with breathing from the chest. Next, have the patient breathe diaphragmatically and note how much easier the breath comes. Repeat the diaphragmatic breathing exercise with the patient’s arms at the sides, relaxed. Show the patient the Diaphragmatic Breathing Practice Log, which structures the practice of diaphragmatic breathing and asks the patient to record her comfort level with the procedure. Instruct the patient to practice diaphragmatic breathing three times daily: (1) once, upon wakening, with the head resting on the pillow and with hands on the diaphragm where they can be seen rising and falling; (2) once in the middle of the day, while seated, again watching the hands on the chest and stomach to monitor breathing; (3) and once in the evening. Emphasize the importance of regular practice. Inform the patient that you will check on the progress of this skill in Session 2.
Review of Provocation Studies (Optional) Patients might have been taught a biological model of panic disorder that stresses the need for ongoing medication treatment. For example, patients might have been told that panic disorder is like having diabetes and that just like a person with diabetes who needs to take insulin, they
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need to continue to take their medication. If questions about such a model arise, present the following discussion. One model that has dominated the field asserts that panic disorder is exclusively biological. However, research over the past several years has demonstrated that a strong psychological component is also involved in panic disorder. The results of several provocation studies (for review see Otto & Whittal, 1995) have emphasized the following points: (a) For the original provocation studies, patients were administered an agent (note that this agent might have been yohimbine, lactate, carbon dioxide [inhaled], forced hyperventilation, or even caffeine) and differences between reactions in people with and those without panic disorder were examined. In response to these agents, people with panic disorder tended to panic and those without panic disorder tended not to panic. This difference was interpreted as evidence for a biological difference between people with and those without panic disorder. (b) An alternative accounting is that any procedure that produces feared panic sensations is capable of eliciting panic attacks (in individuals with and without panic disorder). The essential feature in determining the likelihood of panic attacks is the fear of symptoms, and when people eliminate this fear, the induction of symptoms becomes tolerable, and panic attacks are no longer elicited.
Onset of Panic Disorder (Optional) Questions often arise about why the first panic attack occurred. Most patients had their first panic attack at a time of increased stress (or just after the stress situation is resolved). Explain that many people (approximately one-third of the general population) will have a paniclike episode once a year, but very few people will develop a full panic disorder. Discuss the idea that the genesis of the first panic episode is often far less important than the cycle that develops around it (i.e., the fear-of-fear cycle). Individuals who develop panic disorder apparently
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are those who were frightened by the sensations rather than those who attributed the somatic sensations to other sources (e.g., “Oh, I’m just really uptight today” or “Oh, I shouldn’t have had so much coffee”).
Homework
✎ ✎ ✎ ✎
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Assign Chapters 1–5 of the workbook for review. Have patient read Chapter 6 of the workbook, and complete the exercises. Have patient practice diaphragmatic breathing three times daily and fill out the Diaphragmatic Breathing Practice Log. Have patient rate symptoms this week using the Medication-Taper Symptom Checklist.
Chapter 4
Session 2
(Corresponds to chapter 7 of the workbook)
Materials Needed ■
Stopping Anxiety Medication workbook
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White board
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Diaphragmatic Breathing Practice Log
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Muscle Relaxation Log
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Symptom Induction Log
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Review Medication-Taper Symptom Checklist
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Review diaphragmatic breathing skills; introduce a slow-breathing technique
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Review the behavioral model of panic disorder
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Discuss the role of cognitions in panic disorder
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Initiate interoceptive exposure
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Teach progressive muscle relaxation
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Address difficulties during relaxation
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Discuss the results of provocation studies (Note: Ideally this treatment component is presented in Session 2 but often arises as
Outline
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part of patients’ questions in Session 1 and, hence, may be presented then.) ■
Address questions about the onset of panic disorder (Note: This treatment component may be presented in any of the first five sessions when questions are asked by patients.)
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Assign homework
Overview of Session Goals The primary goal of this session is to help solidify the patient’s knowledge of a cognitive-behavioral model for panic disorder and to introduce the patient to interoceptive exposure procedures. The session also includes continued training in diaphragmatic breathing and the introduction of relaxation techniques as a strategy to help reduce muscle tension that may arise during benzodiazepine withdrawal. Of the session elements, completion of the interoceptive exposure is most important, and the method for this exposure is described with particular attention to helping the patient orient toward the induced sensations independent of the negative (and often future oriented) interpretations of these sensations. For some patients, the first series of practice with the induction of dizziness may be a transformative experience. In this session, patients may be able to see themselves transition from fearing to feeling comfortable with dizziness across three exposures. If this occurs, the therapist should summarize this shift as the essence of treatment. Responding differently to sensations forms the basis of breaking the fear-of-fear cycle and for increasing resilience to benzodiazepine withdrawal sensations. The following learning elements characterize a successful Session 2:
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Patients achieve a better understanding of thinking strategies that promote anxiety and panic.
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Patients demonstrate the ability to identify somatic sensations independently of fears of these symptoms as part of interoceptive exposure.
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Patients have the opportunity to observe a reduction in anxiety as they attend to sensations of dizziness as they are occurring (rather than attending to fears about these sensations).
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Patients are oriented toward the importance of practicing interoceptive exposure as a strategy to further decrease the perceived aversiveness of dizziness.
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Patients demonstrate an ability to shift breathing styles to diaphragmatic breathing.
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Patients demonstrate an ability to follow the tense–relax method for muscle relaxation.
Review of Medication-Taper Symptom Checklist Briefly review the patient’s completion of the Medication-Taper Symptom Checklist. Discuss symptoms that the patient experienced during the last week, and identify these symptoms in relation to the patient’s experience of anxiety and panic prior to the initiation of taper.
Review of Diaphragmatic Breathing Review of Home Practice Collect the patient’s homework (Diaphragmatic Breathing Practice Log). Discuss any difficulties that arose during the diaphragmatic breathing practice and review progress. During this review and subsequent practice of the procedures, be sensitive to mistakes that may arise during instruction in diaphragmatic breathing skills. In particular, watch for effortful use of the abdominal muscles. Patients often push the abdominal muscles outward and pull them in rather than letting the abdomen naturally fall outward during inhalations. If appropriate, review this mistake with the patient. Rehearsal of diaphragmatic breathing procedures should otherwise follow the instructions for the in-session practice trials.
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In-Session Practice Trials Trial 1 Have the patient lean back in the chair and place one hand on the chest and the other hand just above the navel. Have the patient rehearse chest breathing and then switch to proper diaphragmatic breathing. This rehearsal helps patients to discriminate between chest and diaphragmatic breathing and to practice this shift. Provide corrective feedback as necessary.
Trial 2
To aid generalization of diaphragmatic breathing procedures to a variety of body positions and situations, ask the patient to practice these exercises while standing.
Trial 3
To further rehearse the shift to diaphragmatic breathing while experiencing the increased chest tightness that may accompany anxiety, conduct the same exercises under the following conditions: 1.
Have the patient once again sit, interlock the hands, place them behind the head, and stretch the elbows backward (a position causing increased tension across the chest).
2.
Have the patient complete several deep chest breaths, with instructions to notice the chest pressure sensations.
3. Shift to diaphragmatic breathing, noticing the change from chest tension to increased comfort in breathing.
Slow-Breathing Technique This technique helps the patient slow the breathing rate by using a silent cue, “Reeeee . . .laaax.” Instruct the patient to think the word relax while
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breathing. During inhalation, the patient thinks the first syllable reeeee; after a pause, the patient breathes out while thinking the second syllable laaax. The timing of each relax should be fairly slow so that relax is thought in a very comfortable and slow manner, taking approximately 5 seconds for each syllable. Occasionally a patient will feel mildly light-headed during the practice. This sensation can be a result of the patient breathing effortfully while using the more efficient diaphragmatic breathing method. In fact, this effect can be expected in patients who chronically chest breathe or hyperventilate and is due to the body’s inability to compensate immediately for changes in the level of carbon dioxide. Briefly discuss the difference in efficiency and effort for the diaphragmatic and chestbreathing strategies. Instruct the patient to pay particular attention to the sensory feedback of feeling air moving over the lips, tongue, and throat during the diaphragmatic breath, rather than the feeling of chest expansion that is specific to the chest-breathing strategy. Complete this initial training by asking the patient to rehearse slow breathing in time to your hand movements. Raise your hand slowly while the patient inhales (5 seconds) and then lower your hand slowly (5 seconds) while the patient exhales. Have the patient continue diaphragmatic breathing silently for 1 minute. Be sure to observe this practice and correct any difficulties. Therapist Note
Point out to the patient that this exercise is not being done as a treatment for panic disorder, but as part of a general skill for stress management, including managing the symptoms that may emerge as part of medication taper. ■
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Review of the Behavioral Model of Panic Disorder Review the model described during Session 1. This model (refer to Figure 3.4 in the previous chapter) should be drawn on the board prior to the session or drawn by the therapist as the patient reconstructs
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the fear-of-fear cycle. Be sure to include the following elements in the model: (a) The alarm reaction naturally arises in response to fear or danger. (b) Each symptom has adaptive significance (briefly review several). (c) The uh-oh reaction and accompanying thoughts like “I may lose control” or “I may go crazy” arise in response to the alarm reaction. (d) These thoughts are very frightening and lead to increased anxiety. (e) Other cognitions include memories of previous episodes and the fear that these episodes will reoccur. (f ) The hurry-up/tense-up/control response is a natural reaction to perceived threat but serves to increase the likelihood of experiencing somatic sensations. (g) The fear-of-fear cycle leads to increased vigilance and increased anticipatory anxiety and provides more sensations that can be the focus of the cycle. Solicit questions or comments about this model and the assigned reading in the workbook.
Role of Cognitions in Panic Disorder Review the following list of strategies that promote panic. The purpose of this list is to draw the patient’s attention to the maladaptive thoughts and strategies that tend to worsen panic disorder patterns.
Thinking Strategies That Promote Panic
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Pay close attention to your bodily symptoms.
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Think about past anxious episodes and worry about their happening again.
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Actively wish that you will not become more anxious.
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Focus on small increases in anxiety and know that they are signs of the worst.
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Vow never to have another panic attack.
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Make sure you never go back to a situation where you had a panic attack.
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Run away from panic symptoms.
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Expect to master anxiety management techniques immediately.
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Think that something is desperately wrong with you if you do have a panic episode.
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Never doubt the reality of your thoughts.
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Fear panic.
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Use lots of “what if ” thoughts to focus on events that you fear may happen: What if my heart starts to beat faster? What if I have a heart attack? What if I lose control? What if I fall down? What if I go crazy? What if it gets worse? What if I have a seizure? What if other people notice? What if I am having a stroke? What if my panic is worse than ever?
Role of Cognitions in Fear-of-Fear Cycle Discuss several of the cognitions applicable to the patient and their roles in increasing anxiety, apprehension, and panic. For example, you may review the following points: ■
Note how the strategy of paying close attention to bodily symptoms increases the likelihood that symptoms will be the focus of the fear-of-fear cycle. In particular, discuss the fact that
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something is always going on in the body, so the chances are that patients will find sensations on which to focus. If patients interpret these sensations in a fearful manner (within the fear-of-fear cycle), enough fear may be cued so that a panic attack results. ■
Discuss how thinking about past anxiety episodes and worrying about their happening again creates a formula for anticipatory anxiety.
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Discuss how trying not to become anxious may actually increase arousal and sensations of anxiety.
Have the patient identify the cognitions that are most characteristic of anxiety episodes. Note that these sorts of fears naturally arise as part of panic disorder pattern. Your goal is to help the patient identify the dysfunctional thinking style that develops in panic disorder and contributes to the maintenance of the disorder. Rapid identification of anxiogenic thoughts as they occur is a necessary step in teaching cognitive restructuring. Close this discussion by encouraging the patient to become more aware of using these anxiety-producing cognitions and to start targeting these thoughts for change.
Initiation of Interoceptive Exposure Rationale for Exposure to Somatic Sensations While referring to the fear-of-fear model on the board, explain the rationale for stepwise exposure to somatic sensations. The rationale should include the following information: A characteristic of panic disorder is that patients are very sensitive to, and frightened of, somatic sensations of anxiety. This sensitivity and fear often cause patients to respond to certain bodily symptoms, such as rapid heartbeat, with a fullblown panic attack. The goal of interoceptive exposure is for patients to be able to replace this response with one that does not culminate in a panic episode. This is accomplished by weakening the connection between feared sensations and the fear-of-fear cycle. We do this by having patients repeatedly experience the sensations under controlled circumstances so that they can learn to become comfortable with these
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sensations. The initial focus of interoceptive exposure is to help patients attend to somatic sensations as events in themselves that can be tolerated. This awareness provides a basis for helping patients tolerate the initial sensations of medication taper. In subsequent sessions, patients are provided with a broader rationale of interoceptive exposure procedures as they are used to target broader aspects of the fear-of-fear cycle.
Role of Interpretation of Symptoms The introduction to the interoceptive exposure procedures includes a review of the role of the interpretation of symptoms in influencing distress. A discussion of the results of the provocation studies can facilitate this review. If these results have not already been presented, present the information provided in Chapter 3. If this material has been presented, review it. Emphasize that in these studies the way in which the participants viewed their symptoms made a marked difference on how these symptoms were experienced. For example, patients who were fearful of the symptoms tended to have more distress and more panic. State that interoceptive exposure treatment will involve experiencing some of the symptoms of the “alarm reaction” list, along with rehearsal of becoming more comfortable with these sensations. On the board, write the following comments to the left of the “Alarm reaction” list of the fear-of-fear cycle: ■
Okay, I know what these sensations are.
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Let me get used to these sensations and do nothing about them.
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Let me know what these feel like and relax with them.
Induction of Dizziness: Head-Rolling Procedure
Therapist Note
Initial exposure is targeted toward head rolling because (1) dizziness is a commonly feared symptom, and (2) head rolling is a simple procedure that
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is less overwhelming to patients than other induction methods. However, if the patient is not bothered by dizziness, other induction procedures from subsequent chapters may be substituted in this session. ■ Explain that the initial interoceptive exposure exercise involves the induction of dizziness by a head-rolling procedure. Before the initial head-rolling trial, ask the patient about any particular neck problems. If the patient does have neck difficulties, bobbing from the waist while standing may be substituted. First, the patient gently loosens up the neck muscles by turning the head from side to side and back and forth. Then, the patient completes two shoulder shrugs (raising the shoulders to induce tension, holding it, and then letting go of the tension), rehearsing the feeling of letting go of muscle tension. The actual head-rolling procedure involves the patient making small circles with the head while tilting the head forward (to avoid straining the neck muscles by making large head rotations). Demonstrate the head-rolling procedure: Close your eyes, tilt your head forward, and move your head in small circles for approximately 20 seconds. During the demonstration, describe the sensations that you are feeling. At the end of the demonstration, ask the patient to perform the same steps. Again, describe the sensations that the patient may feel during the exercise and upon opening his eyes, such as sudden dizziness. As the patient then completes the exercise, remind him to continue breathing (many patients tend to hold their breath during this procedure). Discuss the amount of anxiety induced by the head-rolling procedure, and encourage the patient to try to notice what the sensations feel like during the procedure (e.g., “I want you to be able to describe what this feels like. Is it dizziness? Where do you feel it? Does it feel weird? Think about how you are going to describe the sensations you are feeling. Remember, you are supposed to feel odd or dizzy from these headrolls”). Immediately upon completing the procedure, ask the patient what he is feeling. One common response is, “I don’t know, I was trying not to let it get worse,” or “I am not sure, I just did not want to panic.” If this occurs, reorient the patient to observing the feelings produced, and differentiate these feelings from future-oriented fears about the sensations. If the patient reports anxiety from the experience, discuss what was so aversive about the sensations. The goal is to help the patient
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process the sensations as somatic events independent of fears about these events. Introduce the next head-rolling trial as another opportunity for the patient to note what the sensations feel like and to work on noticing and relaxing with these sensations as they occur. After completing and processing the second head-rolling trial, it is useful to help the patient adopt a nonpanic frame of reference for responding to the induced symptoms. To achieve this, ask whether the patient had ever tried to induce dizziness as a child. For example, many children will try to induce dizziness by spinning in a circle or by rolling down a hill. If a patient has had these experiences, have the patient recall them. In particular, ask the patient to remember a warm, summer day when playing with friends and the enjoyment or pleasure derived from the induced dizziness. Ask the patient to complete the third trial with these memories in mind (take some time to help the patient form a vivid memory of these childhood events before the head-rolling trial). After completion of this third trial, ask the patient to compare the aversiveness of the sensations to those of the previous two trials. If the trial was more tolerable (or even pleasurable for some patients), discuss the important role of thoughts in determining whether a sensation is experienced as aversive or as pleasurable. Emphasize that the patient changed how the sensation was processed by changing how he thought about it. Describe the importance of this phenomenon for treating the fear-of-fear cycle. (For patients who as children did not enjoy making themselves dizzy, this cognitive intervention can be skipped, and the third trial completed in the same manner as the first two.) For homework, you will ask patients to perform the head-rolling exercises daily (three consecutive 20-second trials), encouraging them to become comfortable with the sensations (“one goal is to get bored with these sensations by next session by inducing them daily”). Remind the patients to prepare for the sensations they are going to experience, as was done during the session: “Just before you start the procedure, note the sensations that you will be inducing, and then relax with them as they arise.”
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Progressive Muscle Relaxation Muscle relaxation is not viewed as a necessary element of treatment for panic disorder, but some patients may experience chronic muscle tension during benzodiazepine withdrawal, and accordingly, having a method for reduction of this tension is a relevant skill. However, care should be taken to help patients avoid conceptualizing relaxation as a strategy for control of panic attacks. The muscle relaxation procedure used in this session is an adaptation of the lengthier procedures described by Bernstein and Borcovec (1973). Begin this exercise by giving a rationale for the tense–relax method.
Rationale Start out by saying that as kids, most of us are generally fairly relaxed. Children, whether they are standing still or running around, tend to have fairly relaxed muscles. But as we become older or as we face difficulties in childhood, we tend to learn ways of tensing up, of preparing ourselves for the day. This tendency may begin in terms of tensing up at times of stress, but over time we tend to forget what it really feels like to let go. So, even when we are sitting in a chair with our feet up, watching TV, our muscles may be fairly tense. We might have forgotten what it really feels like to release the tension in our muscles. Tell patients that the relaxation procedure to be learned is a method to help them regain their ability to release muscle tension. This procedure allows them to relearn what it feels like to let tension go and to relax at a muscular level. This procedure is taught by having them notice what it feels like when their muscles are tense by increasing tension (demonstrate by making a fist with your hand), holding it, then quickly releasing this tension (again, demonstrate with your hand), and noticing the difference in sensations so that they can repeat it when they want to. Emphasize that this procedure can be used throughout the day using the following dialogue: Now, this procedure isn’t just for when you want to sit still and relax—it’s for any time. Whether you’re running, sitting at a desk
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doing work, or driving your car, there are no reasons to retain extra muscle tension. In fact, certain aspects of athletic training are based on relaxing unneeded muscle groups. Gymnasts in particular utilize relaxation skills and meditation skills to help them prepare for their gymnastic performances. The same principle can be applied to running. If you’re going to be running a long distance, there’s no reason to have extra tension in the chest or shoulder muscles. In the same way, if you are sitting at a desk, there’s no reason to have extra muscle tension draining you of energy.
