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CBT Sanderson > Cognitive Behavioral Treatment of Panic Disorder and Agoraphobia > Flashcards

Cognitive Behavioral Treatment of Panic Disorder and Agoraphobia Flashcards

1
Q

ASSESSMENT: Clinical Interview

A

Panic attacks

Feared consequence of the anxiety/panic (catastrophic misinterpretations)

Phobic situations (agoraphobia)

Phobic internal sensations (feared body sensations)

Phobic affect

Phobic cognitions

Safety behaviors

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2
Q

ASSESSMENT: Questionnaires

A

Identify relevant symptoms
Quantify severity
Assess outcome:

Panic Diary
# of panic attacks

Diagnostic Symptom Questionnaire
Severity of panic symptoms

Agoraphobic Cognitions Questionnaire
Negative/catastrophic cognition

Mobility Inventory
Agoraphobic fear and avoidance

BAI

BDI

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3
Q

RECOMMENDATIONS FOR THERAPIST TO INCREASE COMPLIANCE

A

Set times, days in session: give a “prescription” to the patient

Audiotape instructional sessions (e.g., relaxation, cognitive rest, imaginal exposure)

Use a monitoring form and ask patient to return each session

Ask patient to call in or email and report results

Problem solve when noncompliance occurs: brainstorm solutions, deal with it openly

Never think of the patient as resistant (self-fulfilling prophecy)

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4
Q

Panic Focused Cognitive Restructuring

A

Focus on SPECIFIC Panic/Anxiety Provoking Situations:
a. Start with retrospective accounts

b. Eventually move to in-vivo cognitive restructuring

  1. Increase awareness of automatic thoughts during affective episodes
    * initiate self-monitoring
    * ACQ: Learn identify automatic thoughts
  2. Recognize connections between cognition, affect, and behavior
    * how cognitions mediate affect and behavior.

*Panic main catastrophic thoughts
dying
losing control
going crazy

Draw out panic cycle for individual (see handout)

  1. Examine the validity (accuracy, logic) of automatic thoughts:
    * subject automatic thoughts to logical analysis
    * identify cognitive distortions
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5
Q

Common cognitive strategies:

A

Evidence supports

Evidenct does not support:

  • Identify the distortion
  • double-standards
  • what have I or can I learn to provide information about the validity of this fear?
  • define negative terms and substitute less emotionally loaded words (decatastrophizing)
  • re-attribution (alternative perspective: Is there any other way I can view this? Is it more or less likely then my AT?)

Create Behavioral experiment

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6
Q

Cognitive Restructuring Aids

A

Index Cards, smartphone notes

Smartphone recorder

Notebook – log in order to collect ongoing data in a systematic fashion

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7
Q

Beware of Faulty Information Processing

A

Mood-congruent bias: mood influences processing

Confirmatory bias: expectations influence processing (implicit process)

Self-fulfilling prophecy: expected behavior can confirm previous expectation

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8
Q

Respiratory Control

A

Diaphragmatic breathing at regular pace
(approximately 8-12 breaths per minute)

Goal = decrease symptoms of hyperventilation

Move from laying – standing – to practice in actual life-situations

Regular practice necessary to ultimately utilize in panic provoking situations

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9
Q

CONFRONTING EMOTIONALLY DRIVEN RESPONSES: Goals of Exposure

A

Tolerance and acceptance of anxiety and panic while exposed to fear producing stimuli

Removing avoidance, escape, and the use of safety signals

Break association between stimulus and maladaptive fear response (extinction)

Increase confidence and sense of mastery of anxiety and fear provoking stimuli

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10
Q

Exposure to Phobic Situations

A

a. Rationale for situational exposure
b. Preparing for situational exposure
c. Conducting imaginal exposure (in and out of session)
d. Conducting in vivo exposure

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11
Q

Rationale for situational exposure

A

Provokes full emotional response, facilitates increased learning, ecological validity

Explain process of negative reinforcement (avoidance, escape)

Explain extinction (or learning a new response)

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12
Q

Preparing for situational exposure

A

Mobility Inventory–develop fear and avoidance hierarchy

SPECIFIC attention to :
hierarchy gradient
variations for the same stimulus
safety signals

Explain rationale of imaginal and in vivo situational exposure

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13
Q

Conducting imaginal exposure (in and out of session)

A

Inoculation

Priming corrective response

Cognitive coping: reappraisal, acceptance, attention modification

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14
Q

Conducting in vivo exposure

A

In and out of session

Self-directed, therapist-assisted, other-assisted (safe person)

