Boston Counseling Therapy

Panic Disorder and Agoraphobia: Overview and CBT Treatment

Panic Disorder & Agoraphobia:
A Cognitive Behavioral Therapy (CBT) Treatment Protocol

Criteria for Panic Attack

A panic attack is an explicit period of extreme discomfort or fear where at least four of the following criteria develop abruptly and peak within 10 minutes time

Criteria
Palpitations, or excited heart rate
Sweating
Trembling/shaking
Shortness of breath/smothered sensation
Sensations of choking
Chest discomfort or pain
Nausea or abdominal discomfort
Criteria continued
Feeling faint, dizzy, unsteady, lightheaded
Feelings of unreality or detachment from reality (depersonalization)
Fear of losing control or “going crazy”
Fear of death
Numbness or tingling sensations
Hot or cold flashes

A Panic Attack is Not a Codable Disorder
Criteria for Agoraphobia
Anxiety about being in places or situations from which escape might be difficult (or embarrassing), or in which one could possibly suffer a panic attack.
These situations often include crowds, busses, bridges, trains (&autos), and places outside the home
Note: if avoidance is limited to a few situations, it is probably a Phobia. If limited to only social situations, is probably a Social Phobia

Situations (mentioned prior) are avoided, or endured with noticeable distress, & often anxiety about having a panic attack.
Anxiety/phobic behavior not better accounted by another disorder.
Agoraphobia is Not a Codable Disorder

Diagnostic Criteria for Panic Disorder (300.01)
Unexpected, recurrent panic attacks (usually with no known catalyst reported)
Attack followed by a minimum one month of concern about having additional attacks, fear of consequences (losing control, dying, “going crazy”), a significant alteration of usual behavior related to previous attacks

Attacks not due directly to drugs or physiology (i.e. cocaine, hyperthyroidism)
Attacks not better accounted for by another diagnosis (i.e. social phobia, OCD, separation anxiety)
Panic Disorder W/Agoraphobia 300.21
Maintains same criteria as 300.01.
In addition: includes criteria for agoraphobia disorder.
The Diagnostic Interview
An in depth interview is the first step in establishing a diagnostic profile
Recommended: The Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV)
Assesses Anxiety, mood, & somatoform disorders. Screens for psychotic and drug conditions.

Do Not Diagnose!…until medical conditions are ruled out.
PD/PDA like symptoms can be facilitated by:
Caffeine or Amphetamine intoxication
Do Not Diagnose (Cont.)
Caffine/Amphetamine Intoxication
Thyroid conditions
Drug Withdrawal
Pheochromocytoma (a rare adrenal gland tumor)

ALSO, the following can EXACERBATE PD/PDA
Mitral Valve Prolapse (heart palpitations)
Asthma (shortness of breath)
Allergies (shortness f breath)
Hypoglycemia (weakness/dizziness)
Functional Analysis
Various methods of assessment such as the Clinical Interview, Standardized Inventories (the Mobility Inventory, Anxiety Sensitivity Index, etc.), and Behavioral tests will provide the material for a full functional analysis.
Functional Analysis
Panic attack topography: Sensations, frequency, duration, apprehension (how often thinking about them), and type (expected or unexpected)
Antecedents: Situational (where PA occurs), internal issues (thoughts of “the big one”)
Misappraisals: Physical (heart attack), mental (going crazy), and social (others will think…)
Functional Analysis (2)
Behavioral reactions to PA: Escape (avoiding places), help seeking, protection (body checks, drugs)
Behavioral RXNs to anticipation: Avoidance, cognitive avoidance, safety signals (carries meds, always knows where people are, etc.)
Consequences: Family, work, leisure, social
Functional Analysis (3)
Assess general mood.