Instructions for Progressive Muscle Relaxation Exercises Explain that this procedure entails completing a number of tense– relax exercises with different muscle groups. Demonstrate each of these movements with the following dialogue: Let me show you what these exercises are. You will be ■
creating tension in your hands by making fists and holding them until I tell you to release the tension;
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creating tension in your biceps by bending your elbows and bringing your hands up near your shoulders;
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creating tension in your lower neck and upper shoulders and back by raising your shoulders toward your ears, as if you were shrugging;
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creating tension in your upper face by raising (or lowering) your eyebrows while keeping your eyes closed; (At this point, ask the patient to do this exercise. Some individuals have a difficult time creating tension by raising their eyebrows and may want to substitute lowering the eyebrows and wrinkling the brow.)
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creating tension in your lower face by lightly clenching your teeth and pressing your lips together while frowning; and
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creating tension in your chest by taking a deep breath and holding it for a few seconds.
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You are also encouraged to use guided imagery to further enhance relaxation during initial sessions. Chapter 7 in the patient workbook provides information on one such procedure. Ask the patient if there are any questions about this procedure. Answer any questions. The following explanation is an attempt to prevent patients from experiencing a relaxation-induced panic attack. Okay, I’d also like to tell you about some sensations that you may experience during the relaxation procedure. Some people, when they start to relax, will feel a number of sensations. For example, some people will feel some heaviness and warmth in their arms or legs. Other people may actually feel the heart thump two or three times in a row or may even feel a sense of subtle dizziness. All of these are signs that you’re actually relaxing fairly well. Your body is giving you sensations that something very different is happening. Some of these sensations come about because there is a change in the constriction of your blood vessels that forces your heart to adjust its beating. It causes your skin to become warmer, and it gives you some different sensations in your body. If you experience some of these sensations, use them as a cue that you’re doing well in this procedure. Occasionally, some individuals will become uncomfortable with these sensations or will assume that they are a sign of losing control. Actually, the sensations are a sign that you are gaining control, because you are directly influencing how relaxed your muscles are. But if you start to feel uncomfortable, just remind yourself that the sensations are natural and are a good sign. If you want, you can fade off from listening to my voice, allow yourself to become comfortable, and then come back to the procedure whenever you’re ready. All right, any questions so far? (An additional method for controlling relaxation-induced anxiety is provided in Appendix A.) If there are no questions, once again review with the patient the procedures to be performed (repeat the previous dialogue on how to create tension in each muscle group). Finish with the following: In every case, I will describe the exercise to you before you actually are to do it. I will signal you to go ahead and put tension in your muscles by saying the word tension. When I want you to relax, I will say relax, and I would like for you to let go of that tension all at once so that you
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can really feel the difference. For example, when you have your arms up (show the patient the biceps-tension position), I’d like for you to let go all at once just so your arms fall into your lap (demonstrate this with your own movements). .
In-Session Practice After providing this introduction and rationale, ask the patient to sit comfortably and begin the procedure. During the relaxation procedure, you will ask the patient to tense and relax each of a series of muscle groups twice. You will control the amount of time tension is held by saying the word tension to the patient, and then saying relax approximately 5–7 seconds later. In a comfortable voice, ask the patient to notice the difference in the feeling between the tension and the relaxation phases. You should guide the patient toward noticing and enjoying the relaxation phase for approximately 15–20 seconds before moving to the next tension phase on the same or different muscle group. Occasionally, remind the patient that one does not have to induce very much muscle tension to receive the benefits of the procedure; it is often helpful to create just enough tension to “feel it.” The important part of the procedure is to let the tension go. The tense–relax exercise should be completed for the following muscle groups, unless the patient has a specific pain condition or other physical condition that limits movement or makes these exercises uncomfortable or ill-advised. Remember that each exercise should be performed twice before the patient moves on to the next exercise. ■
Hand Tension: Tense the hand muscles by making a fist for 5–7 seconds.
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Upper Arm Tension: Bend the arms by bringing the hands up near the shoulders (tension should be felt in the front of the arms or biceps).
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Shoulder Tension: Shrug the shoulders slightly by raising the shoulders toward the ears.
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Upper Face Tension: Raise the eyebrows while keeping the eyes closed (lowering the eyebrows can be substituted).
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Lower Face Tension: Press the lips together and the teeth together (lightly) while frowning.
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Chest Tension: Take a deep chest breath and hold it.
After completion of the relaxation exercises, assign home practice, noting common errors, such as rushing the procedure or not setting aside time to practice. Emphasize that relaxation training involves 15 minutes out of the whole day for practice. Also emphasize that the patient should use approximately 5 seconds for tension and 15 seconds for letting go and that the letting go, not the tension, is the most important for the relaxation procedure. Caution the patient not to use too much tension, but just enough to feel it. Ask the patient to complete a 15-minute practice session each day during the first week of training.
Difficulties During Relaxation There are three common difficulties that occur when individuals with panic disorder start to practice relaxation techniques: (1) fears of relaxation sensations; (2) fears of being unguarded; and (3) disruptive thoughts. Briefly review these with the patient and address as needed.
Fears of Relaxation Relaxation often induces a number of sensations that are the opposite of arousal sensations. Namely, successful relaxation is associated with feelings of heaviness in the arms or legs, feelings of warmth and, occasionally, several strong heart beats. Explain that these changes occur because we are changing the level of arousal in our bodies. During relaxation, blood flow to the skin may increase, leading to feelings of warmth, and the heart adapts to this change in blood flow by changing its rate of beating. Occasionally, individuals will misinterpret these sensations as a loss of control. Emphasize that these sensations really represent the opposite—they are a sign that we are successfully inducing changes in our level of arousal. Nonetheless, if individuals are unprepared for these sensations and interpret them in terms of the fear-of-fear cycle
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(“This should not happen”; “Something is wrong”; “I am losing control”), they can become anxious in response to the natural feelings of relaxation. Discuss how this result demonstrates the importance of the interpretation of sensations. Panic disorder may teach individuals to be so frightened of bodily sensations that even a relaxation procedure can act as a frightening procedure and induce anxiety. Tell patients that the good news is that this reaction is fairly easy to control. Once a person knows that some feelings of heaviness, warmth, or a changing heart rate are natural, it is very unlikely that he will become concerned about these sensations. If the patient experiences these sensations, he should just remind himself that they are a sign of successful relaxation and enjoy them. If the patient is not comfortable with these sensations at first, he can always take a brief break from the relaxation procedure to remind himself that these are some of the desired and natural effects of the procedure, and then can continue with the exercises whenever he is ready.
Fears of Being Unguarded Fears of being unguarded during a relaxation procedure suggest that an individual may have developed a style of constantly keeping himself tense as a method of coping with the day. Remember, increased muscle tension is a method of preparing for danger. Sometimes, early in childhood, individuals may start preparing for uncertain events by stiffening their bodies. This has been described by some people as developing a sense of body armor: The tension becomes a signal that one is ready for uncertainty, problems, or danger. When it then becomes time to drop this armor during a relaxation procedure, an individual may suddenly feel vulnerable. If this occurs for patients, let them know that they are not becoming unguarded, they are just learning how to decrease excess body tension so that they feel better. The excess body tension does nothing to actually help them and, by relaxing, they are learning to control their bodies more effectively. This is a procedure patients may want to use while working, interacting with others, or exercising. In every case, the goal is the same, to help get rid of excess tension that makes them feel bad.
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To help guide patients through difficult moments in the relaxation procedure, remind them that they are increasing their ability to control their level of muscle tension and can always tense back up if they choose, but that they want to give themselves a chance to feel different while learning a new procedure. Furthermore, this process will help them perform more effectively in whatever they have to do. Often, this reminder plus home practice is enough to help a patient become comfortable with the relaxation process.
Disruptive Thoughts Disruptive thoughts most commonly include thoughts of the many things we have to get done during the day. Explain that the problem is that these thoughts can distract us from enjoying the relaxation and may lead us to hurry through the procedure and keep us from gaining the full benefit of the tense–relax method. To help prevent this from happening, encourage patients to take some extra steps to ensure their comfort during the relaxation procedure as follows: Before starting the relaxation process, take a moment to remind yourself the relaxation practice is for you. Out of the whole day, the time it takes to complete the relaxation practice (about 15 minutes) is your time; it is your 15 minutes during the day to do something for yourself. Your goal is to make the 15 minutes as pleasurable as possible. There is no need to hurry, or to plan out the next activity, because no matter what else is going on, the procedure will take 15 minutes. Enjoy every moment!
Homework
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Have patient read Chapter 7 of the workbook and complete the exercises. Have patient practice diaphragmatic breathing skills three times daily. Instruct the patient to rehearse slow breathing. Practice should be recorded on the Diaphragmatic Breathing Practice Log.
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Have patient perform the head-rolling exercises daily (three consecutive 20-second trials), and record practice on the Symptom Induction Log. Have patient practice progressive muscle relaxation (PMR) daily and record practice on the Muscle Relaxation Log. Have patient rate symptoms this week using the Medication-Taper Symptom Checklist.
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Chapter 5
Session 3
(Corresponds to chapter 8 of the workbook)
Materials Needed ■
Stopping Anxiety Medication workbook
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White board
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Diaphragmatic Breathing Practice Log
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Muscle Relaxation Log
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Symptom Induction Log
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Review Medication-Taper Symptom Checklist
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Review homework
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Contrast the fear-of-fear pattern with the relaxing-with-the-sensations pattern
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Conduct interoceptive exposure
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Discuss the initiation of medication taper
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Conduct relaxation training and introduce the relaxation-cue (RC) procedure
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Assign homework
Outline
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Overview of Session Goals The primary goal of this session is to expand the role of interoceptive exposure as a preparation for medication taper. Although taper-related symptoms are unlikely for most patients in the first week of slow taper, the goal of this session is to help ensure that any emergent symptoms are not interpreted within the fear-of-fear cycle. Interoceptive exposure rehearsal with a broader set of sensations is the primary intervention for this goal. All interoceptive exposure practice is placed firmly within the context of learning an alternative response (noticing the sensations and doing nothing to manage them; relaxing with the sensations) to the current panicogenic processing of these symptoms. Review of all home practice (diaphragmatic breathing, relaxation exercises, as well as the core interoceptive exposure homework) is essential to underscore the step-by-step skill acquisition that is at the heart of cognitive-behavioral treatment. The following learning elements characterize a successful Session 3: ■
Patients achieve a deepened understanding of thinking strategies that promote anxiety and panic.
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Patients demonstrate the ability to respond with less anxiety to three different interoceptive exposure procedures.
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Patients are oriented toward the importance of practicing interoceptive exposure as a strategy to reduce both panic disorder and the aversiveness of benzodiazepine withdrawal sensations.
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Patients are comfortable applying diaphragmatic breathing techniques.
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Patients have rudimentary skills to apply a tense–relax method for muscle relaxation.
Review of Medication-Taper Symptom Checklist Review the patient’s Medication-Taper Symptom Checklist for the last week and compare it to the previous week’s checklist. Now that you
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have 2 week’s worth of data, you can establish a baseline before beginning the medication taper. Knowing the range of diversity of symptoms will help you in designing the relevant interoceptive exposure and identifying which symptoms may be part of the patient’s anxiety experience and not a unique feature of medication taper.
Review of Homework Session 2 was particularly packed with component skills. Interoceptive exposure was initiated, diaphragmatic breathing skills were rehearsed, relaxation skills were introduced, and education about dysfunctional thinking patterns was continued. Each of these elements of treatment requires further attention in Session 3. However, of these elements, the interoceptive exposure element is the most important, and we recommend starting homework review with this intervention.
Interoceptive Exposure Ask the patient about home practice of the head-rolling procedure, and review ratings on the Symptom Induction Log. Discuss comfort with the procedure in the home setting. If the patient describes an improvement in the ability to tolerate these sensations, point out the significance of this change over the course of only one week of practice. Assess how these sensations remind the patient of panic attacks, and ask whether any difficulties were encountered during the procedure. Any difficulties that involve fearful cognitions should be related to the fear-of-fear cycle discussed during the previous session. In addition, comfort and discomfort with the sensations should be discussed in the context of the provocation studies and procedures reviewed previously.
Diaphragmatic Breathing Review the patient’s Diaphragmatic Breathing Log and discuss the patient’s practice. Conduct the diaphragmatic breathing exercise by having the patient shift between chest and diaphragmatic breathing. As in
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previous sessions, this rehearsal is aided by having the patient place one hand on the chest and the other hand on the abdomen and watching for movement of the hands with each breathing technique. Have the patient perform these practices while sitting and standing. Next, conduct a 3–4 minute rehearsal of slow, comfortable diaphragmatic breathing. Again, use your own hand movements to cue the breathing rate (approximately 5 seconds per inhalation and 5 seconds per exhalation). During this procedure, remind the patient to notice the feeling of air moving deeply within the lungs rather than chest movement. To emphasize the movement of air rather than chest expansion, have the patient lightly wet the lips and then purse them to feel the amount of air that moves between them, cooling the lips and mouth. Review how comfortable the patient is with this procedure and offer corrective feedback as necessary.
Progressive Muscle Relaxation Review the Muscle Relaxation Log and discuss the patient’s practice. Discuss any difficulties the patient had in attempting the relaxation exercise and provide feedback as necessary. Address common errors of rushing through the procedure or of not finding enough time to practice the exercise. Emphasize the importance of regular practice (i.e., relaxation is a skill that needs to be practiced and learned, as does any other skill).
Fear-of-Fear Cycle Versus Relaxing-With-the-Sensations Pattern Following review of homework, return to a focus on changing the patient’s core fear-of-fear cycle by emphasizing the role of stepwise interoceptive exposure. Initiate this process by reviewing the fear-of-fear model, drawing the model on the board as you talk (see Figure 3.4). Point out the fearful interpretations of symptoms and remind the patient that these interpretations include both the “uh-oh” component discussed previously and memories of past attacks. Also discuss the
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hurry-up/tense-up/control response, which often leaves patients more anxious. To provide a model for some of the changes that the patient will be making, relative to the symptoms, offer the following examples of pain. I want to give you a couple of examples of the differences between sensations and responses to sensations that are apparent in the area of pain. For the first example, I would like for you to imagine that you just saw a spider, and now you feel something sharp sticking or pinching you in the small of your back. Now, if you are like me, you will experience this pain as very upsetting, and you will immediately grab the painful area as if it is one of the worst pains in the world. Now, if you reach back there and discover that a pin was left in your blouse or shirt, the pain suddenly becomes more bearable. You may realize that most of the arousal and pain had to do with fearing that it was a spider bite rather than the sensation itself. A similar example can be found in headache pain. Did you ever have the experience of having your head hurt and just not being able to stand it and thinking that the pain was unbearable, but then all of a sudden, stopping and noticing exactly what the pain feels like? It may be a throbbing in the front of the head or it may extend to some tightness around to the sides. When you notice these sensations, the pain becomes more bearable. In the same way, headache pain is absolutely unbearable if you think it may indicate a brain tumor. This is because it includes the threat of further injury or death. Compare this pain to the pain you have when you know you just have a tension headache and that if you just relax and calm down, it will probably decrease in intensity. Again, depending on how you interpret the pain, it is either completely unbearable or fairly tolerable. Instruct the patient that this model can be applied to the somatic sensations of anxiety. The emphasis is placed on substituting comfortinducing responses for panic-inducing responses (see Figure 5.1). Again, to help the patient understand, write this material on the board. Simultaneously, discuss the aims of the next few sessions. They are to help the patient learn (a) to know exactly what the sensations feel like,
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Somatic sensations of anxiety
Panic-inducing response Uh-oh!!! What if I ... die? ... lose control?? Catastrophic memories Hurry up/tense up/control
Comfort-inducing response “Relax” with the sensations Note exactly what the sensations feel like Use coping thoughts and coping memories Remember you don’t have to do anything about the sensations
Figure 5.1
Retraining to Choose Coping Responses to the Body’s Alarm Reaction
(b) to relax with the sensations, and (c) to use coping thoughts and coping memories. Emphasize that the goal is not to eliminate the sensations; rather, the goal is for the patient to notice what the sensations feel like and to learn to tolerate them more comfortably. Remind the patient who started this process with the head-rolling procedure that she is now on the way toward reacting in a coping manner (indicate the comfort-inducing responses on the board/see Figure 5.1) rather than in an anxious manner.
Interoceptive Exposure All interoceptive exposure procedures used in this session focus on providing patients additional practice in tolerating specific somatic sensations. Three exposure exercises are used: head-rolling, hyperventilation, and stair-running/jogging in place. In all cases, patients are provided with a description of the sensations they are likely to experience during the exercise, a review of the processes that evoke these sensations, instruction to self-monitor fearful cognitions, and rehearsal of strategies to attend to and tolerate these symptoms.
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During all of these interoceptive exposure procedures, the therapist’s role is, in part, to identify the patient’s attempts to stop the sensations or the patient’s overattentiveness to the sensations. Encourage the patient to refrain from trying to control her body or to fight off the sensations. Furthermore, a patient’s catastrophic interpretation of her sensations can be very useful for demonstrating the anxiogenic effect of such thoughts and for introducing the cognitive countering strategies. The following is an example of how to handle fear of a rapid heartbeat: You seem to have a rather frightened look on your face. What are you thinking about the sensations? The patient may respond that her heart continues to beat fast and that she is worried about losing control. I’m not surprised your heart is beating fast. You just completed an exposure exercise, and it is normal for your heart to beat fast. Also, it would be normal for your heart to continue to beat fast if you’re trying to control it. In general, the more you try to control your heart, the longer it will continue to beat fast. Instead, I would like for you to try to understand what it is about having a racing heart in this situation that causes you to think you might lose control. You also need to identify what you mean by “losing control.” Do you imagine that you’ll faint, run out of the room, or be unable to speak? Once the patient identifies the core fear concerning the rapid heart rate, prompt her to apply the countering tactics for such a thought. Additional methods for controlling anxiogenic reactions to the interoceptive exposure exercises are included in Appendix B. If the patient continues to report high levels of anxiety after an exercise, consider repeating the exercise with particular attention to the patient’s cognitions and allowing ample time for review of cognitions between each induction. In this early session, try to achieve a balance between (a) ensuring that the patient has an opportunity to become less frightened of an induced sensation through repeated practice and (b) allowing the patient to proceed at a reasonable rate through the range of sensations being introduced and to become comfortable with a sensation more slowly by practicing between sessions.
