2.4- Panic Disorder & Agoraphobia

Case 2 - Treatment Goals and Planning: (pp. 22-31)

Answer: B) John’s reliance on safety behaviors (e.g., leaning against walls, carrying Xanax)

Explanation: Perpetuating factors are those that maintain the disorder over time. John’s safety behaviors reinforced his fear of fainting and prevented him from learning corrective information. Family history (A) = predisposing,
first panic attack (C) = precipitating,
supportive spouse (D) = protective.
——————————————————————————————-
- Xanax (alprazolam) is a benzodiazepine.

- Xanax is the name that is used commonly by the people, Alprazolam is the medical name that is used by the company

Case Formulation (4Ps)

Which of the following best represents the perpetuating factors in John’s panic disorder?

A) John’s family history of anxiety disorders
B) John’s reliance on safety behaviors (e.g., leaning against walls, carrying Xanax)
C) John’s first unexpected panic attack in early adulthood
D) John’s supportive spouse assisting him in exposure practices

Answer: B) To reduce the patient’s anxiety about experiencing future panic attacks

Explanation: CBT for panic disorder emphasizes reducing the fear of future panic and avoidance, rather than eliminating panic itself. Relaxation (C) may be supportive, but it is not the core.

Treatment Goal

In cognitive-behavioral therapy (CBT) for panic disorder, what is considered the central goal of treatment?

A) To completely eliminate panic attacks
B) To reduce the patient’s anxiety about experiencing future panic attacks
C) To teach relaxation techniques as the primary coping tool
D) To identify biological markers of panic attacks

Answer: A) To increase his tolerance for physical sensations associated with panic

Explanation: Interoceptive exposure replicates feared bodily sensations (e.g., dizziness). The purpose is to show that these sensations are not dangerous, thus breaking the panic-sensation link.

Interoceptive Exposure

Why did John’s therapist ask him to spin in a chair for one minute?

A) To increase his tolerance for physical sensations associated with panic
B) To test his physical endurance
C) To distract him from catastrophic thinking
D) To induce fatigue before cognitive therapy

Answer: B) Probability overestimation

Explanation: John is overestimating the likelihood of a feared outcome (crash). Catastrophic thinking focuses on the severity of the outcome (e.g., social humiliation in church).

Cognitive Distortions

John predicted that if he had a panic attack while driving, he would lose control of the car and crash. This is best described as:

A) Selective abstraction
B) Probability overestimation
C) Catastrophic thinking
D) All-or-nothing thinking

Answer: C) To test feared predictions through behavioral experiments

Explanation: Prediction testing is a cognitive-behavioral strategy where patients test their catastrophic predictions in real-life or simulated conditions, leading to disconfirmation of irrational beliefs.

Prediction Testing

What was the primary function of prediction testing in John’s therapy?

A) To provide immediate relaxation after panic attacks
B) To confirm John’s catastrophic beliefs
C) To test feared predictions through behavioral experiments
D) To monitor John’s Xanax dosage

Answer: B) Medications prevent patients from fully experiencing and disconfirming feared sensations

Explanation: Anxiolytic medications dampen sensations and anxiety, which can interfere with learning that panic sensations are safe. This reduces the effectiveness of CBT exposure methods.

Medication & CBT

Why might patients on medications such as Xanax respond less effectively to CBT compared to unmedicated patients?

A) Medications permanently increase sensitivity to panic
B) Medications prevent patients from fully experiencing and disconfirming feared sensations
C) Medications eliminate the need for exposure exercises
D) Medications increase the risk of relapse during treatment

Answer: C) Men are more likely to use substances to cope with panic, whereas women more often develop agoraphobia

Explanation: Studies consistently show that men tend toward substance use as a coping mechanism, while women more frequently develop avoidance patterns and agoraphobia.

Gender Differences

Which statement is supported by research on gender differences in panic disorder and agoraphobia?

A) Men are more likely to develop extensive agoraphobic avoidance than women
B) Women are more likely to self-medicate with alcohol than men
C) Men are more likely to use substances to cope with panic, whereas women more often develop agoraphobia
D) Gender plays no role in the presentation of panic disorder

Answer: B) He continued to experience some limited symptoms but showed major improvement

Explanation: “Partial remission” means symptoms are significantly reduced, with some residual symptoms or occasional mild episodes. John still had lingering apprehension in some situations.

Treatment Outcome

At the end of John’s therapy, his panic disorder was described as being “in partial remission.” What does this mean?

A) He no longer experienced any panic symptoms
B) He continued to experience some limited symptoms but showed major improvement
C) His condition had returned to baseline levels
D) His panic disorder had worsened due to medication withdrawal

Answer: B) The therapist’s use of prediction testing

Explanation: Protective factors reduce risk and aid recovery. Prediction testing provided John with corrective learning opportunities, helping him overcome maladaptive beliefs.

Protective Factors

Which of the following acted as a protective factor in John’s treatment?

