Panic Disorder 311
panic attacks. For others, fear of panic, loss of control, and intolerance of anxiety are
associated features of the catastrophic misinterpretation. Although Helen’s catastrophic
misinterpretation remained fear of suffocation, in later sessions she expressed greater
anxiety and apprehension about the return of panic attacks rather than of dying from
suffocation. In the early stage of treatment it is important to obtain a full description
of the various negative consequences that clients think about when they are anxious or
panicky. Helen’s treatment plan required that we target both her catastrophic misinter-
pretation of chest pain and breathlessness (i.e., fear of heart attack or suffocation) and
her apprehension about panic and intolerance of anxiety.
As noted in Table 8.6, the ACQ can provide some initial indication of the patient’s
misinterpretation of anxious symptoms. However, self- monitoring forms that instruct
individuals to record their symptom appraisals during peak anxiety will be most help-
ful. These include the weekly panic log, the Physical Sensations Self- Monitoring Form
(Appendix 5.3), and the Apprehensive Thoughts Self- Monitoring Form (Appendix 5.4).
It may be necessary to use a panic induction exercise during the session to identify the
client’s faulty appraisal process. This may be especially true for individuals who have
limited insight into their anxious cognitions.
Apprehension and Intolerance of Anxiety
It is important to identify the panic individual’s faulty cognitions and beliefs about anxi-
ety, panic, and physical discomfort more generally. The ASI will provide an indication
of an individual’s tolerance of anxiety, especially its physical symptoms. Faulty beliefs
about anxiety can also be deduced from the types of cognitive errors that individuals
commit when anxious (use Identifying Anxious Thinking Errors, Appendix 5.6) and
the focus of their worries (use Worry Self- Monitoring Form, Appendix 5.8). Individuals
with panic disorder often worry about being anxious and panicky, so their worry con-
tent may reveal their beliefs about anxiety and its consequences. Helen had a very good
response to cognitive therapy for panic but continued to endorse a number of beliefs that
ensured recurrent states of heightened anxiety such as “If I have some unexpected physi-
cal discomfort, there must be something wrong,” “I have to deal with this discomfort,
or it could escalate into anxiety and panic,” “I can’t stand feeling anxious, I have to get
rid of the feeling,” and “If I don’t stop the anxiety, it will escalate into panic.” Thus the
latter sessions shifted focus from the catastrophic misinterpretation to normalization
exercises designed to increase her tolerance of anxiety.
Avoidance and Safety- Seeking
A cognitive assessment of panic must also include a list of all the situations and stimuli,
both external and internal, that are avoided for fear of elevated anxiety or panic. For each
situation the patient should rate degree of anxiety associated with the situation (0–100)
and extent of avoidance (0= never avoided to 100= always avoided). In addition the cog-
nitive therapist identifies all the subtle cognitive and behavioral safety cues that may be
used to reduce anxiety. The Behavioral Responses to Anxiety Checklist (Appendix 5.7)
and the Cognitive Responses to Anxiety Checklist (Appendix 5.9) forms can be helpful
in this regards, whereas the Mobility Inventory and Exposure Hierarchy (Appendix 7.1)
may be used to explore avoidance behavior. If the concept of avoidance is broadened to