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Head Rolling Have the patient gently stretch the neck muscles before the initial headrolling trial. During the first trial, instruct the patient to note her thoughts during the procedure and to notice (in detail) the sensations that are produced. Remind the patient that the goal of the procedure is to induce sensations of dizziness, a small amount of nausea, and some thoughts of being out of control because of dizziness. Remind the patient that these sensations are a normal consequence of head rolling because the exercise disturbs the fluid in the inner ear. Have the patient conduct a 30-second head-rolling exercise. For this exercise, the patient makes small circles with the head while tilting the head forward (to avoid straining the neck muscles by making large head rotations). Alternatively, the patient can leave the eyes open and shake the head from side to side. Encourage the patient to continue to breathe normally throughout the procedure. Remind the patient of the possibility of sudden dizziness upon opening the eyes at the end of the 30-second procedure. Discuss the sensations that the patient felt, and ask the patient whether these sensations led to increased anxiety. Draw attention to any decreases in anxiety or fear that the patient achieved. Review the thoughts evoked by the procedure, and discuss them in relation to the fear-of-fear cycle (see Figure 3.4). If appropriate, ask the patient to use memories of childhood experiences to become more comfortable with the induced sensations during the second head-rolling trial. The patient should focus on memories of trying to induce dizziness as a child. Ask the patient to bring the memory to mind before initiating the procedure. Within 10 seconds of the patient completing the head rolling, have the patient stand so that she can experience the sensations while standing and moving about the room. This step helps to prevent the hurry-up/tense-up/control response to the sensations as well as to generalize the experience to a standing position. Watch for any expressions of anxiety (e.g., facial or shoulder tension) throughout this process, and help the patient through such reactions when necessary. Ask the patient who is tense or anxious to drop the shoulders or relax the facial muscles and to allow the sensations to occur.
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Carry out the exercise a third time, while providing further encouragement to the patient to notice exactly what the sensations feel like. Review the sensations induced and any interpretations of sensations that led them to be more or less tolerable.
Hyperventilation The hyperventilation exercise is conducted in a similar manner. Instruct the patient that the hyperventilation procedure requires fast, deep breathing, and that this procedure is designed to cause her to exhale too much carbon dioxide. Explain to the patient that hyperventilation will cause any of several common symptoms, including ■
sensations of dizziness;
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tingling along the scalp, arms, or hands;
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light-headedness;
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numbness (particularly masklike numbness around the mouth);
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brightness of vision;
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blurred vision; and
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perhaps hot flashes or sweating.
Emphasize that these sensations are normal for hyperventilation. Again, ask the patient to tolerate these sensations because they are normal consequences of hyperventilation. Initiate hyperventilation for 30 seconds, having the patient breathe once per second. Demonstrate this procedure. After 30 seconds, have the patient slow her breathing. Immediately assess the sensations that the patient has experienced. Complete this procedure two more times, increasing each hyperventilation trial to 60 seconds. For each trial, (a) review what the sensations will be, (b) emphasize that the sensations are normal, and (c) direct the patient to note which interpretation of symptoms she used and relate these to the examples listed on the board (see Figure 5.1). After one of the trials, ask the patient to stand while experiencing the sensations and
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to apply relaxation techniques by letting the shoulders drop during this procedure. Point out the patient’s ability to move around adequately despite feeling dizzy.
Stair Running or Jogging in Place The third interoceptive exposure exercise is jogging in place or stair running. Complete this exercise from one to three times according to the sensitivity of the patient. Stair running commonly involves the patient running up three flights (three floors) of stairs. Alternatively, the patient can jog in place for 90 seconds. When jogging in place, the patient should lift the knees to waist level at each step. Point out that during stair running, patients are likely to experience heart pounding, breathlessness, and heavy legs. Note that these are consequences of getting the body moving all at once and then stopping the activity before the heart has a chance to adapt. Emphasize that if the exposure were longer in duration, the heart rate would adapt to the level of the activity and would not be as noticeable. Instead, the procedure stops as soon as the heart gets to a very rapid rate. This sudden stopping causes them to experience the heart pounding while they are doing no physical activity. Conduct the exposure and, as with every exercise, have the patients immediately discuss the sensations they experienced and the methods they used to tolerate them.
Discussion of Interoceptive Exposure Exercises After all interoceptive exposure exercises have been completed, discuss the patient’s experience during each of them. Emphasize that once the patient knew what to expect and had some practice, she was able to be more comfortable with the induced sensations. Explain that this comfort is exactly the goal of this initial training—for the patient to become so comfortable with sensations that the sensations themselves cannot trigger the fear-of-fear cycle. To achieve this goal, the patient must complete daily and weekly practice. Assign the patient daily homework using the Symptom Induction Log.
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Initiation of Medication Taper Patients will be initiating their medication taper during this week, as described in Chapter 2 of this guide. Patients may be referred to Chapter 5 of the patient workbook for review. The purpose of this discussion is to help them with viewing taper-related sensations the same as interoceptive exposure sensations. Include the following points in this discussion.
Context of Interoceptive Exposure Many patients feel no sensations during their initial dose reductions, although some patients may experience a few sensations. It is useful to introduce the medication taper in the context of interoceptive exposure: During the past two weeks, sensations were induced via a number of physical exercises; this week, a few sensations may be induced by the decrease in benzodiazepine medication as you taper your dose. You may not notice any sensations during this initial week of taper, but if you do notice sensations, your goal is to react to these sensations in the same way you reacted to the sensations induced in session—you did nothing about them.
Relaxation With or Toleration of the Symptoms Remind the patient to relax with the sensations as they occur but not to try to eliminate them or not to view them as harmful. In short, instead of using exercises to induce the sensations, she is using the medication taper itself. Review the analogy from Session 1 that the medication has, in some ways, reined in the anxiety and that the body may tend to speed up a bit now that she is letting out the reins (just as happens when one lets out the reins on a horse). The goal for the initial week of dose reduction is for the patient to try to tolerate the mild symptoms if they occur.
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Continuation of Interoceptive Exposure Remind the patient that regardless of any taper-related sensations, the exposure practices should be continued daily to increase comfort with the sensations. Provide the following rationale: A common pattern we see is that when patients become anxious, they have a tendency to want to avoid the exposure exercises. Although this reaction makes some sense, it is self-defeating in many ways. Most of the time, patients are anxious because they are worried about sensations coming on. Consequently, they spend all day trying not to have the sensations start, and, of course, they naturally become more and more anxious, thus experiencing the sensations. We have found that when patients go ahead and induce the sensations that they are worried about, they are better able to stop worrying and have a more enjoyable day. In some ways, these patients are getting the worst over with and reminding themselves that the sensations are tolerable, that they do not need to fear them, and that, in fact, they do not need to do anything about them. Use the following dialogue to encourage the patient to continue with interoceptive exposure: So, even if you are starting to have a bad day, sit down right then and complete the exercises using the same procedures that we have used in session: Remind yourself of what sensations you are going to feel so that there are no surprises; complete the exercise, fully expecting to experience these sensations; then, try to relax with the sensations as they occur. After you complete the exercise, don’t wait for the sensations to go away. Just become good at tolerating them. Remind yourself that it does not matter how long they last because they are not dangerous; therefore, you don’t have to get rid of these sensations.
Relaxation Training Review of Full Relaxation Procedure Inform the patient that you are going to lead her through a second practice of the exercise taught in the previous session (either PMR or an alternative relaxation method). Emphasize that part of what helps this
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relaxation to be effective is remembering how good it feels just to let go and allow oneself to relax. Remind the patient that she may experience some sensations as the body becomes relaxed and that these sensations are signs of effective relaxation. Complete the relaxation training as outlined in the previous chapter; this should take approximately 15 minutes. After the relaxation training, review the patient’s comfort with this exercise. Review any difficulties that occurred and offer corrective feedback as necessary. If the patient reports a successful relaxation, point out that this occurred within the same session as did the sensations induced by the interoceptive exposure exercises.
Introduction to the Relaxation Cue Procedure Train the patient in the relaxation cue (RC) procedure. The RC procedure, which takes only 10–15 seconds, entails a brief tension induction (described later) followed by relaxation. Model the procedure for the patient, taking a deep breath, shrugging your shoulders, wrinkling your face, and then letting the tension go. Explain to the patient how you are focusing on the tension induction and the differences in sensations as you let the muscles go. Guide the patient through this procedure. Encourage the patient to focus on the sensations experienced during both phases, paying particular attention to the differences in sensations and those created by quickly releasing the tension. The following tension-induction techniques are used for the RC procedure: ■
Hand Tension: Tense the hand muscles by making a fist for 5–7 seconds.
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Upper Arm Tension: Bend the arms by bringing the hands up near the shoulders (tension should be felt in the front of the arms or biceps).
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Shoulder Tension: Shrug the shoulders slightly by raising the shoulders toward the ears.
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Upper Face Tension: Raise the eyebrows while keeping the eyes closed (lowering the eyebrows can be substituted).
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Lower Face Tension: Press the lips together and the teeth together (lightly) while frowning.
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Chest Tension: Take a deep chest breath and hold it.
Explain to the patient that she will be working toward successful relaxation from two directions simultaneously. First, the patient will become more adept at relaxing by using the 20-minute relaxation procedure. Second, she will become able to relax throughout the day by using the quick RC procedure. Emphasize that both exercises should be practiced daily. Ask the patient to conduct the RC procedure several times daily. Daily practice can be aided by linking the RC procedure with a regularly occurring event, for example, every time the patient hangs up the phone or leaves the office, home, or car, and so on. Homework
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Have patient read Chapter 8 of the workbook and complete the exercises. Assign daily practice of diaphragmatic breathing. Encourage the patient to conduct these practices in more challenging situations (i.e., situations that are less conducive to relaxation or concentration such as during a meeting, while preparing a meal, or while driving). Remind the patient that the ultimate goal is to be able to apply this exercise in any anxietyprovoking situation. The patient is to keep a record of progress on the Diaphragmatic Breathing Practice Log. Assign daily practice of progressive muscle relaxation. The patient is to record practice on the Muscle Relaxation Log. Assign frequent practice of the RC procedure. The patient should conduct a minimum of four practices each day. Assign daily practice of interoceptive exposure. The patient is to conduct three consecutive trials of at least one exercise (e.g., head rolling, hyperventilation, stair running, or jogging in place) per day. Remind the patient that more practice is always better. Practice should be recorded on the Symptom Induction Log. Have patient rate symptoms this week using the Medication-Taper Symptom Checklist.
Chapter 6
Session 4
(Corresponds to chapter 9 of the workbook)
Materials Needed ■
Stopping Anxiety Medication workbook
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White board
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Homework Practice Log
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Symptom Induction Log
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Review homework and symptoms associated with medication taper
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Introduce catastrophic cognitions, probability overestimations, and countering strategies
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Conduct interoceptive exposure
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Conduct progressive muscle relaxation
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Assign homework
Outline
Overview of Session Goals This session continues a focus on transforming the meaning of somatic sensations of anxiety. The primary strategy is still interoceptive exposure, but in this session, additional time is devoted to cognitive restructuring and teaching patients about classic thinking errors in anxiety
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disorders: overestimations of the probability and degree of catastrophe of negative outcomes. Depending on the patient’s focus this week, these skills can be targeted to benzodiazepine withdrawal symptoms or to panic patterns. Again, all interoceptive exposure practice is placed firmly within the context of learning alternatives (noticing the sensations and doing nothing to manage them; relaxing with the sensations) to fearful processing of these symptoms. The following learning elements characterize a successful Session 4: ■
Patients learn about thinking biases in panic disorder—probability overestimations and catastrophizing.
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Patients learn methods for challenging and responding differently to these thoughts.
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Patients apply these skills in the context of interoceptive exposure.
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Patients continue an orientation toward practicing interoceptive exposure as a strategy to reduce both panic disorder and the aversiveness of benzodiazepine withdrawal sensations.
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Patients are comfortable applying diaphragmatic breathing techniques.
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Patients become comfortable with a tense–relax method for reducing bodily tension.
Review of Homework Review of Interoceptive Exposure Practice Review the Symptom Induction Log and discuss the patient’s efforts. Review the exposure procedures to ensure that the patient did the exercises correctly. Have the patient describe the sensations he experienced during the exercises. Assess whether the patient is noticing an increased ability to tolerate the sensations. Inquire about any changes in cognitions during the exposure practices. If the patient is having difficulties, identify any anxiogenic cognitions (i.e., catastrophic interpretations, probability overestimations) that occurred during the exercises. Again,
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point out the role of such cognitions in the fear-of-fear cycle. Reassure the patient that specific attention will be devoted this session to helping him counter such thoughts.
Review of Symptoms Associated With Medication Taper Review the patient’s Medication-Taper Symptom Checklist. This session occurs several days after patients have initiated their medication taper. It is not uncommon for patients to discover that their anticipated level of taper-related distress far exceeded the actual distress experienced during initial dose reduction. Ask patients about any discrepancies between the symptoms they actually experienced and those symptoms they expected to experience. Regardless of whether patients spontaneously note that the taper was not as bad as expected, discuss that this outcome is relatively common. Point out the role of cognitions in this anticipatory reaction. In particular, discuss that patients often have the frightening cognition that panic may return or that generalized anxiety may increase following each dose reduction. Under such circumstances, patients become very vigilant of the symptoms during this process. Describe how this vigilance to symptoms is part of the fear-of-fear cycle. Illustrate this cycle on the board. Write the following headings in a list and draw an arrow from one to the next: Expectation and Attention to Symptoms → Symptoms Frequently Found → Catastrophic Interpretations → Increasing Symptoms → Panic Attack. Explain that patients commonly have the following cognitions during this process: “Am I having any difficulties?” “Are my symptoms getting any worse?” “What if my heart is beating faster?” “I won’t be able to cope.” Inquire about specific thoughts the patient had during the taper experience. Inform the patient that he should start to become aware of this process (specific thoughts and their impact), and that part of the next few sessions will be devoted to helping him change this pattern by (a) decreasing vigilance to symptoms and (b) learning to ignore and challenge misinterpretations of bodily sensations.
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Review of Diaphragmatic Breathing and Progressive Muscle Relaxation Have the patient describe his diaphragmatic breathing and relaxation homework. Draw attention to the patient’s successful practice of skills and improvement. This feedback provides social reinforcement for effective practice. If the patient did not practice, explore the reasons for not practicing and encourage the patient to complete home practice. Review the importance of practice in making these exercises automatic. Be sure to inquire about whether the patient is avoiding the exercise because it elicits somatic sensations. Review any difficulties the patient might have had and offer suggestions whenever appropriate.
Introduction to Catastrophic Cognitions, Probability Overestimations, and Countering Strategies Cognitive Errors and Their Identification In this session, greater attention is devoted to altering anxiogenic thoughts. In helping patients challenge catastrophic thoughts in panic disorder, be vigilant to two primary types of distortions: (1) distortions in the probability of negative outcomes and (2) distortions in the degree of catastrophe of these outcomes.
Probability Overestimation
Define a probability overestimation as a cognitive error in which an individual predicts that an unlikely event is likely to occur (i.e., overestimation of the probability that a negative event will occur). Illustrate probability overestimations by providing several examples:
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“If I panic, I will have a heart attack.”
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“If I panic and experience unreality, I may never return.”
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“If I panic, I may go crazy.”
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“If I don’t get all of my work done, I will never catch up and then I will be fired.”
Catastrophic Thinking
Define catastrophic thinking as one type of misinterpretation in which an event (i.e., panic consequence) is perceived as catastrophic, intolerable, or dangerous, when it actually is none of these. Catastrophic thinking also occurs when individuals grossly underestimate their ability to cope with the consequences of a panic attack. Illustrate catastrophic thinking with a few examples: ■
“If I faint, I may never regain consciousness.”
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“If other people noticed that I was having a panic attack, it would be terrible and I could never face them again.”
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“If everything is not perfect when my friends visit, I will be a failure.”
Preparation for Cognitive Restructuring Depending on the type of negative events predicted by the patient, probability overestimation or catastrophic thinking or both of these distortions might be the primary target for cognitive restructuring. For example, fears of death will be more aptly challenged by consideration of probability overestimations, fears of embarrassment might be more aptly challenged by considerations of the overestimations of the degree of catastrophe, while fears of fainting might be challenged by attending to both the low probability and the ability to cope with this event. Prior to direct evaluation of negative thoughts, be careful to better clarify the nature of the patient’s concerns. That is, the form of negative thoughts is frequently in negative absolutes that are difficult to challenge: symptoms are “unbearable,” “horrible,” or “intolerable.” These are perfect anxiogenic terms—they are affect-laden, nonspecific, and ill defined, yet communicate events that cannot be managed. In short, these are terrific terms to heighten anxiety and the perceived need to avoid. In discussions with the patient, communicate the emotional power of these terms while also communicating the degree to which they are not descriptive of the actual feared outcome. Then ask the patient what
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he means by “horrible” or “unbearable.” Common questions include the following: ■
What would be so bad about that happening?
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What did you think would happen?
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. . . and what would be the consequence of that happening?
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. . . and what would happen then?
This Socratic questioning will help patients clarify their fears and provides the opportunity for you to challenge basic assumptions about the probability or degree of catastrophe of feared outcomes. In session, this discussion may unfold as follows (in the following vignette P represents the patient and T represents the therapist): T: What would happen if you felt panicky in that situation? P: It would be horrible. T: I am glad you used that term “horrible,” because a term like “horrible” is a classic term I hear frequently in the treatment of anxiety disorders. It is a frightening term that is hard to challenge. “Horrible” is horrible, with no possibility of argument. But “horrible” does not really describe your concerns. I want to be really clear on what is concerning to you, so let me ask you some questions about “horrible.” What do you imagine happening that would be so horrible? P: I would lose control. T: What do you picture happening if you lost control? P: I might faint. T: Okay. So your first reaction is the prediction that you would faint. What if you did faint? What would happen then? P: It would be awful. T: What is it about fainting that would be so awful? P: People would think I looked foolish. T: So, what if people thought you looked foolish? Does it really matter what those people think?
