Panic Disorder 319
is observed and provides a test of the catastrophic versus the alternative explanation
for bodily sensations. D. M. Clark and Salkovskis (1986) describe various behavioral
experiments that can be used in the treatment of panic disorder.
A number of behavioral experiments were used to test Helen’s catastrophic inter-
pretations and beliefs. In one homework assignment she was asked to hold her breath
whenever she felt breathless sensations in order to amplify the sensations. After a few
seconds of breath holding, she was told to breathe normally and note differences between
breath holding and breathing. “Was there any evidence that she was exaggerating the
sense of breathlessness prior to breath holding?” “Was she able to breathe normally
after holding her breath?” From these experiences Helen found evidence that indeed
she was exaggerating breathlessness and her breathing was much more normal than
she thought. In another behavioral experiment Helen was encouraged to induce physi-
cal sensations while in fear situations by increasing her physical activity level. These
experiments provided evidence that physical sensations themselves do not automatically
lead to anxiety or panic (e.g., “Even when anxious, increasing my heart rate by run-
ning up stairs does not increase my anxiety level”). Instead she discovered that how she
interprets the symptoms determines whether anxiety escalates into panic (e.g., “When I
know my heart is pounding fast because of exercise I don’t feel anxious”).
Clinician Guideline 8.13
Behavioral experiments provide a critical test of the role that catastrophic thoughts and
beliefs play in the persistence of anxiety and panic symptoms. The experiments are designed
to show that the mere occurrence of physical sensations is not the primary cause of anxiety
but rather it is their catastrophic misinterpretation that leads to panic attacks.Graded In Vivo Exposure
Given that most individuals with panic disorder exhibit at least mild forms of agora-
phobic avoidance, graded in vivo exposure is a major component of cognitive therapy
for panic disorder. When agoraphobic avoidance is severe, in vivo exposure must be
introduced early in treatment and become the main focus of therapy. However, the cog-
nitive therapist uses exposure to challenge the catastrophic cognitions and beliefs of the
agoraphobic individual. Since Chapter 7 provided an extensive discussion of graded in
vivo exposure and its implementation, the reader is encouraged to consult that section
when employing exposure exercises in cognitive therapy of panic.
In our case illustration Helen presented with fairly extensive avoidance of external
situations because of her fear of panic attacks and of being too distant from a hospital
in case she suffered a heart attack or episode of suffocation. A fear hierarchy was con-
structed involving 23 situations ranging from taking a bus trip to a nearby city (rated
10 on a scale of 0–100) to taking a transcontinental flight (rated 100). Helen engaged
in repeated exposure to a variety of situations on her fear hierarchy, gathering evidence
against her most feared outcomes, and confirming the role of catastrophic thinking
in the genesis of panic. Furthermore, the exposure suggested more benign, alternative
explanations for her physical sensations, thereby enhancing her ability to reappraise
unwanted feelings and sensations.