Rationale for CBT treatment for PD/PDA
The success of CBT on PD/PDA is considered one of psychotherapies greatest achievements.
80-100% of clients in CBT treatment for PD/PDA will be without panic at the end of treatment.
Such results are still existent during a 2 year follow-up. A higher rate than effective medications.
Also, 50-80% of these clients are “cured” in that they have no symptomatology (and many of the remaining have only residual symptoms)
Rationale for CBT treatment for PD/PDA (Cont.)
However, as many as 50% of clients retain substantial symptomatology post-treatment. Especially those with agoraphobic issues.
Also, some clients necessitate significantly longer periods of CBT before meaningful/improved In Vivo response occurs.

Basic Components of CBT for PD/PDA

Cognitive Restructuring
Breathing Retraining: this became a central component early for panic intervention because of the high instance of PD/PDA patients who report hyperventilatory symptoms. However, less than 50% of PD patients show a reductions in carbon dioxide. Therefore, hyperventilation might best be viewed as a stress-induce symptom that instigates fear.

Applied Relaxation
Interoceptive Exposure: purpose is to reduce the fear of one’s specific bodily cues (i.e. heart palpitations are harmless, and are not heart attacks)
In Vivo Exposure

Treatment Protocol (Session 1)

Goals of Session One:

Describe anxiety: and identify patterns of anxiety and places/situations in which it occurs. Investigate briefly when first occurred.
Help patient in identifying antecedents: (situational, physical, and mental)
provide a treatment rationale & treatment description
Introduce self monitoring/homework.
Self Monitoring/Homework
Keep in mind the “three-response system:” (when you are anxious, what do you feel, think, and do?)
Log any panic attacks in the panic attack record. This is carried in the patients wallet and completed as soon as possible post-bellum any panic attack.
Self Monitoring/Homework (2)
The Daily Mood Log is used for to rate daily levels of depression, anxiety, and worry about PAs.

Session 2

Goals of this session are the following
Describe the physiology underlying anxiety and panic
The survival value and protective function of anxiety and panic (i.e. fight or flight)
The physiological basis for sensations during a panic attack (sympathetic nervous functioning)
The roll learned and cognitively directed fears and thoughts on panic sensations (panic attacks the seem to come from “out of the blue” are trigger by subtle internal cues)
Session 2 (cont.)
This information both reduces anxiety (and panic attacks) by decreasing uncertainty about panic attacks, and adds credibility/confidence to the CBT process.
Homework (Session 2)
Patients are instructed to read (and re-read) a handout on the physiological symptoms of anxiety and panic
Patients are to develop an alternative conceptual framework and an objective versus subjective self monitoring awareness
The therapist reassures clients the panic will subside as they persist in reading the material

Session 3

Primary Goal: Begin breathing control
Step one: clients asked to hyperventilate by breathing quickly and deep for 1½ minutes (to facilitate panic symptoms); after which the are instructed to sit, close their eyes and breath slowly until panic like symptoms have subsided

50-60% of clients report symptoms during the exercise emulated symptoms of a panic attack in vivo. However, because the environment is considered “safe” clients rate the experience as less anxiety provoking. This is important for the therapist to note—for it displays the significance of perceived safety on the degree of anxiety.

The client is educated on breathing, in specific misinterpretations the client might possess about the issue of “overbreathing”

The client is taught to breathe from the diaphragm, and to rely less on his/her chest muscles
Client is instructed to concentrate on breathing by counting inhalation and thinking the word “relax” as he/she exhales

Homework (Session 3)
The integration of breathing exercises and cognitive control is emphasized.

WARNING: On occasion clients mistakenly believe there are dire consequences should they fail in regulating their breathing, hence increasing anxiety and panic symptoms.
Practice abdominal breathing BID, 10 min.
Continue self-monitoring

Session 4

Goals: 1) Develop breathing control (at this point clients are instructed to practice slow breathing only in “safe” environments. Clients are discouraged to practice slow breathing in panic/anxiety situation, until they are skilled.

Goals: 2) Begin active cognitive restructuring. Steps:
Restate that there is no real threat with PA
Clients are taught their thoughts are guesses, not facts! Furthermore, clients are taught the fallacy of their downward arrow thinking (Panic->Faint->embarrassment->overwhelming shame). Clients taught to observe their automatic thinking and self statements.