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P: Well, no, but I would be so embarrassed. T: Have you ever been embarrassed before? P: Yes. T: Were you able to cope with those feelings of embarrassment and face the same people again? P: Well . . . yes. T: What makes you think that you would not be able to cope if you were embarrassed due to panic? P: It would be very uncomfortable. T: Well, that may be true, but could you cope with it? Would you be able to live through the embarrassment? P: I suppose. T: That is important for you to remember. And I would like you to consider how differently you feel when you think, “I am worried about panic attacks because I am worried about fainting, but even if this unlikely scenario occurs and I faint, I think I could manage the feelings of embarrassment that would bring.” That is a very different thought and has a very different effect from thinking it would be “horrible if I panicked.” You may find it useful to inform the patient that effective coping does not necessarily imply that the consequence or event will be pleasant or easy. Such events may be unpleasant and difficult; however, such unpleasantness or difficulty does not imply that effective coping is impossible.
Countering Catastrophic Thoughts To help the patient generalize the skills of countering catastrophic thoughts, have the patient identify several examples of catastrophic thoughts related to his panic and benzodiazepine withdrawal. Have the patient write these thoughts on a 3 × 5 card or in the workbook. Then teach the patient the procedures for countering
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catastrophic cognitions. Describe the countering strategy as involving two steps: 1.
Imagine the worst consequence actually happening.
2.
Critically evaluate the actual severity of the consequence of the catastrophic event. That is, if the worst actually did happen, would it be as horrible as he imagined it to be and could it be handled if it were to happen? The patient can be taught to think, “So what if______happens?”
Countering Probability Overestimations Similar procedures should be followed to teach the patient procedures for countering probability overestimations. Describe the countering strategy as involving the following three steps: 1.
Treat a thought as a hypothesis or guess, rather than as a fact, that must be subjected to objective evaluation.
2.
Evaluate the evidence that supports and refutes the specific prediction.
3. Explore alternative interpretations of a given situation. Encourage the patient to ask questions, such as those following, to evaluate the probability of an event happening: ■
How many times has ______happened in the past when I have panicked?
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How many times has______not happened when I have panicked?
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Is there any evidence to suggest that______will happen in the future if I panic?
Exposure to the Cognitions In addition, reducing feared events and consequences to actual probabilities can be a useful strategy. For example, if the patient says that he is afraid of vomiting as a consequence of a panic attack, ask how many
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times the patient has actually vomited. If the patient reports that he has vomited once as a consequence of panic and that he has had 50 panic attacks in the past, the actual probability of vomiting is 1/50 or 2%. After the patient has listed his catastrophic thoughts and probability overestimations and has begun to try to counter them, provide additional suggestions for viewing such thoughts objectively by evaluating the accuracy of those thoughts. Present the following explanation: I would like for you to take several moments to examine the thoughts that you have listed. You might have had many of these thoughts on a daily basis. In fact, in many cases, they might have become so automatic that you may not realize that you are focusing on such fearful thoughts. I would like for you to notice how frightening these thoughts are, but I would also like for you to keep in mind that they are just thoughts. They are just ideas. These thoughts, these ideas, have, in many ways, pushed you around for a long time. These are the thoughts that have scared you, have helped make your life miserable, and have helped make bodily sensations seem dangerous. However, what you need to begin to ask yourself is whether the thoughts are really accurate interpretations. If they are accurate, they will be dealt with accordingly. However, if they are not accurate, why allow such thoughts to push you around and create anxiety? I want you to look at these thoughts and become very familiar with them. Once you do, these thoughts will start to lose their ability to make you anxious or frightened. By seeing these thoughts for what they are, they will become less threatening, even boring, and something that you do not need to take seriously. For the next few moments, I would like for you just to read and reread each of these thoughts. As you read them, frequently remind yourself that these are just thoughts that tend to frighten you. After allowing the patient approximately 1 minute to look at these thoughts, continue with the following exercise: Have the patient read his first two or three cognitions. Explain that these fears are quite common (assuming common fears are elicited). Emphasize that the goal is for the patient not to let these thoughts push him around anymore. Rather, through the cognitive countering
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strategies, the patient will learn that such thoughts are inaccurate interpretations of certain events. Ask the patient to read and reread his thoughts once again and to view them as if he were just seeing frightening thoughts written on a piece of paper: The patient need not take them seriously, need not view them as any representation of the truth. In fact, although he may have these thoughts in the future, he need not attend to them. After allowing another minute or two for the patient to focus on his thoughts, discuss the role of these thoughts in increasing fear and further introduce the idea that thoughts need not be accurate to affect emotions. For example, you may present the following explanation: Thoughts can be conceptualized as just another kind of behavior. I can move my right hand back and forth, or I can think a very specific thought. For example, right now I am thinking about what’s in my refrigerator at home. If I think that thought powerfully enough, I may even induce a little bit of hunger as I picture what meals I have waiting for me. The next thing is that my thoughts are not limited by reality. Actually, my refrigerator is fairly empty, but in my thoughts, I can fill it with all sorts of luscious delicacies. However, there is also some cost in not having our thoughts limited by reality. For example, you may have several thoughts written down that suggest you may die, that you may go crazy, or that you may lose control in response to anxiety sensations. Given that you have had over (specific number) panic attacks and that you have not gone crazy or died, we can be quite certain that these thoughts do not conform to reality. Unfortunately, they do have an effect on you. Part of our goal in reviewing these thoughts is to help you review them for exactly what they are, frightening thoughts that do not accurately represent reality. In fact, in treatment programs like this, it is often striking how similar everyone’s thoughts are. Close this discussion of probability overestimations by informing the patient that these thoughts will likely occur in the future. Note that these thoughts may occur during the interoceptive exposure exercises to be completed in the next few minutes. Instruct the patient that if these thoughts do occur to be prepared to say, “Wait a minute, I don’t need to worry in this way about these sensations,” or, “Here’s that frightening thought again. I’m tired of reacting to this thought.” Remind the
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patient of the strategies for countering such thoughts if they do begin to evoke anxiety. Help the patient through this countering process if necessary.
Interoceptive Exposure Conduct interoceptive exposure procedures as outlined in Session 3. Before each exercise, remind the patient of the sensations he will likely experience. Complete three head-rolling trials of 45 seconds each and two hyperventilation trials of 1 minute each (alternative procedures should be substituted in the rare instance that the sensations produced by these procedures are not the object of concern). Each exercise should include the following steps: 1.
Conduct the trial for the specified duration.
2.
During the trial, encourage the patient to notice the sensations and to do nothing to manage them. You want the patient to discover that it is possible to “relax with the sensations.”
3.
After the trial is completed, rate the intensity of the symptoms and the intensity of the anxiety experienced during the exposure trial.
After each exposure trial, have the patient reread his 3 × 5 card or patient workbook and review how the thoughts listed there previously escalated symptoms. Instruct the patient simply to let the sensations happen, rather than try to stop or fight them. Have the patient stand up and move around during the third head-rolling and hyperventilation trials to get used to the sensations in a different context. Have the patient apply the somatic and cognitive coping skills to feel more comfortable while experiencing the symptoms and to deal with any residual anxiety. Assess whether the patient appears to be trying to stop the sensations or is overly attentive to the sensations. Emphasize that he should not try to control his body or fight off the sensations. In addition, a patient’s catastrophic interpretation of his sensations can be very useful for demonstrating the anxiogenic effect of such thoughts and for teaching the application of the cognitive countering strategies.
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Progressive Muscle Relaxation Ask the patient to complete a 10-minute practice of progressive muscle relaxation using the following procedures: ■
Hand and Upper Arm Tension: Tense the hand and arm muscles by making fists and bringing the fisted hands up to the shoulders.
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Shoulder Tension: Shrug the shoulders slightly by raising the shoulders toward the ears.
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Face Tension: Press the lips together and the teeth together (lightly) while frowning and wrinkling the brow.
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Chest Tension: Take a deep chest breath and hold it.
After this brief relaxation practice, review the relaxation cue (RC) procedure and the patient’s application of it. Emphasize that the more a person practices the full muscle relaxation and the RC, the more likely he will be able to utilize these procedures when desired. Remind the patient that the ultimate goal of such practices is to be able to achieve full relaxation with the RC alone, but that the purpose of relaxation is never to try to stop anxiety, but to become less tense while experiencing any physical symptoms that may be present.
Homework From this session onward, specific assignments are written in the Homework Practice Log, and the patient records his practice of each. In addition, the patient is to continue recording symptom induction results on the Symptom Induction Log.
✎ ✎ ✎
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Have patient read Chapter 9 of the workbook and complete the exercises. Assign interoceptive exposure. The patient should practice two exposure exercises. Each exercise should be practiced daily for a minimum of three consecutive trials to facilitate habituation. Encourage the patient to view the medication taper as an additional interoceptive exposure experience. As taper-related symptoms are
noticed, the patient is to identify them, to rehearse relaxing with the sensations, and to utilize the cognitive countering strategies. Although the patient knows the source of these symptoms, he may view the symptoms as uncontrollable. However, the uncontrollability in and of itself does not render the sensations any more dangerous. The aim is for the patient to increase his ability to tolerate the sensations, rather than to try to eliminate or control them. The skills learned during the interoceptive exposure procedures are to be applied to any symptoms that may arise from the medication taper.
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✎ ✎ ✎
Have the patient review and counter his most problematic cognitions (i.e., the ones written on the 3 × 5 cards) at least twice daily and at other times if necessary. If the thoughts were not written in the patient workbook, they should be transferred to the patient workbook during the week. The purpose of this review is to allow the patient to view such thoughts objectively and to review these thoughts at times when he is not anxious. The goal is for the patient to become “bored with these thoughts,” that is, to reach the point when the thoughts do not elicit or exacerbate anxiety. Assign RC practice several times a day and full progressive muscle relaxation every other day or more if needed. Assign daily practice of slow, diaphragmatic breathing. Have patient rate symptoms this week using the Medication-Taper Symptom Checklist.
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Chapter 7
Session 5
(Corresponds to chapter 10 of the workbook)
Materials Needed ■
Stopping Anxiety Medication workbook
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White board
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Homework Practice Log
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Symptom Induction Log
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Review homework
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Conduct in-session rehearsal of RC procedure
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Review symptoms associated with medication taper
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Teach the “benzodiazepine flu” model
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Review catastrophic cognitions, probability overestimations, and use of countering strategies
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Conduct interoceptive exposure
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Teach concept of cognitive coaching
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Assign homework
Outline
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Overview of Session Goals This session continues a focus on transforming the meaning of somatic sensations of anxiety and on ending the fear-of-fear cycle. Patients are provided with additional information to consider in the context of ongoing interoceptive exposure. In this session, the range of sensations induced in interoceptive exposure is expanded with the use of additional exercises. Likewise, patients are introduced to a model for increasing the tolerability of withdrawal sensations (benzodiazepine flu), as well as conceptualizing withdrawal sensations as a form of interoceptive exposure useful for the management of panic disorder over time. Also, patients receive an expanded version of cognitive restructuring in the context of the Coaching Story. Home practice of regular diaphragmatic breathing and muscle relaxation is starting to be de-emphasized in this session, with the assumption that the patient is beginning to use these procedures as needed, and is relying much more heavily on home practice to eliminate fears of somatic sensations. The following learning elements characterize a successful Session 5: ■
Patients learn comfort with a broader range of sensations and expand their comfort with withdrawal sensations, if present.
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Patients learn about thinking biases more generally, and begin a process of more globally monitoring negative thinking and substituting in more adaptive alternatives.
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Patients continue an orientation toward practicing interoceptive exposure as a strategy to reduce both panic disorder and the aversiveness of benzodiazepine withdrawal sensations.
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Patients are using the relaxation cue to reduce bodily tension.
Review of Homework Review of Interoceptive Exposure Practice Collect the Homework Practice and Symptom Induction logs and discuss the patient’s interoceptive exposure homework. Help the patient
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compare the degree of anxiety experienced during these exercises to that experienced during early exposure trials in Session 2. Review decreases in the level of anxiety and inquire about changes that may be related to any decrements (e.g., changes in cognitions, increased ability to separate the experience of sensations from the experience of anxiety, successful countering of cognitions). If the patient did not complete the forms or exercises, encourage her to do so in the future, emphasizing the importance of self-monitoring and regular practice. Be sure to inquire about reasons for not completing the exposure and allay concerns if necessary. Remind the patient about the importance of regular practice. When reviewing the interoceptive exposure practices, ask the patient whether she decreased the frequency of practices when feeling anxious. If so, encourage the patient to complete these procedures despite anxiety by explaining that many patients feel much less anxious after completion of the interoceptive exposure exercises because patients tend to worry about the practices beforehand. Once they have completed the practice, they often find that these sensations are not as bad as they had imagined and that they are able to stop worrying for the rest of the day. The interoceptive exposure practices also provide patients with an opportunity to rehearse their coping skills. These types of practices increase the likelihood that such procedures will be helpful at times of naturally occurring anxiety.
Review of Diaphragmatic Breathing, Muscle Relaxation, and RC Procedure Initiate this inquiry into home practice by asking the patient if there were any changes in daily tension levels once she began to use the relaxation cue. Encourage patients who are having difficulty by reminding them that old habits are hard to break and that the use of new skills may take some time to feel natural. Immediately following this discussion, review the use of the RC procedure. Also inquire about the use of diaphragmatic breathing and full muscle relaxation skills.
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In-Session Rehearsal of RC Procedure The purpose of this practice is to review the patient’s use of the RC procedure. First, ask the patient to take a deep breath and tense her shoulders and face. Then have the patient hold this position for approximately 5 seconds, followed by relaxation (i.e., a quick release of tension and exhalation). During the 10–15 seconds after this relaxation, encourage the patient to notice sensations of relaxation and comfort. Have the patient continue to let the muscles relax for several additional seconds. Lead an additional practice of the RC procedure with the patient standing to promote generalization of this skill to situations less conducive to relaxation. The other goal of the RC procedure is to reduce levels of tension across the day; hence, regular practice should be encouraged. Remind the patient that these skills will be particularly useful for managing general increases in anxiety that might occur as part of the medication taper.
Review of Symptoms Associated With Medication Taper Review the patient’s Medication-Taper Symptom Checklist. Ask the patient whether she experienced any difficulties with the medication taper over the past week, and inquire about the methods the patient used to deal with any symptoms associated with the taper. Be sure to remind the patient about the role of vigilance and anticipatory anxiety in exacerbating withdrawal symptoms. Also remind the patient about the temporary nature of these symptoms and that the goal of treatment is to make these sensations tolerable.
“Benzodiazepine Flu” Model Introduce the cognitive coping technique of “benzodiazepine flu” as another method for managing sensations associated with medication taper. This strategy encourages patients to apply their strategies for coping with other somatic sensations (i.e., the flu) to those symptoms experienced as part of the medication taper. Use the flu (or common cold) as one example in which patients are not afraid of the symptoms,
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are able to cope with the symptoms, take care of themselves, and go about their business as best they can. Patients may not enjoy such symptoms; in fact, they are probably quite uncomfortable. However, patients are able to tolerate such symptoms without fear until the flu runs its course. Encourage the patient to regard any withdrawal symptoms as an episode of the “benzodiazepine flu.” Patients should treat themselves just as they would if they had the flu. Patients may not enjoy the experience, but it is tolerable in the context of a slow-taper program. Moreover, practice with tolerating the withdrawal symptoms is a useful skill for longer-term management of the panic disorder; patients are able to practice doing nothing to manage somatic sensations of anxiety regardless of their source in anticipatory anxiety, stress, panic sensations, or benzodiazepine withdrawal symptoms.
Review of Catastrophic Cognitions, Probability Overestimations, and Countering Strategies Ask the patient to review her list of three or four primary cognitive errors. Review the patient’s efforts at identifying and countering these thoughts on a daily basis. Provide the patient with the following example of the impact such thoughts have on her experience of anxiety: These are the thoughts that have pushed you around for some time. These are thoughts that are among some of the most frightening thoughts a person can think. If we take these thoughts seriously, it is fairly natural to feel more anxious. For example, if we wanted to be cruel, we could do the following: We could find a person off the street, equip her with a cell phone, and every time we called her on the phone, we would announce a particular catastrophic thought. For example, we’d call in and say, “I wonder if you’re about to die,” or “Are you sure you’re not about to fall down now? Something terrible may be happening in the next few minutes.” Our aim would be to call in to that person when we know she is in anxiety-provoking situations already. For example, when that person is in a business meeting, we’d call, emphasizing that she may have particular trouble with her heart pounding and may have to run out of the room. Over the course of just
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a few days, we would probably make this person extremely nervous. In fact, to do such a thing we’d have to be fairly cruel people. Of course, this is exactly the sort of thing that has been happening to you. You have been having these frightening automatic thoughts, often on a daily basis, particularly in situations where you are already nervous. If we assume that some of these thoughts are going to continue out of habit, the nicest thing you can do for yourself is to not take these thoughts seriously. In fact, I’d like to treat them just like the thoughts in our example. I would like for you to realize the distortion in these thoughts, counter them, and not lend them any more credence than they deserve. By countering the negative predictions (probability overestimations) and by decatastrophizing, you will ensure that these thoughts lose their ability to evoke or maintain high levels of anxiety. Review several episodes of anxiety and identify examples of cognitive errors. Coach the patient on how to counter such cognitions.
Interoceptive Exposure Rationale Before conducting the interoceptive exposure, provide patients with a more detailed rationale for this procedure. The presentation of the interoceptive exposure strategies is placed in a broader context, one that integrates patients’ experiences with the procedure thus far but one that also applies it in more detail to the control of the panic disorder. The rationale should include the following information. A characteristic of panic disorder is patients’ oversensitivity to and fear of somatic sensations of anxiety. Such sensitivity and fear often cause patients to respond to certain bodily symptoms, such as a rapid heartbeat, with a full-blown panic attack. The goal of interoceptive exposure is to retrain the patient to have a different response by weakening the connection between feared sensations and the fear-of-fear cycle. Emphasize that this response occurs at several levels and involves the following: ■
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a cognitive component by which patients learn to coach themselves differently or to interpret the sensations in a different way, or both;
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a behavioral component by which patients relax instead of tensing up and confront the sensations head-on rather than using avoidance, distraction, and escape as coping responses; and
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a physiological component by which the body becomes comfortable with somatic sensations (or better able to tolerate them) and no longer automatically fires the alarm reaction.
