Clinical Psychology Lecture 13

Goals of CBT for Panic Disorder

1. Education/monitoring: To understand the nature of panic attacks, panic disorder, and agoraphobia 

2. Cognitive component: To learn about factors that cause panic disorder 

3. Behavioral component: To learned about this program for overcoming panic and agoraphobia 

4. Relapse prevention: To determine whether or not this program is right for you 

Benefits of recording panic and anxiety

1. To help you feel more in control, by being able to identify when and where panic attacks are more likely to happen 

2. Identify the specific ways in which you experience anxiety; your physical feelings, your thoughts, and your behaviors 

3. To be able to judge your level of anxiety and panic more accurately 

4. To evaluate the success of your attempts to change 

Panic Attack Record, Daily Mood Record, Progress Record 

The Panic Cycle

(1) Physical symptoms of racing heart, (2) Negative thoughts of heart attack, (3) Escape from situations to find medical help 

Interruption to Panic Cycle

(1) Physical symptoms of racing heart, (2) Thoughts that “It is harmless”, (3) Continue with usual activities, (4) Symptoms of racing heart go away 

Step-by-Step Analysis of Panic Attack

1. Where were you and what was going on when the panic attack first started? 

2. What happened first? A physical symptom, negative thought, or a behavior?  

3. What happened next? How did you react to the first physical symptom or negative thought? Did you notice more physical symptoms, more negative thoughts, or did you do something, such as seek help, lie down, or exit wherever you were? 

4. What happened next? Did the physical symptoms get worse, did you become even more scared about negative things happening? 

5. What was next? 

6. How did it end? 

A Simplified Model of Panic Attack

(1) Physical symptoms due to stress, anxiety about panic, normal physical changes, (2) Anxiety about symptoms due to interoceptive conditioning and negative mistaken beliefs that the physical symptoms are dangerous, (3) More symptoms, (4) Panic 

Table 4.1 Physiology of Fear

Physical Change	Purpose	Symptom
Increased heart rate and strength of heartbeat	Speed up delivery of oxygen and removal of carbon dioxide	Racing or pounding heart
Redirection of blood flow away from skin, toes, and fingers and toward the big muscles	Provide the big muscles with energy for fight-flight response, lose less blood if attacked	Pale and cold, especially in hands and feet
Increase rate and depth of breathing	Provide more oxygen for muscles as energy for fight-flight response	Fast breathing. Also, dizziness, lightheadedness, shortness of breath, feelings of hot or cold, sweating, chest discomfort, visual changes, if the increased oxygen is not used
Increase activity in sweat glands	Cool body to prevent exhaustion from overheating from overheating	Sweating
Pupils (eyes) dilate	Increase visual field to scan for danger	Eyes more sensitive to light
Less energy to digestive system	Direct all energy to fight-flight response	Dry mouth, nausea, stomachache, cramps, diarrhea
Increased muscle readiness	Preparation for fight-flight response	Muscle tension, muscle cramps, trembling, shaking
Release of natural pain killers (opioids)	Dulls pain sensitivity to allow continued fighting of fleeing if injured	Less sensitive to pain

Education about Anxiety-Breathing Link

1. Overbreathing 

a. Chronic hyperventilation 

2. Indicators 

a. Feeling short of breath 

b. Feeling like suffocating 

c. Chest pain or pressure 

d. Frequent yawning, sighing, or air gulping 

e. Breathing quickly and shallowly when frightened 

f. Response to hyperventilation exercise 

3. Physiological effects 

a. Increased oxygen in blood (not tissue) 

b. Decreased carbon dioxide 

c. Upshot: less oxygen to brain and body 

d. Balance out of whack 

Diaphragm breathing

Breathing component: Belly (not chest) breathing, normal amount of air, smooth breathing 

Meditative component: Count as breathe in, “relax” as breathe out, focus on breath 

Practice: Twice a day, 10 min, relaxing situations, quiet place 

Thinking skills

Thoughts mediate effect of Event on Emotion 

Examples of the Influence of Thought About Physical Symptoms on Emotions

Event	Thoughts About the Event	Emotion
Pain in chest	Sign of heart attack	Panic
Pain in chest	Sign of indigestion	No panic
Pain in chest	Sign of muscle pain	No panic
Pain in chest	Sign of cancer	Panic
Pain in chest	Sign of tension and stress	No panic

Identifying thoughts

What am I afraid of? And if that were to happen, then what? And if that were to happen, what would that mean? 

Evaluate odds of negative outcome

Targets overestimation of likelihood of negative outcomes 

E.g., Changing Your Odds: (1) Negative thought, (2) How many times has it happened?, (3) Reasons why I continue to worry about:, (4) What is the evidence?, (5) What are the real odds, (6) What are different thoughts? 

Challenge your perspective

Targets catastrophic thinking about inability to manage negative outcomes 

E.g., Changing Your Perspective: (1) Negative thought, (2) Will this pass, and will I survivie?, (3) Ways of coping 

Two primary cognitive errors associated with anxiety-related disorders

1. Overestimation of likelihood of negative outcome 

2. Catastrophic thinking about inability to cope with negative outcome 

Exposure (PD)

Facing physical symptoms 

1. Rationale: Face symptoms directly so learn not harmful and can tolerate 

2. Symptom assessment: Identify which exercises produce symptoms similar to those in PA 

3. Create hierarchy: Rank similar exercises according to anxiety level 

4. Practice: Work way up hierarchy 

Observed reduction in anxiety (“habituation”) with continued exposure to feared symptoms, activities, and situations 

Facing feared activities 

Facing agoraphobia situations 

Medications used to treat Panic Disorder

Medication	Brand Name	Initial Dose	Dosage Range
SSRL
Fluoxetine	Prozac	10 mg/day	10-60 mg/day
Paroxetine	Paxil	10 mg/day	10-60 mg/day
Sertraline	Zoloft	25 mg/day	50-200 mg/day
Benzodiazepines
Alprazolam	Xanax	0.25-0.5 mg/day  (3 times per day)	0.25-4 mg/day   (3 times per day)
Clonazepam	Klonopin	0.25 mg/day	1-3 mg/day

Accomplishments, Maintenance, and Relapse Prevention

a. Progress evaluation 

b. Practice plan 

c. Long-term goals 

d. Your high-risk times