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Chapter 6
Cognitive Interventions for Anxiety
Courage is not the lack of fear but the ability to face it.
—LT. Jo h n B. pu T n aM Jr. (23-year-old
American airman killed in World War II)Pierre is a 33-year-old married man with two preschool children who had a
15-year history of panic disorder and a single episode of major depression in
remission. Past treatment was primarily pharmacotherapy that proved quite
effective in reducing his depression but had less impact on his anxiety symp-
toms. Pierre was now interested in pursuing a course of CBT for anxiety and
panic symptoms.
At intake Pierre met diagnostic criteria for panic disorder. He reported at
least five full-blown panic attacks in the past month that included heart palpi-
tations, sweating, nausea, shortness of breath, hot flushes, dizziness, and light-
headedness. Nausea was the initial physical sensation that often precipitated a
panic attack. Pierre was fearful that the nausea would lead to vomiting. His
greatest fear was losing control and vomiting in a public setting. As a result he
was hypervigilant for any signs of nausea or abdominal discomfort. He discov-
ered that social situations were more likely to trigger nausea and heightened
levels of anxiety and so he tended to avoid these situations or leave as soon as
he felt abdominal discomfort. Because of his apprehension about heightened
anxiety and panic, Pierre developed limited agoraphobic symptoms in order to
avoid the risk of panic.
The main cognitive basis to Pierre’s anxiety was his belief that “feeling
nausea or abdominal discomfort in a public setting could cause vomiting, or
at least intense anxiety or panic.” His catastrophic misinterpretation of nausea
was not related to a fear of vomiting per se (i.e., he was not fearful of becom-
ing ill), but rather that he would have a panic attack that would cause intense
embarrassment from vomiting in public. He could only recall one incident in
which he vomited in response to a severe panic attack. It appears that this
incident may have been caused by a recent increase in his medication. More
recently there was evidence that the anxiety may be generalizing to other situ-
ations such as flying, travel away from home, and sleep.