Provide patients with a conditioning example. In particular, provide a commonplace example of habituation to a regularly occurring stimulus. If you do not have examples of your own, you may use an example similar to the following: One example is the way in which people get used to strange noises. Most patients will be able to note times when they have had a new doorbell or a new telephone ring. They might have been very surprised or startled by the ring. But after several days of hearing the ring or bell over and over again, they become very comfortable with the sound. After providing patients with these or other examples, emphasize that extinction is the goal of interoceptive exposure. Inform patients that currently certain sensations they associate with panic attacks set off an alarm (the fight–flight system) within the brain. Panic disorder has, in part, taught patients to be very sensitive to these sensations. The goal is to have the brain become so tolerant of these somatic sensations and the sensations so commonplace that when these sensations are experienced, no alarm will sound. Ensure that patients understand this concept. Review with them any progress in becoming more tolerant of the sensations. Close this discussion of the rationale with the reminder that no one is free of occasional somatic sensations of anxiety. Remind patients that anxiety is a natural and valuable event and is not dangerous in any way. Provide an example of the adaptive consequences of anxiety (e.g., it mobilizes a person to get out of the way of an oncoming car). Also discuss that various other emotions bring about somatic sensations similar to those experienced during anxiety and panic. At this point, it might be helpful to point out that patients with anxiety disorders often lose the ability to differentiate anxiety from other emotional states. One reason for this lack of differentiation is that the physiological changes are
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similar across a variety of emotional states. For example, when someone is exhilarated, angry, or sexually aroused, the person’s heart rate, blood pressure, muscle tension, and sweating all increase. It is not uncommon for patients to fail to notice these sensations of arousal while angry. However, immediately after the argument (or other anger cue), they may notice the sensations, interpret them in a fearful manner, and then spiral into a panic attack. Regular daily events can also induce somatic sensations. Patients frequently engage in activities that increase heart rate, such as exercise, standing up too fast, or rushing through the day. The goal of the interoceptive exposure is not for patients to escape or avoid these sensations, but to become better able to tolerate the sensations without responding to them with fear. Consequently, the sensations are less likely to be noticed and interpreted as an important event. This result is one reason regular practice of interoceptive exposure is essential. The same principle can be applied to benzodiazepine taper-related symptoms. The goal is for the patient to become better able to tolerate the sensations. Again, remind the patient that becoming more comfortable with the taper sensations will be useful for dealing with future episodes of anxiety.
Practice To determine which exercise produces sensations most similar to the patient’s naturally occurring panic or withdrawal experience, the patient should complete each of the following exercises at least once. Be sure to instruct the patient to refrain from utilizing her coping strategies during these induction procedures. In all cases, encourage the patient to complete the exercise for the specified duration. However, if necessary, the exercise can be terminated. After each exercise, have the patient rate herself using the rating scale 0–10 (0 = none, 5 = moderate, 10 = extreme):
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■
physical sensations experienced,
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the intensity (0–10) of these sensations,
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the intensity (0–10) of any anxiety experienced, and
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the degree of similarity (0–10) between the induced sensations and taper symptoms and naturally occurring anxiety.
Tube Breathing
The purpose of this exercise is to produce sensations of restricted breathing, an urgency to breathe, and fears of suffocation. These sensations are induced by having the patient breathe through a thin straw, such as a coffee stirrer or a cocktail straw for 2 minutes. Instruct the patient not to breathe through the nostrils; encourage the patient to hold the nostrils together.
Hand or Mirror Staring
Sensations of derealization or depersonalization can be induced by having the patient stare into a mirror (if available) and say her name silently over and over again for a 1–2 minute period. Alternatively, the patient can stare at her hand for approximately 3 minutes and repeat silently, “This is my hand, this is my hand, this is my hand. . . .”
Muscle Tension
This procedure produces sensations of muscle tension; at times, some numbness or tingling; and a general discomfort that is sometimes accompanied by an urge to escape. The patient tenses the muscles throughout the body for 1 minute or holds a push-up position for several (e.g., 3–5) minutes.
Bending Over
A flush reaction as well as some light-headedness can often be induced by having the patient bend over and place her head between the knees for approximately 1 minute and then quickly return to an
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upright position and lift the head. Many patients will also experience sensations of a hot or “pressurized” face when the is in the down position.
Light Staring
Difficulties concentrating while reading written material or visual disturbances (e.g., spots, blurred vision) can be induced by having the patient stare at a bright light for approximately 30 seconds (do not use fluorescent lights as the stimulus). Immediately after staring at the light, the patient is asked to read a short paragraph.
Throat Tightness
Some sensations of throat tightness can be simulated by having the patient start to swallow and then holding her throat in the “mid-swallow position.” The patient is asked to hold this position for 5–10 seconds. (Patients often have difficulty holding this position for more than 10 seconds.) After all of the exercises are completed, ask the patient to identify the two procedures that induced symptoms most similar to panic or withdrawal symptoms (i.e., those with highest similarity ratings). If no exercises elicited similar sensations, have the patient complete the head-rolling or hyperventilation procedure or the following alternative procedures as appropriate. In all cases, follow the general procedures described in Session 3.
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■
To induce chest pain, have the patient interlock her fingers and place hands behind the head while stretching elbows backward. Then, have the patient take one deep breath and then continue trying to take chest breaths at the rate of one breath per second. Continue for 1 minute.
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To induce body heat, ask the patient to wear a down coat or several sweaters during the session (or, for home exposure, while watching television).
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To induce throat tightness, have the patient either use the swallowing procedure described previously or wear a tight scarf or a necktie around the neck.
After the patient has identified the two exercises that elicited the most anxiety, conduct three exposure trials of each one. After these trials, remind the patient of the importance of regular practice. Point out that she is already much more comfortable with these sensations (or better able to tolerate the sensations) than when treatment started. Emphasize that she must continue this process with daily practice. Instruct the patient to practice one or two exercises daily over the next week. Each exercise should be practiced a minimum of three consecutive trials to promote habituation. Remind the patient to complete the ratings for each exercise on the Symptom Induction Log.
Cognitive Coaching As part of training in the use of cognitive techniques to decrease anxiety, self-coaching is often helpful. The following narration should be presented as another method of cognitive coping. Introduce this material by telling the patient that you would like to relate a story that is relevant for general mood management as well as for coping with anxiety and panic. I’d like to talk for a few moments about baseball and coaching. Baseball or softball is a good topic because most people played these games when they were in grade school on a girl’s or boy’s team or perhaps on a coed team. Baseball is also interesting because it seems to be a sport that is fairly well known for extreme coaching styles as well as for extreme reactions from parents. In particular, I want to talk about a couple of different types of coaches who might coach a Little League team. Let me give you a scenario to start with. Imagine that little Jane is in the outfield. She has been hanging around out there for some time waiting for something to happen, and the other team has just hit a pop fly. Jane sees a fly ball coming. She backs up and backs up with glove ready, and the ball comes and goes over her head. Jane has missed catching the ball. The other team is rounding the bases.
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Jane has to turn around and scramble to find the ball and do the best she can to stop the hit from becoming a home run. Well, there are a couple of ways a coach may react to this. Let’s pick a certain kind of coach—Coach A. Coach A’s response is to run out on the field and say, “I can’t believe you missed that ball! What’s the matter with you? You really screwed up! Tell you what, if you mess up like that again, you are going to be sitting on the bench for the next several innings. Don’t mess up anymore!” And then the coach will storm off the field. Now, Jane, if she is anything like me, would be standing there trembling, tense, almost in tears, hoping desperately that a fly ball never comes her way again. If a ball does come to her again, chances are that she will do poorly because (a) she probably has tears in her eyes and probably can’t even see the ball, and (b) she doesn’t have any idea how to do better if another fly ball does come. But the effects are probably even worse for the next game. If we were Jane’s parents, we’d probably see her start getting uptight before practice or before the next game or complaining of stomachaches before going to a practice. And chances are that even if she doesn’t ever improve in baseball, she probably won’t enjoy the game as much. She may spend a lot of time being terrified in the outfield. Now let’s look at Coach B reacting to the same scenario. Coach B goes out on the field and is fairly honest, saying, “Well Jane, you missed the ball. What you need to remember is that when a pop fly is hit, it always looks like it is closer in than it really is. Because of that it’s important that you take a few extra steps backward and try to catch the ball more at chest level. Also, keep your other hand ready so you can trap the ball when you catch it. I’d like for you to try it again and just do the best you can.” And then Coach B leaves the field. Now, it isn’t likely that Jane feels good about having missed the ball, but there are several important differences resulting from Coach B’s style. First, Jane knows what to do differently next time and so has a chance of improving. Second, and probably even more important, Jane isn’t quite so upset. She is not happy for having missed the ball, but she was treated a little bit more reasonably and therefore may do a little bit better the next time a pop fly comes her way.
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Now for the parents, it’s fairly easy to know which coach to pick. Most of us would pick Coach B. Chances are, Jane will end up being a better baseball player with Coach B because of effective coaching; she knows what to do differently the next time. But even if we don’t care if our kid is going to be a champion baseball player, we would still pick Coach B because Jane is likely to enjoy the game. Baseball after all, is a game, and presumably it’s meant to be enjoyed. So, if we want Jane to smile and look forward to going out and playing, we’d pick Coach B. Now, although it’s fairly unanimous that as parents we would pick Coach B, we hardly ever pick Coach B when it comes to ourselves. Most of us coach ourselves from a Coach A perspective. If we screw up, we scream at ourselves: “Why did I do that, how could I have been so stupid? What a jerk!” And worse, we often feel like little Jane. We feel bad. We feel tense. We may almost get tears in our eyes. And the real crime is that we’re not talking about a baseball game. We are talking about life. We tend to coach ourselves in a way that makes us feel miserable in life. We would hardly ever coach someone else as mercilessly as we coach ourselves, and this harshness has a real cost to us. I told you this story because I would like for you to start thinking about how you coach yourself. Namely, I’d like for you to watch how you talk to yourself and decide whether you coach yourself more in terms of Coach A or in terms of Coach B. My bet is that you use a Coach A style. Somewhere along the way, we seem to get this silly idea that the more we yell at ourselves, the more cruel we are to ourselves, the better we’ll do. We know that’s not the way it works. None of us would ever try to coach a team by going into the locker room and telling everybody how they screwed up, that they’ll probably never change, that their mother was probably right about them, and that they’re probably going to lose the next inning. That’s a good way of making sure that everybody hates the game. Here again, the purpose of life isn’t necessarily winning an inning; it’s enjoying the game. Your assignment this week is just to check yourself several times a day and notice your coaching style. If you find yourself using a Coach A style, try to switch to a Coach B style. Coach B’s style tells you the truth, saying, “Yeah, you made a mistake,” but it also focuses on what you need to do differently and doesn’t yell at you so that your performance or mood becomes worse.
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Homework
✎ ✎
Have the patient list and monitor assignments in the Homework Practice Log.
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Assign daily use of the RC procedure.
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Have the patient observe her coaching style.
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Have patient read Chapter 10 of the workbook.
Assign interoceptive exposure training a minimum of three times per day. The patient should be instructed to complete exercises that elicit sensations most similar to her panic attack symptoms or withdrawal symptoms. Practice should be recorded in the Symptom Induction Log. Have patient rate symptoms this week using the Medication-Taper Symptom Checklist.
Chapter 8
Session 6
(Corresponds to chapter 11 of the workbook)
Materials Needed ■
Stopping Anxiety Medication workbook
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White board
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Homework Practice Log
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Symptom Induction Log (patients can either use this log or the homework practice log depending on the specificity desired in constructing assignments and rating symptoms)
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Review homework
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Review symptoms associated with medication taper
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Review cognitive errors and use of countering strategies
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Review interoceptive exposure homework and conduct in-session practice
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Introduce interventions for sleeping difficulties
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Assign homework
Outline
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Overview of Session Goals This session continues a focus on transforming the meaning of somatic sensations of anxiety and ending the fear-of-fear cycle. Cognitive restructuring is completed in the context of interoceptive exposure, with the goal of helping patients end anxiogenic responses to symptoms. These skills are also applied to benzodiazepine withdrawal sensations, with review of the benzodiazepine flu model. Home practice of regular symptom inductions with interoceptive exposure is the most important homework. Learning elements for Session 6 are essentially the same as for the previous session: ■
Patients learn comfort with a broader range of sensations and expand their comfort with withdrawal sensations, if present.
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Patients learn about thinking biases more generally, and begin a process of more globally monitoring negative thinking and substituting in more adaptive alternatives.
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Patients continue an orientation toward practicing interoceptive exposure as a strategy to reduce both panic disorder and the aversiveness of benzodiazepine withdrawal sensations.
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Patients use the relaxation cue to reduce bodily tension.
Review of Homework Self-coaching This session is opened with a discussion of the coaching styles (A and B) that were introduced in Session 5. Discuss the patient’s use of these coaching strategies, using specific examples provided by the patient. Be sure to ask which strategy (A or B) the patient used and what effects each strategy had on withdrawal symptoms or anxiety. Point out differences whenever possible. You may want to review Table 8.1 and discuss if the patient has any of these tendencies.
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Table 8.1 Ways to Make Yourself Feel Really Bad If you make a mistake, think about it frequently. Treat even small errors as if they will affect your whole life. Never focus on your own needs and never take time to examine what you really want. If you make one error, think back about all the other times you have made an error. If you have trouble coping with something, assume that you will always have trouble. Call yourself names when you make mistakes. Never think about pleasant events and never take credit for positive changes. Never plan how you could do things differently; just yell at yourself. Believe that you can do better by really making yourself feel bad. Always compare yourself to an unreachable ideal. Do not give yourself credit for improving if you are not yet perfect. Don’t take breaks after you work really hard. Treat yourself worse than you treat everyone else.
Frequently, patients ask about the source of a Coach A style. Explain that this style often develops out of a tendency to try to prevent mistakes (i.e., to be perfect). We learn that mistakes are frequently punished; consequently, we learn to punish ourselves severely in an attempt to avoid mistakes. Emphasize that this strategy tends to make one feel miserable and does not work as well as the straightforward Coach B style. Use the following example as well as others to illustrate the maladaptive nature of too much self-punishment: A poor self-coaching style frequently occurs with panic attacks. Many patients, after having an attack, will become very angry with themselves for having had the attack. They become angry that they have the disorder, they become angry that they let themselves “have” a panic attack, and they become angry that the attack had an impact on their day. In the process of becoming angry, they may continue feeling bad for an hour or two after the attack. This reaction tends to produce many other sensations, such as increased muscle tension and increased irritability, which just exacerbate the problem. Although becoming angry is common and seems to be fairly natural, I encourage you to be aware of this reaction and to try to inhibit it. Adopting a Coach B
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style after an attack is much more adaptive and may decrease the duration of any residual anxiety. Use this example to engender further discussion of coaching styles and their impact. Self-coaching preceding panic attacks should be targeted in detail. Discuss the coaching styles that help bring about anticipatory anxiety or panic episodes, stressing that patients often fall into the habit of coaching themselves into having a panic attack by focusing on anxiety-provoking thoughts such as “I hope I don’t get any more anxious,” “I hope I won’t have a bad time like last time,” or “I hope I won’t get so nervous that I have to run out of the meeting.” Emphasize the cost of this sort of coaching.
Diaphragmatic Breathing, Muscle Relaxation, and RC Techniques Review the patient’s practice of diaphragmatic breathing, muscle relaxation, and RC techniques.
Review of Symptoms Associated With Medication Taper Review the patient’s Medication-Taper Symptom Checklist. Ask the patient to report any sensations caused by the medication taper and his methods of coping with these sensations. Pay particular attention to possible misinterpretations of symptoms, and point out the effects of the misinterpretations to the patient. Ask the patient to describe how he dealt with such misinterpretations. As the patient describes cognitive errors, discuss the role of such thoughts in the fear-of-fear cycle. Review the cognitive coping strategy of the “benzodiazepine flu” and the patient’s efforts to utilize this strategy. Remind the patient that the strategy involves remembering that he coped successfully with fairly severe symptoms when having the flu. Emphasize that individuals typically do not become anxious about these sensations, but simply wait until they get better. Encourage the patient to apply the same strategy to withdrawal symptoms as they occur.
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Review of Cognitive Errors and Use of Countering Strategies Review the concepts of catastrophic thinking and probability overestimation. At this stage, the patient should understand these concepts as well as the relevant countering strategies. Therefore, this discussion should be less didactic than before. Simply encourage the patient to describe his understanding and use of these concepts, and remind the patient that catastrophic thinking refers to the tendency to perceive an event as catastrophic or intolerable when, in fact, it is not. That is, the patient imagines the event to be much worse than it actually is or grossly underestimates his ability to cope with the event if it does occur. Explain that during times of anxiety and panic, individuals with panic disorder tend to focus on the least possible action. For example, when a patient is in the center seat at a movie theater, he focuses most on getting up to leave. While driving on an overpass, the patient may focus most on not being able to escape from the car. One aspect of more effective self-coaching is focusing on all the options that are available, rather than just on the one action that is not possible. Provide the patient with the following example, if relevant: It is fairly common for people who have some fears of driving to focus specifically on one or two things that they cannot do. Namely, a person with this fear may be going along, listening to the radio, enjoying the drive in the car, and then get in a traffic jam. Once the car begins to slow down, this person may start to experience a cognitive imperative to go faster. As the traffic slows even more, this person may begin to focus more and more on moving through traffic and may start to have urges to jump out of the car and to go ahead on foot. Consider the actual differences between the two events of driving along before the traffic jam and being stuck in the traffic jam. There is only one difference: The wheels of the car have stopped moving. The person is still sitting in a nice, comfortable car and still has several responses available. The only change is that the wheels have stopped moving. In fact, it is fairly common for people to become very hurried. They may start drumming their fingers on the steering wheel or edging up very close to the car in front of them. None of these helps the wheels to turn faster; they only serve to make the person feel more miserable.
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Explain that when in this situation the patient may not be sitting comfortably in his car seat, but instead may be, conceptually, pressed up against the front windshield, hurrying the car along. Emphasize that this conceptualizing merely engenders the sensations of anxiety and discomfort. The alternative coping response is to sit back comfortably in the car seat and have as good a time as possible while waiting for the wheels to start moving again. Available responses include turning on the radio and enjoying some music, looking out the window and enjoying the scenery, or thinking about some of the pleasant things to do once arriving at the destination. None of these responses affects how much the wheels move, but they do help the person feel more comfortable. Stress that these alternative responses are not done to distract the patient from the somatic sensations. Instead, the symptoms can be noticed for what they are—body sensations. The patient can then relax with the sensations and allow himself to be become more comfortable in the car despite the presence or absence of the symptoms or the presence or absence of the traffic jam. This example can also be extended to a brief discussion of probability estimations. Recall for the patient that probability estimations refer to the tendency to overestimate the likelihood that a negative event or outcome will occur. Identifying these types of cognitive errors requires the patient to imagine what would happen if a panic attack occurred while he was driving over an overpass or bridge or while seated in the middle of the movie theater. Countering such fears requires an evaluation of the evidence supporting and refuting the identified fears.
