Panic Disorder 293
tion of certain internal sensations. D. M. Clark (1988) argued that catastrophic misin-
terpretations can be rapid and outside conscious awareness so the panic attack appears
spontaneous. Once activated the panicogenic schemas and catastrophic misinterpreta-
tions tend to dominant the information- processing apparatus during panic. It is highly
biased, giving processing priority to danger cues and minimizing or ignoring schema-
incongruent safety information.
Symptom Intensification and Defense
The catastrophic misinterpretation of bodily sensations will cause an intensification of
the feared internal sensations by heightening vigilance and an internal focus on intero-
ceptive cues (Beck, 1988; D. M. Clark, 1997). A vicious cycle occurs in which the escalat-
ing intensity of the physiological or mental sensation further reinforces the misinterpre-
tation that indeed a physical or mental disaster is imminent. Helen, for example, would
notice that her breathing was a little irregular and felt like she was not getting enough air.
Her initial appraisal “I am not breathing normally, I don’t think I am getting enough air”
(exaggerated threat interpretation) led to an increased focus on her breathing. She would
breathe deeply and try to establish a more controlled breathing rate. But the heightened
focus on her breathing intensified her sense of breathlessness (symptom intensification)
that in turn deepened her conviction that her respiratory problem was getting worse and
even more likely to lead to suffocation (catastrophic misinterpretation).
In addition to an automatic intensification of symptoms, the catastrophic misin-
terpretation will result in immediate attempts to escape. Again, efforts to escape are
viewed as an automatic and involuntary response to panicogenic schema activation and
the catastrophic misinterpretation of the bodily sensation. A person fearful of chest
tightness may quickly cease a particular activity when the somatic sensation is detected.
A patient who had a profound sense of derealization in his hotel room after driving in
heavy traffic in New York City immediately laid down and then had several alcoholic
drinks in order to relax. His responses were an attempt to escape from the sense of
derealization which he interpreted as a symptom of going crazy. When in a state of
heightened anxiety and panic, the escape response triggered by the catastrophic mis-
interpretation can occur quite automatically without deliberate, effortful planning. As
noted in Figure 8.1, the intensification of physical sensations and escape responses will
contribute to the continued activation of the panic- relevant schemas.
Loss of Reappraisal Capability
According to Beck (1988), the dissociation of the higher level reflective processes (Phase
II) from the automatic cognitive processing (Phase I) is a necessary condition for a
panic attack. Thus we consider the loss of reappraisal capability the central process at
the secondary, elaborative phase that is responsible for the persistence of anxiety and
panic. Activation of the physiological threat schemas and subsequent catastrophic mis-
interpretation of bodily sensations dominates information processing and inhibits the
panic- stricken patient’s ability to generate alternative, more realistic, and benign inter-
pretations of the fearful sensations. If reappraisal of the perceived threat is possible, the
catastrophic misinterpretation would be challenged and the escalation into panic would
be thwarted.