Un-useful Statement/insufficient: “I feel terrible—something terrible might happen now!”
Useful for challenging misassumptions “I am afraid if I get too anxious when driving that I will drive of the side of the road and die!”
Homework: Question odds, look at evidence for thoughts. Continue monitoring.

Session 5

Session Goals: Enhanced breathing control
Fixing a second cognitive error: Catastrophizing– is where a client views a situation as dangerous, unbearable, or catastrophic.

“If I faint, people will think that I am weak; and that would be unbearable.”

“The whole evening is ruined if I start to feel anxious.”

Decatastophising: to realize the scenarios are not as bad as you first thought.
How to manage/cope with bad situations.
Teach that awfulizing physiological symptoms is to give them control.

Session 6

Goal: Begin Interoceptive Exposure (IE)
Clients are often not aware of the things they avoid to avoid the physical sensations that accompany them…
Exercise
Emotional discussions
Suspenseful movies
Steamy rooms (shower with door closed)
Certain foods
Stimulants (i.e. coffee)

The purpose of interoceptive exposure is to repeatedly induce the sensations that are feared, so that the fear response weakens.

Clients are to rate their sensation intensity 0-8
Shake head back and forth for 30 seconds
Head between legs for 30 seconds, and lifting up quickly
Running for 1 minute
Holding breath for as long as possible
Session 6 (Cont.)
Complete muscle tension for one minute
Pushup position as long as possible
Spinning in a swivel chair for 1 minute
Breathing through a straw with plugged nose
Breathing as slow as possible for 2 minutes
Staring at a mirror for 2 minutes

If these don’t work, make them worse
Take a deep breath and hold it, then hyperventilate
Wear heavy clothes in aheated room
Choke the patient with a tongue depressor, a high collared sweater, or a necktie!
Startle the client with a loud noise during relaxation!

Anxiety will often be lower in session that in vivo. Discussion can center on the misassumptions that make naturally occurring panic symptoms more frightening.

Session 7
Repeat interoceptive exposure
At this time clients are instructed to apply breathing control at times of anxiety
Cognitive restructuring continues with “hypothesis testing,” which is experimental design to disconfirm catastrophic hypotheses.

Test: will one fall if he/she does not lean on a wall while feeling dizzy? Will someone comment on how weird a client is, in public?
More induction and coping in this session.

Session 8
Continue interoceptive exposure and hypothesis testing.
Review daily, in vivo, practice of IE

Session 9
Goals: extend interoceptive exposure to natural activities (i.e. exposure to daily tasks that have been dreaded or avoided outright).
Exercise
Eating avoided foods (spicy, filling)
Saunas and steamy showers
Caffeine!

Suspenseful movies
Disneyland rides

Clients are requested to ID maladaptive cognitions and restructure prior to each activity. Remove safety signals (i.e. lucky charms, rituals, cell phones) if appropriate.

Session 10
Begin exposure to feared/avoided agoraphobic situations (in vivo)
1) Be careful to remove safety behaviors/objects.
2) An emphasis on pre-event cognitive restructuring
In Vivo exposure: targets situations in which anxiety and panic are expected to occur, and from which escape is difficult (as opposed to IE in the therapy office).

Rationale for In Vivo: Much like IE, prolonged exposure will lower the power of the feared situation. Amount of time devoted to In Vivo will be directly related to client’s agoraphobia.

In Vivo Exposure WILL FAIL if:
Haphazard designs/attempts
Exposure too brief
Exposures spaced too far apart
Conducted without confidence/sense of mastery
Conducted while maintaining catastrophising ideations.

Session 11
If possible a spouse is introduced into counseling and coached on how to support the PDA partner with daily In Vivo exposures.
Sessions 12-15
In Vivo exposures completed independently, or with a partner, over the last week are reviewed, and general principles are reinforced. Therapist feedback on cognitive restructuring and partner’s coaching technique are provided, if necessary.

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