Interoceptive Exposure Review of Interoceptive Exposure Homework Collect the Symptom Induction Log and discuss the patient’s interoceptive exposure homework. A useful approach is to have the patient compare the degree of anxiety experienced during these exercises to the level of anxiety experienced during early exposure trials in Session 2. Provide reinforcement to patients reporting decrements in the level of anxiety and inquire about changes that may be related to these decrements. If the patient did not complete the forms or did not complete
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the exercises, encourage him to do so in the future, emphasizing the importance of regular practice. Be sure to inquire about reasons for not completing the exposure and allay concerns if necessary. While reviewing the interoceptive exposure practices, ask the patient whether he decreased the frequency of practices when feeling anxious. Encourage completion of these procedures despite the anxiety since the patient is likely to feel much less anxious after their completion. Encourage patients to treat any taper-related symptoms just like they would sensations from an interoceptive exposure exercise. If they can learn to tolerate the symptoms of taper now, they will be better able to manage future stress symptoms without becoming panicked. (Refer back to Figure 1.3.)
In-Session Practice Ask the patient to identify the interoceptive exposure procedures that are most relevant for him (from the list from Session 5). The patient is to complete at least four trials of each exercise. If no specific procedure is chosen, use head-rolling and hyperventilation procedures. As with previous interoceptive exposure practices, (a) review the specific catastrophic thoughts and probability overestimations; (b) review for the patient the types of sensations to be induced by the exercise; (c) ensure that the patient performs the exercise with enough vigor to induce the sensations; (d) remind the patient to just relax with the sensations and try not to control or otherwise manage them; and (e) encourage the patient to stand up, walk around, and interact with others (if in a group) while experiencing the sensations at their worst. Also encourage the patient to use diaphragmatic breathing, RC, and cognitive countering procedures. This in-session practice should incorporate the following components: ■
Review the symptoms most likely to be experienced during the exposure procedure.
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Review catastrophic thoughts and probability overestimations that have escalated symptoms in the past.
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During one of the exposure exercises, instruct the patient to rehearse these cognitive errors during the exposure process. Have the patient note whether or not anxiety increases due to rehearsal of these cognitive errors and, if so, the consequences of that increase.
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Complete a subsequent exposure trial in which the patient instead utilizes cognitive coping thoughts, such as focusing on what the sensations specifically feel like, remembering having enjoyed these sensations as a child, relaxing with the symptoms without trying to eliminate them, reminding himself that these symptoms are natural, and so on.
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Immediately following at least one of the trials, have the patient stand and move about while still experiencing the sensations.
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For every trial, emphasize that the patient should not try to control the symptoms but, instead, should try to relax and notice what the sensations feel like.
If the patient becomes anxious because of the symptoms elicited, employ the procedures outlined in Appendix B.
Interventions for Sleeping Difficulties Patients may have increased difficulty falling asleep due to the benzodiazepine taper. The following strategies can help patients minimize this difficulty:
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Instruct the patient in the use of relaxation skills for falling asleep. Encourage the patient to use the guided imagery (in Chapter 7 of the workbook) to further increase relaxation as well as the full or abbreviated muscle relaxation procedure.
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Have the patient try practical things that help falling asleep, such as taking a hot shower approximately 2 hours before retiring.
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Suggest that the patient stop all active daily activities at least 1 hour before retiring. This lapse allows time for the mind to “coast” and will help naturally slow down the level of arousal.
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Have the patient remove worry from the bedroom. That is, if he begins to worry while in bed, he should try to allow his thoughts to return to feelings of being comfortable in bed. If worry continues, he may want to leave the bedroom and write down the topics that he is worrying about—these topics are for worry during the day. When the patient feels he can let the topics go, he can return to bed.
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Tell the patient not to “compete” against the clock trying to get to sleep. Competition is arousing. Direct the patient not to watch the clock, but focus on feelings of being comfortable in bed whether he sleeps or not. If he finds himself feeling frustrated, he should get out of bed and read a book or watch television until he feels drowsy.
Homework
✎ ✎ ✎ ✎
✎
Have patient read Chapter 11 of the workbook. Have the patient list all homework assignments in the Homework Practice Log. The Homework Practice Log serves as a reminder of the strategies to apply on a daily basis. The patient should continue application of cognitive self-coaching and cognitive restructuring techniques. Instruct the patient to continue daily interoceptive exposure. If comfortable exposure was not achieved, the same exercise should be repeated during the next week. If comfortable exposure was achieved, a different exercise should be conducted. Remind the patient to conduct three consecutive trials per day. Encourage the patient to view the medication taper as an additional interoceptive exposure experience. The patient should attend to his sensations and rehearse relaxing with them. Although the patient knows the source of the sensations—the medication taper rather than a specific exposure exercise such as head rolling—the aim is for the patient to
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become comfortable with these sensations, rather than trying immediately to eliminate or control them. Also, encourage use of the “benzodiazepine flu” model and cognitive countering strategies. Have the patient rate symptoms using the Medication-Taper Symptom Checklist.
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Encourage the patient to use interventions for sleep difficulties if needed.
Chapter 9
Session 7
(Corresponds to chapter 12 of the workbook)
Materials Needed ■
Stopping Anxiety Medication workbook
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White board
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Homework Practice Log
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Review symptoms associated with medication taper
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Review skills learned to date
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Review focusing on appetitive goals rather than on harm avoidance
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Conduct in-session interoceptive exposure
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Plan for in vivo or naturalistic exposure, or both
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Assign homework
Outline
Overview of Session Goals This session continues a focus on transforming the meaning of somatic sensations of anxiety and on ending the fear-of-fear cycle. A new element of treatment is the integration of interoceptive exposure with in vivo exposure practice. Emphasis in this and subsequent sessions is on helping patients learn comfort with feared sensations, while also
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eliminating other elements of the fear-of-fear cycle (e.g., the tense-up response to symptoms). Learning elements for Session 7 are essentially the same as for the previous session but with the addition of learning safety in avoided situations using in vivo exposure: ■
Patients learn comfort with a broader range of sensations and expand their comfort with withdrawal sensations, if present.
■
Patients learn about thinking biases more generally, and begin a process of more globally monitoring negative thinking and substituting in more adaptive alternatives.
■
Patients continue an orientation toward practicing interoceptive exposure as a strategy to reduce both panic disorder and the aversiveness of benzodiazepine withdrawal sensations.
■
Patients have initial opportunities to extend learning of safety to avoided situations using in vivo exposure.
Review of Symptoms Associated With Medication Taper Review the patient’s Medication-Taper Symptom Checklist. Assess taper sensations experienced and lead a discussion on how the patient coped with these sensations. Pay attention to possible misinterpretations of symptoms, and have the patient describe the countering strategies used. Point out the role that anxiogenic thoughts play in the fear-of-fear cycle. If necessary, help the patient apply the cognitive coping strategies discussed in Sessions 4 and 5. Review the use of the cognitive coping strategy of “benzodiazepine flu.” Encourage its use for coping with withdrawal symptoms as they occur.
Review of Skills Learned Prior to the session, draw the fear-of-fear cycle on the board. During the session, interventions are reviewed and drawn into their place on the fear-of-fear diagram (see Figure 3.5). Each technique for coping with
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anxiety should be reviewed, with particular emphasis on the patient’s use of the technique.
Interoceptive Exposure Remind the patient that the purpose of interoceptive exposure is to break the link between the somatic sensations and the alarm reaction. Ask about the patient’s understanding of the full rationale for interoceptive exposure. The patient should understand that because internal sensations can automatically trigger a panic reaction, a crucial component of treatment is to decrease this automatic fear reaction. One way to do this is to experience the feared sensations repeatedly in a controlled way to help the patient separate the experience of sensations from the anxiety. This controlled repetition engenders extinction. That is, when something is experienced repeatedly, it becomes less fearful. For example, if a novice skier skis only once a year, skiing may remain a fearful experience. In contrast, if that person skis every week, the fear decreases. Remind the patient of the examples of decreased physical sensations (e.g., the lessening of nausea in pilots from flying repeatedly). Remind the patient that because repeated exposure to the sensations is important, she should stop all attempts to minimize or avoid the sensations.
Cognitive Misinterpretations A second focus of treatment has been on the cognitive component of the uh-oh response. The patient has learned to identify fearful thoughts and to rehearse and counter them so that they do not have the power to elicit as much anxiety. This process has included working to become more comfortable with these fearful thoughts by viewing them for what they are: simple ideas that the patient can either respond to with anxiety or ignore. In addition, the patient has learned to evaluate the evidence supporting or refuting anxiety-provoking predictions and to evaluate her ability to cope with certain panic consequences. Remind the patient that she has had training in ignoring the thoughts by practicing having those thoughts while completing the interoceptive exposure exercises.
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The patient has also worked to replace the thoughts with specific coping skills. One aspect of these coping skills is learning to relax with the sensations. The patient has learned to note in detail what the sensations feel like and to do nothing about them. Another cognitive coping strategy is to focus on all the responses that are available. The best example of this strategy is the driving example from Session 6. The patient has practice focusing on all of the available responses rather than on the least possible action. Finally, cognitive techniques have included self-coaching, with emphasis on switching from a critical self-coaching (Coach A) style to a supportive but usefully directive (Coach B) style.
Somatic Responses Emphasis has also been placed on the patient’s inhibiting the hurryup/tense-up/control response by rehearsing attempts to relax with the sensations and by applying cue-controlled relaxation. The patient has also learned to use cue-controlled relaxation as a technique for decreasing more general anticipatory anxiety.
Appetitive Goals Versus Harm Avoidance Discuss with the patient that a panic disorder often leaves the individual chronically worrying about avoiding danger. This tendency is the natural consequence of the panic disorder. For the patient to break the panic cycle, part of treatment must include helping her relearn what is pleasurable rather than only focusing on avoiding harm. Part of this process involves the patient noticing negative self-coaching in daily thinking patterns. The following example extends the previous work on coaching style and is designed to help the patient further develop positive self-coaching. (A different example can be substituted.) We previously discussed the Coach A and Coach B thinking styles. But now I’d like for you to think further about how you coach yourself. Consider this example of coaching hockey. If you were the coach of a hockey team, it would be unusual for you to go into a locker room
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between periods and tell the team that it is fairly unlikely that they will make goals; or remind them that they frequently miss goals; or remind them that, in fact, many of their goal attempts miss by quite a distance; or remind your team that the other team is very tough and that, despite their struggle, the game will not likely go well. You would also not remind the players of their personal shortcomings or ask them to focus on their shortcomings during the game. It would really be out of line for you to remind the players that occasionally they slip and fall on the ice; or to remind them that often they are knocked down by players on the other team; or to remind them that, even with a good record, they will probably lose a quarter of their games. All these things, especially if done by the coach, would sap motivation from the team and make it hard to enjoy the game. Yet, as you might have guessed, this is the very kind of thing that people do to themselves. When planning some sort of pleasant event, like an automobile ride to a park, patients frequently review all the things that may go wrong.
Worry Time Because of their experiences with panic disorder, patients’ thoughts may often center on worries. A frequent focus on worries helps reduce the quality of one’s day and tends to increase anxiety and tension. One strategy for breaking this pattern is to try to save all of one’s worries for a specific “worry time.” Usually, the “worry time” is scheduled for the early evening after work. Have the patient pick a regular time and place for worry. It should be a place outside the bedroom, preferably at a desk in another room. Instruct the patient to keep a pen and pad handy during the “worry time,” and as she worries, to write out her primary concerns, then allow herself to think constructively about her problems. “Worry times” should last approximately 45 minutes and should be followed by the full relaxation procedure. Explain that this method is to be used for recurrent worries, not the typical problems that come up over the course of a day—these should be solved when they arise. In contrast, when recurrent worries come up during the day, patients should save them for their daily “worry time.”
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If patients get a strong urge to worry, they can write out their worry on a piece of paper and save the worry for the designated time. Although it will take a week or two of practice, this procedure can help patients reduce needless worry and improve their problem solving when they do sit down at their “worry desks.” If patients’ use of “worry time” pays off, they may find themselves with less to think about during the day. This extra thinking time can be filled nicely by the next assignment: planning pleasant events.
Planning Pleasant Events Tell the patient that this week you would like for her to focus on stopping negative thinking patterns and instead begin thinking about all the pleasant events that she would like to do. Specifically, ask her to think about the goals that she would like to achieve during the next 3 months. Have her imagine that it is 3 months from the current month and that she is looking back on the last 3 months. The following questions may be helpful: ■
“What sort of memories would you want to fill that time?”
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“What events haven’t you done for a while that would fit nicely into these 3 months (e.g., going to a movie, going to a park, going out to a coffee shop with a friend, or visiting a place or a store that you have not visited for a long time)?”
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“What kind of interactions would you like to have with your children or with your family members?”
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“What kind of interactions would you like to have with your friends?”
Encourage the patient to start planning these events. Inform the patient that it is natural, as she thinks of some of these things she wants to do, to hear warnings in her head: “What about a panic attack there?” “What if I get nervous?” “What if my stomach starts getting upset?” When those kinds of thoughts come up, the patient should remind herself that they are old thoughts, that she need not pay attention to
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them, and that she has learned some skills to react to anxiety very differently from the way she did before. Emphasize that some anxiety is natural when doing something new, but she should go ahead and try these things. To help patients return to an active lifestyle that is focused on having periods of fun rather than just minimizing feelings of anxiety, it is helpful to consider the range of activities that may bring them pleasure. Table 9.1 provides a list of activities that patients may find pleasurable. Because the mood-promoting effects of exercise are powerful, the list begins with physical activities. Any level of exercise is a good start, but over time, for exercise to have its desired effect as a buffer against stress and a promoter of a positive mood, it must be done for 30 minutes a day, 3 days per week. Review the list, and have the patient pick out several activities that she believes would add quality to her life. Have the patient schedule in these activities over the coming month. In considering the list, have the patient think of the variations on themes that may make an activity especially rewarding. For example, going swimming at a local pond instead of the local pool or grilling in a local park instead of one’s backyard may make the activity more memorable. Likewise, little things added to a regular activity—buying one’s favorite childhood candy at the movie theater or fixing a cup of hot chocolate to drink while reading a novel—can transform an experience by evoking past pleasant memories.
Not Being Careful Around Symptoms Tell the patient that, overall, the phrase to remember for the next several weeks is “Do Not Be Careful With Yourself Around Your Symptoms” (write down on the board). Remind the patient that much of the work done in the last several weeks was designed to help her be less careful around the symptoms of panic. Interoceptive exposure exercises have been aimed at helping reduce the degree to which she protects, controls, or tenses up when confronted by these symptoms. Reiterate that often the best way to increase anxiety is to try to prevent it. This struggle keeps the focus on negative events. Instead, the patient is to further
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Table 9.1 Activity List 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
Take daily walks for pleasure Jog (park, track, or gym) Rollerblade Ride a bicycle Go swimming Paddle a canoe or kayak Go fishing in a local stream or pond Go skiing Go ice skating Play tennis Kick around a soccer ball Join a softball league Play volleyball Shoot baskets with a friend Set up a racquetball date Call two friends and go bowling Play with a frisbee Take a kid to mini golf Start a program of weight lifting Take a yoga class
21. Go to an indoor rock climbing center and take a lesson 22. Build a snow fort and have a snowball fight 23. Catch snowflakes in your mouth 24. Sign up for a sculpting class 25. Paint (oils, acrylics, or watercolor) 26. Climb a tree 27. Go for an evening drive 28. Go to a drive-in movie 29. Volunteer to work at a soup kitchen 30. Join a museum Friday night event 31. Play a musical instrument 32. Volunteer to walk dogs for a local animal shelter 33. Play with children 34. Visit a pet shop and look at the animals
35. Sit on a porch swing 36. Go for a hike 37. Go out for an ice cream sundae 38. Rent a garden plot at a local farm or community space 39. Grill dinner in the back yard 40. Read the newspaper in a coffee shop 41. Schedule a kissing only date with your romantic partner 42. Buy flowers for the house 43. Get a massage 44. Reread a book you read in high school or college 45. Bake cookies for a neighbor 46. Have a garage sale (perhaps with a neighbor) 47. Start a program of daily morning sit-ups or push-ups 48. Go to an art museum and find one piece you really like
49. Buy a magazine on a topic you know nothing about 50. Repaint a table or a shelf 51. Go to a diner for breakfast 52. Plan an affordable 3-day vacation 53. Start a collection of heart-shaped rocks 54. Woodworking—build a table or a chair 55. Take a dance class 56. Learn to fold dollar bills into origami creatures 57. Learn to juggle 58. Go to a concert 59. Organize a weekly game of cribbage or bridge 60. Plan a drive in the country 61. Buy a cookbook and make three new meals 62. Rent a video, make popcorn, and invite friends over
rehearse not being careful with herself with the interoceptive exposure procedures. Therefore, during this session, you want the patient to do all the exercises with vigor in an effort to really maximize the intensity of the sensations.
Interoceptive Exposure Procedures Review of Homework Collect the Symptom Induction Log. In reviewing the interoceptive exposure homework, ask whether the use of interoceptive exposures was decreased at times of anxiety. Encourage the patient to complete the exercise, despite anxiety during the day. Remind the patient of the benefits. In fact, tell the patient that such times are best for practicing the exercises because many patients feel much less anxious after completing the interoceptive exposure procedure. This reaction occurs because patients prove to themselves that they can tolerate the feared sensations and because the need to worry about these sensations during the rest of the day is decreased. Interoceptive exposure exercises also provide them with opportunities to rehearse their coping skills.
In-Session Practice of Interoceptive Exposure Primary interoceptive exposure procedures to be completed during the session are (a) hyperventilation for 1 minute, (b) head rolling for 45 seconds, (c) stair running or jogging in place, and (d) mirror staring or hand staring to induce derealization or depersonalization, if necessary. The patient is to complete several trials of the most relevant exercises. If no specific procedures are especially relevant for the patient, use head rolling (or spinning in a chair for stronger sensations) and hyperventilation. In addition to these procedures, two of the alternate exercises that
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most closely approximate the patient’s symptoms are to be completed. These can include throat tightness for 30–60 seconds by tightening a necktie or by preventing swallowing, tube breathing for 2 minutes, spinning in a chair for 1 minute, and so on. As with previous interoceptive exposure practice, review the specific anxiogenic thoughts; review the types of sensations to be induced by the exercise; ensure that the patient completes the exercise with enough vigor to induce the sensations; remind the patient to try to relax with the sensations rather than trying to control them; and encourage the patient to stand, walk around, and interact with others while experiencing the sensations at their worst.
In Vivo or Naturalistic Exposure In vivo or naturalistic exposure can help patients decrease avoidance and generalize learned skills. Encourage patients to expose themselves to feared, naturally occurring situations or activities that induce panic-like sensations. Present the following rationale: This week, along with using physical exercises to induce sensations, I want you to use your environment. In the previous sessions, you used physical exercises to induce somatic sensations. This week, I would like for you to expose yourself to situations and activities that used to induce panic sensations. These situations might involve the subway, heights, exercise, caffeine, etc. One purpose of these exposure exercises is to provide you with opportunities to practice applying your newly learned skills to more naturally occurring anxiety and panic. If the sensations occur, try to react to them just as you have rehearsed here. You should also approach the exposure just as you do here. That is, review the sensations that you might experience, treat them as no big deal, and go into the procedure feeling confident. Try to pay particular attention to thoughts, as well, and counter maladaptive thoughts whenever possible. Help the patient identify an activity or situation that she would like to target during the week. The activity or situation should be one that the patient avoids fairly regularly and that elicits moderate levels of anxiety
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(the goal is for patients to complete the exposure). Again, ensure that the patient does not choose the most feared activity or situation. If possible, this exercise should be completed about three times. The exposure practices should be conducted before the next session.
