Cognitive Behavioral Treatment of Panic Disorder and Agoraphobia Flashcards
ASSESSMENT: Clinical Interview
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
ASSESSMENT: Questionnaires
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
RECOMMENDATIONS FOR THERAPIST TO INCREASE COMPLIANCE
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)
Panic Focused Cognitive Restructuring
Focus on SPECIFIC Panic/Anxiety Provoking Situations:
a. Start with retrospective accounts
b. Eventually move to in-vivo cognitive restructuring
- Increase awareness of automatic thoughts during affective episodes
* initiate self-monitoring
* ACQ: Learn identify automatic thoughts - 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)
- Examine the validity (accuracy, logic) of automatic thoughts:
* subject automatic thoughts to logical analysis
* identify cognitive distortions
Common cognitive strategies:
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
Cognitive Restructuring Aids
Index Cards, smartphone notes
Smartphone recorder
Notebook – log in order to collect ongoing data in a systematic fashion
Beware of Faulty Information Processing
Mood-congruent bias: mood influences processing
Confirmatory bias: expectations influence processing (implicit process)
Self-fulfilling prophecy: expected behavior can confirm previous expectation
Respiratory Control
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
CONFRONTING EMOTIONALLY DRIVEN RESPONSES: Goals of Exposure
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
Exposure to Phobic Situations
a. Rationale for situational exposure
b. Preparing for situational exposure
c. Conducting imaginal exposure (in and out of session)
d. Conducting in vivo exposure
Rationale for situational exposure
Provokes full emotional response, facilitates increased learning, ecological validity
Explain process of negative reinforcement (avoidance, escape)
Explain extinction (or learning a new response)
Preparing for situational exposure
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
Conducting imaginal exposure (in and out of session)
Inoculation
Priming corrective response
Cognitive coping: reappraisal, acceptance, attention modification
Conducting in vivo exposure
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
Preparing for Interoceptive Exposure
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)
Conducting interoceptive exposure (in and out of session)
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)
Preparing for Affect Exposure
Developing a fear and avoidance hierarchy of affect producing situations
Explaining rationale of affect exposure
Addressing any concerns about triggering affect (cognitive reappraisal)
RELAPSE PREVENTION
- Arrange patient to continue “therapy” on his/her own - “disease management” model
- Preparation to deal with “lapses” as well as high-risk (challenging) situations
- Occasional meetings with therapist to review progress
- Consider group therapy if available (e.g., support group for panic)
- Two factors associated with relapse following CBT: comorbidity and medication use
PANIC DISORDER: Core Symptoms, Important Coexisting Features
- Panic Attacks:
symptoms + concern/change in behavior - Agoraphobia: active versus passive avoidance, severity of functional impairment, quality of life
- Depression: secondary vs primary
- Chronic hyperarousal, worry, vulnerability, hypochondriacal features
- Suicidality
- Substance Abuse
ETIOLOGICAL COMPONENTS INVOLVED IN PANIC DISORDER
Triple Vulnerability:
Biological/Genetic Predisposition
Cognitive/Psychological Vulnerability
Behavioral Style
NIMH PANIC CONSENSUS STATEMENT: Treatment Guidelines
Medications: Benzodiazepines (xanax, ativan, klonopin)
TCAs (tofranil/imipramine)
SSRIs
MAOIs
Psychological Treatment: CBT Treatment Package (includes an array of evidence-based procedures).
Panic Disorder: Biological/Genetic Predisposition
Hyper-arousal to threatening stimuli
Hyperventilation (suffocation alarm)
Decreased parasympathetic response
Panic Disorder: Cognitive/Psychological Vulnerability
Heightened sense of vulnerability (vulnerability schema)
Anxiety Sensitivity and emotional avoidance
Stress and coping style
Panic Disorder: Behavioral Style
Avoidance of anxiety-provoking stimuli
Avoidance of anxious arousal itself
What to do with cognition during exposure
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)
Strategies to increase patient compliance during situational exposure
Gentle pressure
Accountability
Monitoring of thoughts, physical sensations, behaviors, emotions–descriptive, objective
Problem-solving
Conducting affect exposure
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
Negative predictors of relapse
Hypochondriasis
Cluster A personality disorders (schizoid, schizotypal, paranoid
Substance abuse