A) His heavy alcohol use before treatment
B) The therapist’s use of prediction testing
C) His long history of untreated panic disorder
D) His reliance on safety behaviors

Answer: B) It leads to misinterpretation of first panic attacks as dangerous or life-threatening

Explanation: Misinterpretation of initial panic attacks (e.g., “I’m dying of a heart attack”) can create a fear of recurrence, fueling the cycle of panic disorder.

Public Awareness

According to the case discussion, why might public unfamiliarity with panic attacks increase the likelihood of developing panic disorder?

A) It increases the chance of medication overuse
B) It leads to misinterpretation of first panic attacks as dangerous or life-threatening
C) It prevents people from accessing therapy immediately
D) It directly causes genetic vulnerability

Answer: C) Family history of anxiety disorders

Explanation: Predisposing factors increase vulnerability (e.g., genetic/temperamental risk).

Predisposing Factors

Which of the following is a predisposing factor for John’s panic disorder?

A) His use of Xanax for panic relief
B) His first panic attack “out of the blue”
C) Family history of anxiety disorders
D) Avoiding highways after panic attacks

Answer: B) Precipitating factor

Explanation: The initial “trigger event” that brings on symptoms is a precipitating factor.

Precipitating Factors

John’s first panic attack occurred while driving home from work. This is best classified as:

A) Predisposing factor
B) Precipitating factor
C) Perpetuating factor
D) Protective factor

Answer: B) Sitting near exits in church to escape if panic occurs

Explanation: Safety behaviors (e.g., staying near exits) maintain anxiety by preventing corrective learning.

Safety Behaviors

Which of the following is an example of John’s safety behavior?

A) Monitoring his anxiety diary
B) Sitting near exits in church to escape if panic occurs
C) Ranking fear items on his FAH
D) Attending therapy sessions weekly

Answer: B) Catastrophic misinterpretations of bodily sensations

Explanation: Misinterpreting normal sensations (e.g., “heart racing means I’ll faint”) escalate anxiety into panic and perpetuates panic disorder.

Panic Cycle

Which of the following maintains the panic cycle according to the integrative model?

A) Lack of sleep
B) Catastrophic misinterpretations of bodily sensations
C) Excessive exercise
D) Hypoglycemia

Answer: B) To organize exposure tasks from least to most feared

Fear and Avoidance Hierarchies (FAHs)

Why are FAHs used in CBT for panic disorder?

A) To measure heart rate changes
B) To organize exposure tasks from least to most feared
C) To identify unconscious conflicts
D) To test medication side effects

Answer: B) Spinning in a chair to induce dizziness

Explanation: Spinning induces dizziness, mimicking panic sensations safely.

Interoceptive Exposure

Which of these is an example of interoceptive exposure used with John?

A) Driving on the interstate at night
B) Spinning in a chair to induce dizziness
C) Talking back to automatic thoughts
D) Recording his panic frequency

Answer: B) Situational exposure

Situational Exposure

John’s task of driving to Exit 10 alone after dark is an example of:

A) Interoceptive exposure
B) Situational exposure
C) Relaxation training
D) Behavioral activation

Answer: A) Probability overestimation

Cognitive Therapy

In therapy, John learned that overestimating the likelihood of fainting while panicking is an example of:

A) Probability overestimation
B) Catastrophic thinking
C) Selective abstraction
D) Mind reading

Answer: B) Catastrophic thinking

Explanation: He perceived the social consequences as catastrophic.

Catastrophic Thinking

John feared that fainting in church would lead to unbearable shame from others’ judgment. This is:

A) Probability overestimation
B) Catastrophic thinking
C) Overgeneralization
D) Emotional reasoning

Answer: B) Disconfirm catastrophic beliefs through experience

Prediction Testing

The main goal of prediction testing in CBT is to:

A) Test whether panic attacks are genetic
B) Disconfirm catastrophic beliefs through experience
C) Teach relaxation techniques
D) Reduce medication dependence

Answer: B) Women often rely less on substances to cope

Gender Differences

Why are women more likely than men to develop agoraphobia following panic attacks?

A) Women are more biologically prone to fainting
B) Women often rely less on substances to cope
C) Men avoid medical treatment
D) Agoraphobia is not linked to gender

Answer: B) They suppress sensations needed for exposure learning

Medication & CBT

Which is a reason medications can reduce CBT effectiveness for panic disorder?

A) They enhance catastrophic thoughts
B) They suppress sensations needed for exposure learning
C) They worsen avoidance behavior
D) They make panic attacks more frequent

Answer: B) He showed significant improvement with some lingering symptoms

Outcome

At the end of treatment, John’s diagnosis was “panic disorder with agoraphobia, in partial remission.” This indicates:

A) He fully recovered and no symptoms remained
B) He showed significant improvement with some lingering symptoms
C) His symptoms worsened after treatment
D) He no longer needed therapy

Answer: B) It prevents the misinterpretation of first panic attacks as dangerous

Explanation: Misinterpreting early panic episodes as life-threatening fuels disorder development.

