Panic Disorder 321
Given Helen’s relative youth and good physical health, she was encouraged to increase
her physical activity level and record her physiological arousal. This proved quite effective
in helping Helen realize she could tolerate chest tightness and breathless sensations, and
that these sensations could be evoked without danger. Also the breath- holding exercises
when anxious again provided evidence of tolerance and safety. Later in the therapy ses-
sions cognitive restructuring always focused on processing the safety features of anxious
experiences. Helen was repeatedly asked questions such as “Looking back, what aspects
of the situation indicate that it was safer than you originally thought”? Toward the end
of treatment, Helen would spontaneously generate safety reinterpretations of anxiety-
provoking situations and reported a greater sense of safety in her daily life.
Clinician Guideline 8.15
A perceived sense of safety and tolerance of the physical symptoms of anxiety are impor-
tant goals for cognitive therapy of panic. They are achieved by cognitive restructuring and
behavioral exercises that emphasize the client’s natural tolerance of discomfort and the rein-
terpretation of safety features associated with anxiety- provoking situations.Relapse Prevention
As is done in the treatment of other anxiety disorders, relapse prevention should be built
into the final sessions of cognitive therapy for panic. The therapist must ensure that the
client realizes that occasional panic attacks will occur, that unexpected physical sensa-
tions may occur from time to time, and that anxiety is a normal part of life. Relapse can
be minimized if the client has realistic expectations of treatment outcome and adopts a
healthy perspective on anxiety and panic. In addition, significant reduction in the cli-
ent’s “fear of fear” can improve the chance of reduced relapse and recurrence of panic.
The client who continues to fear panic attacks (e.g., “I just hope I never have to experi-
ence those terrible panic attacks again”) is probably most vulnerable to relapse when the
physical symptoms of anxiety reoccur.
In addition to correcting unrealistic expectations about treatment and the “return
of fear,” a number of other measures can be taken to prevent relapse. Therapy sessions
can be gradually faded and booster sessions scheduled. An intervention protocol can be
written down that clearly specifies what to do if unexpected physical symptoms return
or the individual experiences a resurgence in anxiety. However, the most important
relapse prevention strategy for panic may involve having panic disorder patients inten-
tionally produce their feared physical sensations when in anxiety- provoking situations.
Those individuals who progress to the point where they can exaggerate their physical
symptoms while feeling highly anxious may be better inoculated against future unex-
pected resurgences of anxiety and panic.
Clinician Guideline 8.16
Relapse prevention is enhanced when cognitive therapy clients are prepared for the unex-
pected return of fear and panic. In addition relapse and recurrence of panic disorder may