Cognitive coping: reappraisal, acceptance, attention modification

Attention to and gradual removal of safety signals (which inhibit full exposure)

Examples of items for Situational Exposure (depends upon relevance to the individual):
*Driving (roads, traffic) 
*elevators
*crowded places
*being home alone 
*trains 
*walking a distance from a safe-zone
*bridges
*stores
*theaters
*restaurants
etc etc
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15
Q

Preparing for Interoceptive Exposure

A

DSQ: developing a fear and avoidance hierarchy of fear provoking internal sensations

Explaining rationale of interoceptive exposure

Addressing any concerns about triggering physical sensations (cognitive reappraisal)

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16
Q

Conducting interoceptive exposure (in and out of session)

A

Attention to and gradual removal of safety signals

Examples of items for Interoceptive Exposure:

Respiratory symptoms
suffocation
(e.g., holding breath, voluntary hyperventilation, breathing through snorkel)

Cardiac symptoms
heart attack
(e.g., exercises such as use of treadmill, walking up stairs, caffeine)

Dizziness/Unsteadiness
fainting
(e.g., spinning in a chair, shaking head back and forth)

Sedative stimuli
loss of control
(e.g., a cold remedy, alcohol, tranquilizers)

Depersonalization/Derealization
mental catastrophe
(e.g., bright lights, blinking lights, repeated blinking,
staring at complex patterns such as spirals, stripes)

17
Q

Preparing for Affect Exposure

A

Developing a fear and avoidance hierarchy of affect producing situations

Explaining rationale of affect exposure

Addressing any concerns about triggering affect (cognitive reappraisal)

18
Q

RELAPSE PREVENTION

A
  1. Arrange patient to continue “therapy” on his/her own - “disease management” model
  2. Preparation to deal with “lapses” as well as high-risk (challenging) situations
  3. Occasional meetings with therapist to review progress
  4. Consider group therapy if available (e.g., support group for panic)
  5. Two factors associated with relapse following CBT: comorbidity and medication use
19
Q

PANIC DISORDER: Core Symptoms, Important Coexisting Features

A
  1. Panic Attacks:
    symptoms + concern/change in behavior
  2. Agoraphobia: active versus passive avoidance, severity of functional impairment, quality of life
  3. Depression: secondary vs primary
  4. Chronic hyperarousal, worry, vulnerability, hypochondriacal features
  5. Suicidality
  6. Substance Abuse
20
Q

ETIOLOGICAL COMPONENTS INVOLVED IN PANIC DISORDER

A

Triple Vulnerability:

Biological/Genetic Predisposition

Cognitive/Psychological Vulnerability

Behavioral Style

21
Q

NIMH PANIC CONSENSUS STATEMENT: Treatment Guidelines

A

Medications: Benzodiazepines (xanax, ativan, klonopin)
TCAs (tofranil/imipramine)
SSRIs
MAOIs

Psychological Treatment: CBT Treatment Package (includes an array of evidence-based procedures).

22
Q

Panic Disorder: Biological/Genetic Predisposition

A

Hyper-arousal to threatening stimuli

Hyperventilation (suffocation alarm)

Decreased parasympathetic response

23
Q

Panic Disorder: Cognitive/Psychological Vulnerability

A

Heightened sense of vulnerability (vulnerability schema)

Anxiety Sensitivity and emotional avoidance

Stress and coping style

24
Q

Panic Disorder: Behavioral Style

A

Avoidance of anxiety-provoking stimuli

Avoidance of anxious arousal itself

25
Q

What to do with cognition during exposure

A

Content: Reappraisal

Process: Acceptance/cognitive defusion – accept thoughts as they are

Attention modification (mindfulness) – refocus attention away from anxiogenic thoughts

***Utilize behavioral, interoceptive, cognitive, affective exposure as appropriate
(Note. each may not be relevant to every patient)

26
Q

Strategies to increase patient compliance during situational exposure

A

Gentle pressure

Accountability

Monitoring of thoughts, physical sensations, behaviors, emotions–descriptive, objective

Problem-solving

27
Q

Conducting affect exposure

A

Examples of items for Affective Exposure:

Watch a horror or suspenseful television show or movie,

Read an article that causes anxiety (unrelated to specific cognitive
psychopathology)

Go on an amusement park ride that creates anxiety

Strategies for compliance:
Gentle pressure

Accountability

Monitoring of thoughts, physical sensations, behaviors, emotions–descriptive, objective

Problem-solving

28
Q

Negative predictors of relapse

A

Hypochondriasis

Cluster A personality disorders (schizoid, schizotypal, paranoid

Substance abuse

CBT Sanderson (10 decks)

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