Homework
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Have patient read Chapter 12 of the workbook. Have patient list and monitor the assignments in the Homework Practice Log. Assign daily interoceptive exposure, incorporating at least two exercises and three consecutive trials of each exercise. Have patient complete an in vivo or naturalistic exposure three times during the week and to apply cognitive and somatic skills to manage any anxiety. Have patient rate symptoms using the Medication-Taper Symptom Checklist.
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Chapter 10 Session 8
(Corresponds to chapter 13 of the workbook)
Materials Needed ■
Stopping Anxiety Medication workbook
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White board
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Homework Practice Log
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Review symptoms associated with medication taper
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Review in vivo and naturalistic exposure
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Discuss agoraphobic avoidance
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Conduct generalization training
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Assign homework
Outline
Overview of Session Goals This session continues a focus on transforming the meaning of somatic sensations of anxiety and ending the fear-of-fear cycle. The integration of interoceptive exposure with in vivo exposure practice continues in this session. Emphasis in this and subsequent sessions is on helping patients learn comfort with feared sensations across situations.
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Learning elements for Session 8 are essentially the same as for the previous session: ■
Patients learn comfort with a broader range of sensations and expand their comfort with withdrawal sensations, if present.
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Patients learn about thinking biases more generally and begin a process of more globally monitoring negative thinking and substituting in more adaptive alternatives.
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Patients continue an orientation toward practicing interoceptive exposure as a strategy to reduce both panic disorder and the aversiveness of benzodiazepine withdrawal sensations.
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Patients have opportunities to extend learning of safety to avoided situations using in vivo exposure and have initial practice directing their own therapy.
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Patients practice focusing on pleasant events rather than harm avoidance.
Review of Symptoms Associated With Medication Taper Review the patient’s Medication-Taper Symptom Checklist. Assess taper sensations the patient experienced and discuss methods used to cope with those sensations. Pay attention to possible misinterpretations of symptoms and ask the patient to describe the countering strategies used. Be sure to point out the role that anxiogenic thoughts play in the fearof-fear cycle. If necessary, help the patient apply the cognitive coping strategies discussed in previous sessions. As needed, review use of the cognitive coping strategy of “benzodiazepine flu.” Encourage the patient to use this strategy for coping with withdrawal symptoms as they occur. As needed, review the application of diaphragmatic breathing, progressive muscle relaxation, and sleep-difficulty interventions in the context of discontinuation symptoms or anxiogenic reactions to other somatic sensations. At this point in the treatment, emphasis should be placed on eliciting appropriate treatment interventions directly from the patient.
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Ask the patient to (a) identify strategies that may be helpful for a problem under discussion, (b) identify successful strategies used in previous weeks or used by friends experiencing anxiety or stress, or (c) identify the part of the fear-of-fear cycle that is most relevant to the problem being discussed. (The previous session reviewed the individual interventions available for each aspect of the cycle; hence, the patient may be better able to identify treatment alternatives using this approach.)
Review of In Vivo and Naturalistic Exposure As a method of decreasing avoidance and generalizing skills, the patient was asked to expose himself to feared, naturally occurring situations or activities that induce anxiety sensations. Review the rationale before reviewing the patient’s progress on this assignment: Last week, in addition to using physical exercises like head rolling to induce somatic sensations, I asked you to expose yourself to situations and activities that used to induce panic sensations. If the sensations occurred, you were to react to them just as you have rehearsed here. I also asked you to approach this exposure just as you have done with the interoceptive exposure exercises completed in session. You were to review the sensations that you might experience, treat them as no big deal, review possible coping strategies, and go into the exposure feeling confident. Review with the patient how he conducted the exposures. During this review, the goal is to help the patient better identify problem-solving strategies. To accomplish this goal, relate any difficulties to the fearof-fear cycle written on the board (see Figure 3.4) and discuss the appropriate interventions, if any, that may aid the patient. Stress that the patient should not have expected to complete the exposure without anxiety the first time—that some anxiety is expected and natural. Also point out that although the patient was anxious, nothing (i.e., no dire consequences) happened. Indeed, this realization is one function of the exposure. Also focus on the reasonable progress made by the patient during initial attempts and ensure that he understands procedures for
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continuing this progress over the next several weeks. This process is the start of helping patients view themselves as their own therapists and is a prelude to the next intervention.
Agoraphobic Avoidance Agoraphobic avoidance is the avoidance of situations associated with panic attacks or from which escape would be difficult if an attack occurred. Explain that generally the fear of symptoms is at the heart of agoraphobia. In recent sessions, the patient has shown that he can manage anxiety symptoms with less or no medication, and that these symptoms do not have the same capacity to trigger the alarm response. Situational exposure was then used to further master this skill. Situational (in vivo/naturalistic) exposure provides the patient with a chance to learn that he can manage symptoms, even if they occur in one of his phobic situations. To complete this knowledge, the patient will need to continue building on his previous practice in a step-by-step fashion. During this stage, it continues to be important to help the patient identify positive goals for situational exposures. That is, rather than setting out to simply reduce anxiety in avoided situations, help the patient consider the pleasant events that he wants to achieve in once-avoided situations. For example, rather than having a goal to go to the mall for 30 minutes to reduce anxiety, help the patient establish a vision of what can be achieved at the mall (what shopping, purchases, or sights, sounds, events would lead to pleasure at the mall). In all cases, patients should plan to anticipate or induce symptoms during these exposures; the goal is to achieve pleasure and goals in these situations despite the presence of symptoms. In the previous session, the patient was asked to increase focus on pleasant events and to substitute positive planning for “What if . . . ?” preparations for difficulties. Review the patient’s application of this intervention. As necessary, discuss these attempts in the context of the following information.
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Breaking Down Fears Into Component Parts If the patient has difficulties with specific situational activities, help him break the assignment into component parts, emphasizing completion of interoceptive exposure in each component part. The goal is to help him realize that he can tolerate the symptoms in situations that are increasingly similar to his top avoided situations. For example, if the patient were phobic of driving in traffic on the expressway, he would first start with symptom induction at home, then in his car in his driveway, then in his car while parked some distance from home, and then in his car prior to driving. The patient both learns to be comfortable with symptoms in a range of contexts, and learns, in a stepwise fashion, to drive and focus on the road appropriately despite the presence of symptoms.
Expecting Danger Discuss with the patient the role that expecting danger plays in increasing anxiety. Expectation of danger is the essential cognitive component of anxiety, and the natural bodily response is increased sensations of anxiety. Close this discussion with a more general focus on whether or not the patient was overly careful with himself. This discussion is a review of last week’s assignment, “Do Not Be Careful With Yourself Around Your Symptoms.” Explain that being overly careful is another way of preparing for difficulties, and remind the patient that an excellent way to increase anxiety is to try to protect oneself from symptoms. This self-protection keeps a person’s focus on negative events.
Generalization Training The completion of the interoceptive exposure procedures in naturally occurring situations, as well as the problem solving of other anxiety difficulties, has increasingly placed the patient in the therapist role. The next intervention is designed to formalize this process.
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Tell the patient that as this is the last of the weekly sessions, you would like to discuss some of the changes that he has been making. Over the course of this treatment, a great amount of information has been presented, all of which has focused specifically on the fear-of-fear cycle and alternatives to this cycle. The principles have been fairly straightforward: ■
Learn to understand the fear-of-fear cycle and its consequences.
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Work to inhibit the anxiogenic effects of cognitive misinterpretations.
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Learn to become more tolerant of bodily sensations of anxiety so that you do not react fearfully to these sensations.
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Apply these skills to taper-related sensations.
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Increase your ability to coach yourself effectively.
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Be wary of the effects of trying to be careful with yourself.
The following approach may be helpful in this review: I think of this stage of treatment as pretraining. Over the course of the following weeks, you will start to make these interventions second nature. Recovery can be viewed as a process that continues long after you discontinue formal treatment. I would like to tell you about some general findings about psychotherapy treatment. In many psychotherapy books (not specifically behavior therapy), there is some discussion about the changes patients go through and their decision to stop treatment successfully. When asked why they decided to stop treatment, the most common response from patients is “Well, what my therapist used to say to me, I now say to myself.” This response suggests that the patients have learned to do their own therapy. It is not that they stopped treatment and did not apply what they learned. Instead, they learned to apply the “method” of therapy themselves. In that way, they never stopped treatment; they simply do it themselves. We have the same sort of goal for this program. You have learned a great amount of information, and, many times during the last several sessions, you probably found yourself anticipating what I was going to say. In fact, during the last three sessions, you have been playing the role of the therapist in leading yourself through the interoceptive exposure exercises.
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Tell the patient that in the next several weeks, we want to formalize this process. Three booster sessions are scheduled for 2-, 3-, and 4-week intervals. Nonetheless, throughout this time, the patient will continue to apply daily the skills he has learned in therapy. Recommend that the patient continue with formal weekly sessions on his own to ensure that his progress continues. In these sessions, the patient will do exactly what was done in therapy: Review progress, identify difficulties, practice individual interventions, and develop a plan about what needs to be done in the next week. The only difference is that the patient will do these things alone at home. For the next week, ask the patient to hold a session at the same time of day as his usual therapy appointment. The following week, during the booster session, you will act as the supervisor of the patient acting as the therapist. You will turn your attention to helping the patient perfect his abilities as a behavior therapist for panic disorder and anxiety. After discussion of this material, four additional points should be stressed: 1.
Remind the patient of the difference between panic disorder and everyday anxiety. Emphasize that the goal of treatment is not to stop all anxiety. Everyone feels anxiety occasionally. Anxiety is a natural reaction to stressful situations that everyone experiences (e.g., during small arguments in relationships or thinking of a difficult interaction at work). Part of the difficulty of panic disorder is that it teaches fear of anxiety, even fear of normal anxiety. The goal of treatment is, in part, to help the patient become comfortable again with normal anxiety.
2.
Progress occurs in a step-by-step manner, and the patient should allow himself the freedom to proceed at a reasonable rate. Also, progress does not always occur smoothly but, more commonly, involves many ups and downs. However, over time, the expectation is that the “ups” will become longer and the “downs” will become shorter.
3.
Review the interventions used thus far and encourage the patient to review and decide on the skills that he should apply during the next week.
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4.
Remind the patient that, despite the fading of regular behavior therapy, he will continue visits with a prescribing physician or other mental health professional to review taper symptoms and to continue the taper process as needed (e.g., as determined by the patient’s starting dose).
Homework
✎ ✎ ✎ ✎ ✎
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Have patient read Chapter 13 of the workbook. Assign daily interoceptive exposure, incorporating at least two exercises, if necessary. Have the patient continue exposure to avoided situations and activities and naturalistic exposure. Be sure to help the patient identify those that would be appropriate for practice. Assign the continued use of self-therapy sessions during weeks when the patient does not come in for a booster session. Have the patient rate symptoms this week using the Medication-Taper Symptom Checklist.
Chapter 11 Booster Sessions: Sessions 9–11
(Corresponds to chapter 14 of the workbook)
Materials Needed ■
Stopping Anxiety Medication workbook
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White board
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Homework Practice Log
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Review medication taper symptoms
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Review treatment progress
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Review specific topics: catastrophic thoughts and probability overestimations, in vivo and naturalistic exposure versus interoceptive exposure, and somatic coping skills
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Continue with generalization training
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Assign homework
Outline
Overview of Session Goals At this point in the benzodiazepine taper program, patients have been provided with a model of panic disorder and with the skills necessary for controlling the occurrence and escalation of somatic sensations of anxiety. Patients are well along in the discontinuation process, or they have completed their benzodiazepine discontinuation. The goals for this
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stage of treatment are (a) patients’ continued application of therapy skills to their discontinuation difficulties and (b) extension of their therapy skills to ensure their success in maintaining a panic-free status over the long term. The strategies for patients to use at this stage of treatment are (a) applying interoceptive exposure procedures in a more naturalistic manner (e.g., inducing somatic sensations once associated with anxiety through everyday activities such as running upstairs, drinking caffeinated beverages, or exposure to once-phobic situations), and (b) discriminating behavior patterns associated with the fear-of-fear cycle and applying alternative responses at an early stage in the process. Examples of these behavior patterns include the following:
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Use of diaphragmatic breathing or muscle relaxation techniques to prevent a dire consequence rather than to lessen the degree of physical sensations experienced. Implicit in an attempt to prevent a dire consequence is the assumption that somatic sensations herald a catastrophic event.
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Use of subtle avoidance while attempting to practice anxiety-provoking tasks. This pattern may include use of distraction techniques or a tendency to hurry through a feared task. In terms of the fear-of-fear cycle originally drawn on the board, this reaction is a return of the hurry-up/tense-up/control response. The alternative response is passively noting the somatic sensations for what they are and doing nothing about them.
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Active avoidance of physical sensations or anxiety-provoking situations. Patients may report a very high level of bodily self-awareness, avoiding activities that were identified as targets for in vivo exposure, or avoiding activities that would elicit physical sensations, such as exercise. These tendencies point to a return of the fear-of-fear cycle and indicate the need for reassignment of specific PCT strategies such as interoceptive exposure and cognitive restructuring.
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Increased “fearful beliefs” about symptoms or pessimistic assumptions about the ability to cope. This pattern may include patients’ assumptions that they had been “lucky” during previous stages of
treatment and must, therefore, be careful to avoid recuing of panic attack patterns. This pattern may include the assumption that the panic disorder is “lying in wait.” The corollary to these assumptions is that no real skills or alternative responses to the fear-of-fear cycle have been learned or that these kinds of responses cannot lead to long-term change in panic or anxiety patterns. Relevant interventions are the identification of these assumptions as part of the pessimistic, catastrophic thinking in the fear-of-fear cycle itself and the application of cognitive interventions for these thoughts. Some patients who have been taking high doses of benzodiazepines for a prolonged period of time may have more protracted discontinuation symptoms and may, therefore, need at least a brief review of medicationtaper symptoms in every booster session. Because the fear-of-fear cycle is discussed in Sessions 9–11, it should be drawn on the board prior to each session (see Figure 3.4).
Review of Medication Taper Symptoms Review the patient’s Medication-Taper Symptom Checklist. Regardless of whether the patient is continuing with or has completed the taper schedule, continue to encourage the patient to practice skills for successfully managing anxiety or panic. Difficulty with this particular taper attempt does not mean that subsequent taper attempts (in the next week, month, or year) will not be successful. This point should be discussed in session, along with appropriate encouragement to practice skills and to continue the taper process as soon as the patient and her monitoring physician deem it appropriate. The discussion of the patient’s experiences with medication taper symptoms should include assessment of current interpretations of symptoms, identification of catastrophic or pessimistic patterns, and examination of these thoughts in terms of the fear-of-fear cycle. Corresponding cognitive coping strategies, as discussed in previous sessions, should be reviewed. Each booster session should also include a brief review of the “benzodiazepine flu” cognitive coping style, for two reasons. For
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some patients, this intervention is directly relevant because they are still experiencing discontinuation symptoms. For other patients, this discussion provides a review of a successfully used coping strategy and consolidation of skills if necessary for later application. Presumably, symptoms will arise in the future as part of episodes of stress, physical illness, or other random events, and the goal for these patients is to remember that they utilized an effective strategy for interpreting and coping with similar somatic symptoms (at least as cued by medication taper). Discussion of taper difficulties should also include a review of the application of diaphragmatic breathing, progressive muscle relaxation, and sleep-difficulty interventions in relation to the discontinuation symptoms or anxiogenic reactions to other somatic sensations. During these discussions, emphasis should be placed on eliciting appropriate treatment interventions from the patients and on reviewing their application.
Review of Treatment Progress In the booster phase, patients are placed in a position of greater responsibility for their own treatment, including specific assignments of reviewing their progress in weekly home sessions. This idea was introduced in Session 8, when patients were asked to complete formal weekly home sessions in which they reviewed their progress, identified difficulties, practiced individual interventions, and developed a plan about what needed to be accomplished over the next week. In the session that followed, you assumed the role of acting as the supervisor of the patient-therapist. The review of progress should include discussion of this model. Ask patients how they guided their own treatment. Patients should be asked to provide a brief synopsis of the difficulties encountered and the strategies used to overcome them. To help patients assume a useful therapeutic attitude toward themselves and any remaining symptoms, have them report successes and difficulties with treatment from a third-person perspective. That is, patients report what went well during their treatment of the patient, what did not go well, the specific problems the patient had and the likely source of these problems,
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and what they recommend to help the patient eliminate these problems. As patients describe any difficulties in applying the strategies, pay particular attention to attempts to control symptoms as though they were trying to prevent a dire consequence. Any tendency toward this reaction should be identified and discussed in the context of the fearof-fear cycle. In addition to identifying specific difficulties, you should support and encourage patients’ attempts at being their own therapist. In particular, acknowledge any successful problem-solving attempts made by the patients, as in the following examples: ■
That’s great. You were able to identify the hurry-up/tense-up/control response and apply the relaxation skill when you needed to. That’s fantastic.
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It sounds like you were able to notice that you were thinking more catastrophically; you identified the distortion in your idea, and you coached yourself effectively through that episode. Great.
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It sounds like you were having some fairly strong discontinuation symptoms, but you viewed them in terms of a flu and were able to tolerate them. Your reaction is a clear improvement in your ability to tolerate symptoms, and that is going to be quite valuable to you in the future when symptoms due to other events such as stress arise. When these symptoms occur, if you apply the same skills you used during this last week, you should have a much more comfortable time going through a period of stress and anxiety. That’s great.
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You did have a panic attack, but apparently you were immediately able to apply some of your new skills, so that the panic episode did not last more than a few minutes. Also, fairly soon afterward, you felt much more comfortable and did not have problems for the rest of the day. That sounds like a clear improvement.
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I like the way you went ahead and went jogging even though you were feeling nervous. Also, I think it’s very important that you noticed somatic sensations while jogging but were able to interpret them appropriately. That is an important skill. I’d like you to keep practicing that.
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This is the first time you have reported taking the subway and thinking about where you were going and the fun you were going to have rather than attending to how long it was between each stop or what body sensations you were having. Clearly you didn’t try to ignore any body sensations, and that’s good. You just let your body feel however it wanted to feel and you kept thinking about what you wanted to accomplish during the day. That sounds great.
