Panic Disorder 279
of mental instability or “going crazy.” Catastrophic misinterpretations are discussed
more fully in our review of the cognitive research.
Apprehension of Panic
Individuals with panic disorder report extreme distress, even terror, during panic attacks
and so quickly develop considerable apprehension about having future attacks. This fear
of panic is a distinguishing feature of the disorder and is included in DSM-IV-TR as a
diagnostic criterion (APA, 2000). Presence of fear and avoidance of panic attacks dif-
ferentiates panic disorder from other anxiety disorders in which panic attacks occur but
the “fear of panic” is missing.
Extensive Safety Seeking and Avoidance
Safety- seeking behavior and avoidance of panic- related situations are common responses
to panic attacks and may be seen as coping strategies to prevent the impending disaster
(e.g., overwhelming panic, a heart attack, loss of control). Phobic avoidance is common
in panic disorder and is elicited by the anticipation of panic attacks in particular (Craske
& Barlow, 1988). The phobic situations associated with agoraphobia are quite variable
across individuals because the avoidance is elicited by the anticipation of panic attacks
and not by the situations themselves (White & Barlow, 2002). White et al. (2006)
reported that 98% of panic disorder cases have mild to severe situational avoidance,
90% experiential avoidance (i.e., use safety signals or thought strategies to withdraw
or minimize contact with a phobic stimulus), and 80% interoceptive avoidance (i.e.,
refusal of substances or activities that could produce the physical sensations associated
with panic). Furthermore, they found that severity of agoraphobic avoidance was pre-
dicted by elevated fear of physical symptoms of anxiety (i.e., anxiety sensitivity) and low
perceived control over threat. Together these findings indicate a close but complicated
relationship between panic attacks and the development of avoidance responses.
Perceived Lack of Control
Beck et al. (1985, 2005) noted that a striking characteristic of panic attacks is the feel-
ing of being overwhelmed by uncontrollable anxiety. This apparent loss of control over
one’s emotions and the anticipated threat causes a fixation on the panicogenic sensa-
tions and a loss of capacity to use reason to realistically appraise one’s physical and
emotional state (Beck, 1988; see also Barlow, 2002).
Panic Distinct from Anxiety
McNally (1994) argues that panic should not be seen as an extreme form of anxiety
involving the anticipation of future threat but rather as an immediate “fight-or- flight”
response to perceived imminent danger. In the cognitive model of anxiety presented
in Chapter 2, panic attacks would fall within the “immediate fear response” (Phase
I), whereas apprehension about panic, avoidance, and safety- seeking would constitute
secondary processes (Phase II) that maintain a state of heightened anxiety about having
panic attacks.