306 TREATMENT OF SPECIFIC ANXIETY DISORDERS
appears to be important in terminating, and possibly inhibiting, panic (Lohr et al.,
2007; Rapee, 1995a). However, there are clearly healthy and unhealthy ways to achieve
this state of safety (Schmidt et al., 2006). Helping individuals with panic disorder adopt
stronger beliefs in safety explanations for bodily sensations may be the most effective
approach in panic disorder, whereas reliance on actual safety- seeking behavior (e.g.,
distraction, avoidance) may block access to disconfirming evidence and contribute to
the persistence of panic symptoms, though this latter conclusion still requires consider-
able investigation in light of more recent findings that safety behavior may not be as
deleterious as once thought.
Cognitive assessment anD Case formulationDiagnosis and Symptom Measures
Assessment for panic disorder should begin with a structured diagnostic interview like
the SCID-IV (First et al., 1997) or ADIS-IV (Brown et al., 1994) given that panic attacks
per se are highly prevalent in all the anxiety disorders. The ADIS-IV is recommended
for the diagnosis of panic disorder because it has high interrater reliability for the disor-
der (k = .79; Brown, Di Nardo, & Barlow, 2001) and provides a wealth of information
on panic symptoms. It distinguishes between situationally cued and unexpected panic
attacks and severity ratings are obtained on all the DSM-IV symptoms for both full-
blown unexpected panic attacks and limited symptom attacks. In addition information
is collected on extent of worry over future panic attacks, situational triggers, avoidance,
interoceptive sensitivities, safety signals, and negative impact associated with recurrent
panic attacks. The module on agoraphobia provides ratings on the degree of apprehen-
sion and avoidance associated with 20 situations commonly avoided in agoraphobia.
Various self- report panic symptom measures should also be administered as part of
the cognitive assessment. In Chapter 5 we reviewed evidence that the BAI (Beck & Steer,
1990) assesses the physiological symptoms of anxiety (e.g., Beck, Epstein, et al., 1988;
Hewitt & Norton, 1993), thus making it a particularly sensitive measure for panic dis-
order. Leyfer, Ruberg, and Woodruff- Borden (2006) calculated that a BAI Total Score
cutoff of 8 would identify 89% of individuals with panic disorder and exclude 97%
without panic disorder. The ASI is another measure that is highly relevant for panic (see
Chapter 4) given that individuals with panic disorder score significantly higher than
individuals with all other anxiety disorders. Below we briefly discuss four panic symp-
tom measures that are especially useful when assessing panic disorder.
Agoraphobic Cognitions Questionnaire
The Agoraphobic Cognitions Questionnaire (ACQ) is a 15-item self- report question-
naire that assesses thoughts of perceived negative or threatening consequences (i.e., fear
of fear) associated with the physical symptoms of anxiety (Chambless et al., 1984).
Individuals with agoraphobia score significantly higher than those with other anxiety
disorders, especially on the ACQ—Physical Concerns subscale (Chambless & Gracely,
1889), and the instrument is sensitive to treatment effects (Chambless et al., 1984). Indi-
viduals with panic attacks report higher ACQ scores than those without panic attacks
(Craske, Rachman, & Tallman, 1986). The mean ACQ Total score for panic disorder