274 CHAPTER 7
order to prevent an increased heart rate) or to avoid situations associated with panic
attacks (such as crowded theaters). Campbell, prior to his panic attacks, would jog
4–5 miles a day, but he stopped after his first panic attack: “I was afraid to go
outside, afraid of having an attack right there on the street” (Campbell & Ruane,
1999, p. 108). Once he learned about panic disorder and how to combat it, he chal-
lenged himself to resume jogging. He began by walking alone down the block. Each
day he went for a longer walk, and then he gradually started running.
Exposure for patients with agoraphobia addresses the particular situations they
try to avoid. At the beginning of exposure treatment, patients may use imaginal
exposure, exposure to mental images of the fear-inducing stimuli, progressing from
least to most anxiety-inducing situations. They may then switch to in vivo exposure—
direct exposure to the feared or avoided situation or stimulus (Barlow, Esler, &
Vitali, 1998). The therapist or another person may accompany the patient on
the fi rst few in vivo exposures, or the patient may decide to have the experience
alone. Not all patients, however, are willing or able to go through such exposure
therapy; dropout rates have ranged from 3% to 25% (Chambless & Gillis, 1994;
van Balkom et al., 1997). Of those patients who do undergo exposure treatment,
60–75% improve, and are still improved at follow-up 6–15 months later (Barlow,
Esler, & Vitali, 1998). However, some patients continue to have residual symptoms
of panic or avoidance, even though the treatment is largely successful.
To decrease a patient’s reaction to bodily sensations associated with panic,
behavioral therapists may use interoceptive exposure: They have the patient
intentionally elicit the bodily sensations associated with panic so that he or she
can habituate to those sensations and not respond with fear. During exposure
to interoceptive cues, patients are asked to behave in ways that induce the long-
feared sensation, such as spinning around to the point of dizziness or intentionally
hyperventilating (see Table 7.7 for a more extensive list). Within approximately
30 minutes, the bodily arousal subsides. This procedure allows patients to learn
that the bodily sensations pass and no harm befalls them. Because patients had pre-
viously avoided activities that were associated with the sensations, they never got to
see (and believe) that such sensations did not lead to a heart attack or suffocation.Cognitive Methods: Psychoeducation and Cognitive Restructuring
Cognitive methods for panic disorder help the patient to recognize misappraisals of
bodily symptoms and to learn to correct mistaken inferences about such symptoms.
First, psychoeducation for people with panic disorder involves helping them to un-
derstand how their physical sensations are symptoms of panic and not of a heart
attack or some other harmful medical situation. The therapist describes the biology
of panic and explains how catastrophic thinking and anxiety sensitivity can lead
panic attacks to develop into panic disorder. Campbell read a pamphlet about panic
disorder that described his symptoms perfectly. Having learned about the disorder
in this way, he was better able to handle future panic attacks: “One of the most
important things I have learned about my panic disorder over the years is that al-
though my heart may be racing and I may feel like I’m having a heart attack, I know
that I’m not. And I know it’s going to stop” (Campbell & Ruane, 1999, p. 204).
Second, cognitive restructuring is then used to transform the patient’s initial
frightened thoughts of a medical crisis into more realistic thoughts, identifying the
symptoms of panic, which may be uncomfortable but do not indicate danger (Beck
et al., 1979). For instance, a therapist helps a patient identify the automatic negative
thought about bodily arousal (“I won’t be able to breathe... I’ll pass out”) and
then challenges the patient about the belief: Was the patient truly unable to breath,
or was breathing only diffi cult? Has the patient fainted before? In this way, each
of the patient’s automatic negative thoughts related to panic sensations are chal-
lenged and thereby reduced. Learning to interpret correctly both internal and exter-
nal events can play a key role in preventing panic attacks that occur when a person
experiences symptoms of suffocation (Clark, 1986; Taylor & Rachman, 1994).P SNIn vivo exposure
The behavioral therapy method that consists
of direct exposure to a feared or avoided
situation or stimulus.
Interoceptive exposure
The behavioral therapy method in which
patients intentionally elicit the bodily
sensations associated with panic so that they
can habituate to those sensations and not
respond with fear.