Public Awareness

Why might public education about panic attacks help prevent panic disorder?

A) It reduces genetic vulnerability
B) It prevents the misinterpretation of first panic attacks as dangerous
C) It eliminates stressful life events
D) It replaces the need for therapy

Answer: C) Repeated confrontation reduces fear through habituation and learning

Exposure Principle

The principle underlying exposure therapy is:

A) Panic sensations are always life-threatening
B) Avoidance reduces long-term anxiety
C) Repeated confrontation reduces fear through habituation and learning
D) Catastrophic thoughts should be ignored

Answer: B) It helps maintain treatment gains and prepares for setbacks

Relapse Prevention

Why is relapse prevention important after CBT for panic disorder?

A) Panic disorder always returns after therapy
B) It helps maintain treatment gains and prepares for setbacks
C) It teaches patients to rely on medications long-term
D) It eliminates the need for self-monitoring

Answer: B) To provide structured, graded exposure tasks

Explanation: FAHs rank feared situations/activities by difficulty and guide gradual exposure.

Exposure Hierarchies

What was the purpose of John’s Fear and Avoidance Hierarchies (FAHs)?

A) To eliminate all physical symptoms of panic
B) To provide structured, graded exposure tasks
C) To measure family history of panic
D) To track medication side effects

Answer: B) “Drive up the interstate to Exit 10, alone, after dark”

Explanation: Situational FAH = real-life avoided situations. Interoceptive tasks (D) are part of a different hierarchy.

Example of Situational FAH

Which of the following would be a valid item on John’s situational FAH?

A) “Stop taking Xanax for two days”
B) “Drive up the interstate to Exit 10, alone, after dark”
C) “Record daily mood ratings”
D) “Spin in a chair for one minute”

Answer: B) Another person would feel similar anxiety if they had the same thought

Explanation: This ensures the cognition is truly anxiety-provoking and relevant.

Identifying Cognitions

Which guideline did the therapist give John to ensure he had identified an important cognition?

A) It should be measurable with a 0–10 scale
B) Another person would feel similar anxiety if they had the same thought
C) It must be a conscious thought
D) It must occur daily

Answer: C) It provides evidence that feared outcomes do not occur

Explanation: Disconfirmation of feared predictions reduces anxiety.

Prediction Testing

Why is prediction testing effective in CBT for panic disorder?

A) It confirms irrational beliefs
B) It increases tolerance for uncertainty
C) It provides evidence that feared outcomes do not occur
D) It eliminates the need for exposure

Answer: A) They strengthen catastrophic thinking by preventing corrective learning

Explanation: Safety behaviors block exposure-based learning, keeping fears intact.

Safety Behaviors

Why do safety behaviors perpetuate panic disorder?

A) They strengthen catastrophic thinking by preventing corrective learning
B) They eliminate panic attacks completely
C) They reduce avoidance
D) They help identify cognitions

Answer: B) Panic attacks followed by persistent concern and avoidance

Explanation: Panic disorder requires recurrent attacks plus concern/avoidance.

Panic Disorder Diagnosis

Which DSM-5 feature was present in John’s case?

A) Panic attacks triggered only by specific cues
B) Panic attacks followed by persistent concern and avoidance
C) Panic limited to nocturnal episodes
D) Panic due to substance withdrawal

Answer: C) Men tend to self-medicate with substances, women with avoidance

Explanation:
Men → alcohol/drugs,
Women → avoidance/agoraphobia.

Gender Differences

Which is true regarding gender and panic disorder?

A) Men are more likely to develop agoraphobia than women
B) Women are more likely to use alcohol to cope than men
C) Men tend to self-medicate with substances, women with avoidance
D) Gender has no effect

Answer: B) Some symptoms remained, but major improvement occurred

Explanation: Partial remission = significant improvement with mild residual symptoms.

Treatment Outcome

At the end of therapy, John was in “partial remission.” This means:

A) Panic disorder fully resolved
B) Some symptoms remained, but major improvement occurred
C) Symptoms worsened due to exposure
D) Symptoms returned to baseline levels

Answer: B) Functional impairment and avoidance reduce quality of life

Explanation: Avoidance limits activities, leading to hopelessness/depression.

Depression Comorbidity

Why is comorbid depression common in panic disorder?

A) Panic disorder always causes depression
B) Functional impairment and avoidance reduce quality of life
C) Antidepressants directly induce panic
D) Genetics of depression and panic are unrelated

Answer: B) Avoidance of places where escape/help is difficult if panic occurs

Explanation: Core feature = avoidance of perceived unsafe escape scenarios.

Agoraphobia

Which best describes agoraphobic avoidance?

A) Avoidance of all medical settings
B) Avoidance of places where escape/help is difficult if panic occurs
C) Avoidance of unfamiliar foods
D) Avoidance of all interpersonal contact