Specific Review Topics In addition to medication taper symptoms and treatment progress (with special attention to the patient assuming the role of self-therapist and using self-guidance), each booster session should include a review of the following specific topics.
Catastrophic Thoughts and Probability Overestimations During the booster sessions, continue to provide a review of any cognitive errors that may arise. During this phase, some patients may experience increasing fears that the panic attacks may return. Directly address (e.g., write on the board the fear-of-fear cycle diagram) these pessimistic expectations and specific catastrophic thoughts, such as, “It’s all coming back,” “I can’t do this by myself,” “What if something happens now that I’m off medications,” “Maybe I should be careful now that I’m off medications,” “Maybe I shouldn’t do too many things. What if I get a really bad attack now that I’m off medications; I will be right back where I started.” Specific interventions, such as cognitive countering procedures, should be reviewed, with the goal of helping patients not to attend emotionally to their catastrophic thoughts. In particular, remind patients to regard these thoughts as hypotheses rather than as facts and to remember that these thoughts may be negatively biased when they are anxious. Have patients recall that this reaction is part of the phenomenology of anxiety—anxiety has the effect of making an individual more vigilant to potential danger. Thus, when
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anxious, individuals are more likely to overinterpret the dangerousness of events. During every session, remind patients to evaluate how they are coaching themselves. The coaching analogy, to this point, has been applied directly to panic sensations, general anxiety sensations, reactions to panic episodes, interpretations of daily events, and, more generally, a focus on appetitive events rather than on harm avoidance. Encourage patients to continue evaluation of their self-coaching behaviors and to describe further progress.
In Vivo and Naturalistic Exposure Versus Interoceptive Exposure In Sessions 7 and 8, patients were encouraged to substitute exposure to phobic situations for some of the interoceptive exposure procedures. Patients were to expose themselves to situations that had previously induced anxiety or panic sensations (e.g., subways, heights, and closed spaces). If panic-like sensations arose, patients were to react to these sensations just as they had rehearsed in session and at home with the interoceptive exposure procedures. Spend time during each booster session reviewing this assignment. The goal of this review is to help patients better identify problem-solving strategies. To this end, relate any difficulties experienced to the fear-of-fear cycle written on the board, and discuss appropriate interventions. As always, remind patients that there is no expectation to complete the exposure well the first time and that some anxiety is expected and natural. If anxiety did emerge during the exposure, emphasize the fact that the feared panic or anxiety consequences did not occur. The discussion should also focus on the reasonable progress patients made during the initial and subsequent attempts. During Sessions 9–11, patients are further exposed to the notion of naturalistic exposure. Naturalistic exposure refers to the extension of interoceptive exposure procedures to daily events. Rather than setting aside specific times to complete one of the formal interoceptive exposure procedures, patients are encouraged to induce sensations as part of regular daily events. Such daily events include the following examples.
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Running Up a Set of Stairs
Before running up the stairs, patients should review the sensations that they are likely to experience and how they might have interpreted these sensations catastrophically in the past. Encourage patients to allow themselves to experience these sensations comfortably. Patients should then sprint up the stairs and note the sensations experienced as they continue on with their daily activities.
Exercise
Exercise provides an excellent method for inducing number of somatic sensations. Encourage patients to return to any avoided physical exercises. For those patients starting new exercises, encourage them to start slowly and reasonably. In addition to the rapid heart rate, sweating, and, perhaps, light-headedness that may occur as part of any aerobic exercise, patients can also experience specific sensations of dizziness from sit-ups or back extensions. Certain athletic equipment may have specific sit-up or backbend chairs that provide for greater movement of the head during sit-up or back-extension exercises and, hence, should be discussed as a possible means of inducing sensations as part of regular fitness activities. Therapist Note
Be aware that, at times, patients may try to complete physical exercises while overcontrolling the breathing rate. If patients report difficulties during exercises such as running, assess whether or not they are trying to limit their breathing exclusively to either diaphragmatic breathing or breathing through the nose, when clearly neither is reasonable given the vigor of the physical activity. ■ ■
Caffeine Intake
Patients may also induce sensations by using caffeine. Whereas it is important not to encourage a return to chronically high levels of caffeine
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intake (for reasons of general health), if no contraindications are present, patients can be encouraged to use limited caffeine intake as an exposure exercise. Caution patients that for several hours after consuming caffeine, they may experience sensations of arousal. These sensations may include sweating, muscle tension, mildly speeding thoughts, or mild heart palpitations. For this exercise in particular, encourage patients to try not to control or stop the sensations but, instead, to recognize what they are and to tolerate them.
Household Chores
Patients completing routine household chores, such as vacuuming or picking up clothes or other items from the floor, may use body movements to create somatic sensations. Namely, patients can bend over and straighten up rapidly during each movement of picking up clothes, or they can overemphasize movements while vacuuming so that they are “bobbing.” These movements approximate some of the movements of the head-rolling procedures.
Difficult Situations
Any exposure to difficult situations (e.g., heights, blood draws, traffic jams, and conflicts with others) should be viewed as an exposure exercise and should provide patients with an opportunity to rehearse appropriate coping skills while noting the body sensations that are evoked at these times. Assign and review these naturalistic exposure exercises during each of the booster sessions. Again, the goal is the patient becoming comfortable with any somatic sensations that may arise. Reaching this level of comfort takes abundant practice, and the naturalistic exposure exercises help patients incorporate regular practice into their daily lives. For all these procedures, describe the importance of full exposure to feared situations. Emphasize that exposure to these sensations must occur without avoidance or distraction in order for the practices to be helpful.
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Somatic Coping Skills Review the slow-breathing and diaphragmatic breathing procedures and their rationale. The rationale should include reduced discrimination between preventing a dire consequence versus dampening physiological sensations. During these booster sessions, routinely note how patients are breathing. Spontaneously note when patients are using chest breaths rather than diaphragmatic breathing and encourage them to switch to comfortable, slow, diaphragmatic breaths. During each booster session, review the use of the RC procedure. In order for patients to remain adept at this procedure, they should be completing the full relaxation procedure at least once a week during Sessions 9 and 10 and at least once every 2 weeks thereafter. Encourage patients to use the RC procedure whenever leaving a particular situation (e.g., leaving work). This strategy is designed to help patients remember to use the cue regularly and to “shut the door on work” by letting go of tension through the procedure. Patients may also be reminded to use the RC procedure when hanging up the telephone or closing a car door. Again, this is a reminder to help patients apply the RC procedure on a regular basis and to continue to be aware of ways in which they hold tension in their muscles. Review of interoceptive exposure procedures should be completed during every session. Review patients’ use of interoceptive exposure procedures and conduct additional exposure procedures. Patients should complete at least two exposure exercises per session. In the case of group treatment, encourage patients to pair off and lead each other through these procedures. Patients should choose the procedures that have given them the most difficulty during the preceding week. The therapist’s role is to observe the procedures used and to provide corrective feedback as needed.
Generalization Training In many ways, the goal of Sessions 9–11 is generalization training. But, in each session, the therapist should draw specific attention to the generalization material presented in Session 8. Specific emphasis should be
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placed on the notion that patients have learned skills during treatment, and as with any skill, patients must practice these procedures regularly. Caution patients against the strategy of “leaving well enough alone” and remind them that this is a form of avoidance. Patients should conduct weekly review sessions and guide their own treatment. Patients should remember that there will likely be times when they are anxious or stressed or panicky. Patients should be cautioned to not construe these events as indications that they are relapsing or that their skills do not work. Instead, they should view these events as natural consequences of stress and as opportunities to practice the skills that they have learned.
Session 9 Overview: Session 9 Session 9 is the first session that is not conducted on a weekly basis, and, hence, extra attention should be paid to ensuring that patients have continued regular practice of their skills over the 2-week interval. This includes individual review of anxiety and panic difficulties and identification of PCT strategies that need to be practiced. This session is the first attempt to reinforce individual practice, and extra time should be devoted to a discussion of the importance of regular practice, regular review of symptomatology, and inhibition of old patterns. In this discussion, the therapist assumes the role of a supervisor of the patient’s self-treatment. The therapist should specifically elicit and encourage self-monitoring and the use of appropriate PCT self-management strategies. Session 9 also occurs when patients may still be completing medication taper or have just finished the taper. As a result, more attention is given to review of taper sensations for these patients. Some patients may also be in the initial stages of being medication free, and attention should be placed on helping them avoid anxiogenic misinterpretations of any anxiety sensations that are present. In particular, discuss tendencies to be hypervigilant to sensations and to misinterpret the meaning of individual anxiety or panic episodes. This session should close with specific discussion of the generalization training material and assignment of continued practice of all skills.
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Homework: Session 9
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Have patient read Chapter 14 of the workbook. Assign daily practice of at least one formal interoceptive exposure, physical exercise, and regular practice of naturalistic exposure to exercises. Assign exposure to phobic situations, if the patient is having difficulty with certain situations. Have the patient increase appetitive events. This assignment may include aspects of naturalistic exposure, because the patient should be encouraged to do things that she has not done for some time, such as attending social events; going on day trips; visiting places, such as museums or theaters, where escape may be restricted. Assign continued practice of the RC procedure. Also remind the patient to use environmental cues (e.g., when hanging up the phone, getting into the car, or closing doors) as reminders for using the RC procedure. Discuss with the patient the importance of regular self-monitoring, and assign additional self-monitoring. Discuss the date of the next follow-up session, again emphasizing regular practice. Remind the patient that you will play the role of therapy supervisor and that the patient is responsible for guiding her own treatment during this period.
Session 10 Overview: Session 10 By this session, patients should have discontinued medication (unless they started on a very high dose or were not able to discontinue), and the goal is to help patients maintain this medication-free status. Specific attention is given to identifying a return of the fear-of-fear cycle and to helping patients identify aspects of this cycle that may be present. Specific attention is also given to the tendencies of patients to be careful with themselves and not to practice the symptom induction
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procedures. This session should include a specific review of the importance of regular practice and encouragement for patients to guide their own treatment. Much more of the session content will include patients’ review of their symptoms and the problem-solving strategies they have used to control symptoms. Discuss problems that may arise for patients who may be trying to eliminate anxiety rather than trying to decrease the intensity of anxiety symptoms.
Homework: Session 10
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Have patient review Chapter 14 of the workbook. Assign daily practice of at least one formal interoceptive exposure, physical exercise, and regular practice of naturalistic exposure to exercises. Assign exposure to phobic situations, if the patient is having difficulty with certain situations. Emphasize the patient’s use of all coping strategies. Overall, the greatest emphasis should be placed on the patient viewing herself as the therapist and continuing a very active program during the next 4 weeks or more.
Session 11 For this last session, one of the goals is patients’ development of a model for the future. Ask the patients to review how they have changed during the course of the program. In particular, elicit the primary changes that they have achieved. These may be specific only to certain aspects of the fear-of-fear cycle. Some patients might have made the greatest change following interoceptive exposure procedures; other patients might have attributed the greatest change to different cognitive reactions to the somatic sensations (as a result of both the cognitive interventions and the interoceptive exposure procedures). The patients’ successes with the medication taper should also be treated as a model for symptom management in the future. Identify all the successful changes that have been observed during the sessions, providing specific examples for each patient if possible. Emphasize that this skill acquisition is a model for
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the future and that the patients should continue to guide their own behavior therapy. In addition, present the following information: When patients are in a group or individual treatment like this that offers active treatment elements, the therapist often sees an improvement over time in a stepwise manner across the weeks of the sessions. When the number of sessions decreases or the treatment ends, patients sometimes have a tendency to interpret negatively any changes in symptomatology that may occur. Patients may have some negative thoughts such as “Oh my gosh, it didn’t work” or “I blew it, it’s all coming back.” Let patients know that a downturn is fairly natural. It is perfectly reasonable for someone to have a slight downturn either because of the loss of support of coming to therapy or just because of a momentary increase in stress. What is important for patients to remember at this stage is that this downturn is not a sign that the treatment interventions did not work. Instead, it is just a sign that now is the time to apply the coping skills. When patients see it as a signal to apply coping skills, they do not worsen as they might have feared. Instead, they continue in a pattern of having ups and downs, with every downturn simply being another signal to continue to apply their coping skills. Ask patients to remember this for the next several weeks. Review expectations following the end of treatment. Close the session by once again emphasizing the importance of practice and by briefly sharing with each patient what it was like to work with her. Remind patients that homework does not end with treatment; instead self-treatment becomes such a regular part of patients’ lives that they are, in essence, completing homework.
End of Treatment To help patients complete their transition to managing their own treatment, the workbook provides an intervention checklist. This form is designed to remind patients of some of the basic symptom patterns in panic disorder and some of the relevant interventions for these patterns. A review sheet is also included at the end of the last workbook chapter to help patients review their symptoms at 1, 3, 6, 9, and 12 months after
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the last therapy session. Recommend that patients photocopy this sheet and write in the dates for these reviews, and then hold a session with themselves at the appointed date. This brief review of symptoms and methods, accompanied by rereading relevant sections of the workbook, should help them maintain and extend their treatment gains. Let patients know that if they have increased difficulties with anxiety that are hard to manage, they can give you a call. Emphasize that difficulties with anxiety do not signal a need for return to medication. Patients may just need a booster session for a brief tune-up of their skills.
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Appendix A Response to Relaxation-Induced Anxiety
To help prevent relaxation-induced anxiety, prepare the patient for the sensations that he may feel and explain that these sensations, if they occur, are additional signs of successful relaxation. This preparation helps prevent anxiogenic misinterpretations and reactions to these sensations (e.g., “I shouldn’t feel heavy; something is wrong!” “I feel odd; I may be losing control”). Generally these simple introductory interventions are sufficient to prevent significant anxiety reactions to the sensations associated with successful use of the progressive muscle relaxation procedures. However, if muscle relaxation induces anxiety despite this preparation, the therapist should use the following intervention. Have the patient describe the sensations that led to an uncomfortable feeling. Discuss the genesis of these sensations in terms of relaxation effects (e.g., warmth or tingling produced by changes in the blood flow to the skin, heaviness due to decreases in muscle tension, and occasionally strong heartbeats associated with adjustments to changes in blood flow). Discuss these sensations as signs of successful relaxation and encourage the patient to reinterpret these sensations in this manner. Ask the patient to continue with the next exercise and to allow enjoyment of these sensations as they occur. Reassure the patient that he will become more comfortable and will likely enjoy these sensations in time.
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Appendix B Responses to Anxiety Attacks Induced by Interoceptive Exposure
The following procedures are for use if a patient becomes significantly alarmed by an interoceptive exposure trial. As outlined in the session-bysession instructions, the therapist should be adept at helping the patient identify catastrophic cognitions and probability overestimations and helping him apply cognitive strategies to correct this anxiogenic thinking. Interoceptive exposure trials provide opportunities for the patient to rehearse these interventions in a controlled setting in preparation for anxiety-producing situations in vivo. In all cases, the general theme is to have the patient note symptoms, allow the symptoms to occur, and relax passively despite the presence of those symptoms—doing nothing to try to control the symptoms. The patient is given feedback on ways he may be inducing more anxiety by increasing muscle tension in the face or shoulders or by increasing the rate of breathing. Specific instructions can include the following. ■
Leaving the body responses alone. Explain to the patient that the rapid heartbeat, hot flashes, feelings of dizziness, and other symptoms are normal responses to the exposure exercises. Emphasize that you understand that he feels uncomfortable but that you would like for him to relax with the sensations. The patient should not try to do anything about the sensations but, instead, should notice what the sensations feel like, describe them to you in detail, and simply let them happen. Explain that trying to control the symptoms has never helped but that relaxing with the sensations will. Model this behavior for the patient, allowing yourself to sit back in the chair and demonstrate doing nothing despite the presence of odd or bothersome somatic sensations. Continue to examine with the patient catastrophic cognitions and probability overestimations as appropriate.
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Challenging catastrophic thoughts. As the symptoms are occurring, ask the patient to focus on the symptoms and to answer the question, “What is the worst thing about these sensations?” In particular, ask the patient to focus on a particular sensation and to explain why this sensation is creating so much anxiety. If the patient expresses specific catastrophic thoughts, identify the thoughts as such and question the evidence that supports or refutes the catastrophic predictions. Have the patient continue to focus on the sensations, to do absolutely nothing about them, and to relax with the sensations while countering any catastrophic thoughts.
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Focusing on competence. Have the patient stand while he is experiencing some of the difficulties. Emphasize that, despite the presence of symptoms, he is moving about effectively. Ask the patient to stand and move about or to complete a presumed difficult task (e.g., read aloud) while experiencing symptoms to help him realize that in the presence of strong sensations he does not lose control or competence. At every point, the key is to not distract from or try to control the symptoms.
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About the Authors
Michael W. Otto, PhD, is Professor of Psychology at Boston University and Director of the Center for Anxiety and Related Disorders. Dr. Otto specializes in the cognitive-behavioral therapy (CBT) of anxiety, mood, and substance-use disorders. Dr. Otto’s research focuses on difficultto-treat populations, including the application of cognitive-behavioral strategies to patients who have failed to respond to previous interventions, as well as developing novel strategies for bipolar disorder and substance-use disorders. Regarding anxiety disorders, Dr. Otto has conducted both small- and large-scale trials examining the role of CBT in individual and combined treatment formats, including programs to help patients discontinue antianxiety medications. Dr. Otto has published over 250 scientific articles, chapters, and books spanning his research interests and was recently identified as a “top producer” in the clinical empirical literature. Dr. Otto is past president of the Association for Behavioral and Cognitive Therapies (formerly AABT), a fellow of the American Psychological Association, and a member of the Scientific Advisory Board for the Anxiety Disorders Association of America. Dr. Otto is richly involved in clinical training and dissemination of research findings and is a regular provider of continuing education and continuing medical education workshops across the United States. Mark H. Pollack, MD, is Director of the Center for Anxiety and Traumatic Stress Disorders at the Massachusetts General Hospital and Professor of Psychiatry at Harvard Medical School. His areas of clinical and research interest include the acute and long-term course; pathophysiology and treatment of patients with anxiety disorders including panic disorder, social anxiety disorder, post-traumatic stress disorder (PTSD), and generalized anxiety disorder and associated comorbidities; development of novel pharmacologic agents for mood and anxiety
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disorders; uses of combined cognitive-behavioral and pharmacologic therapies for treatment of refractory patients; presentation and treatment of anxiety in the medical setting; and the pathophysiology and treatment of substance abuse. He has published over 300 articles, reviews, and chapters and is editor-in-chief of the journal CNS Neuroscience and Therapeutics, lectures widely in national and international forums, serves on numerous editorial and advisory boards, and is currently chairman of the Scientific Advisory Board of the Anxiety Disorders Association of America.
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