328 TREATMENT OF SPECIFIC ANXIETY DISORDERS
summary anD ConClusionThe problem of recurrent panic attacks provides the clearest example of the cognitive
conceptualization of fear. Occurrence of at least two unexpected panic attacks, appre-
hension or worry about further attacks, and avoidance of situations thought to trigger
panic are hallmarks of panic disorder.
A revised cognitive model of panic disorder was presented in Figure 8.1. The essen-
tial components of this model are (1) increased attention or hypervigilance for certain
physical or mental sensations, (2) activation of physiological or mental threat schemas,
(3) the catastrophic misinterpretation of physical symptoms as indicating an imminent
dire threat to self, (4) further intensification of the physical symptoms of anxiety, (5) loss
of ability to reappraise symptoms in a more realistic, benign manner, and (6) reliance
on avoidance and safety seeking to reduce heightened anxiety and terminate the panic
episode. Empirical evidence, reviewed for the model’s six key hypotheses, found strong
support for increased responsiveness to internal states, the activation of prepotent physi-
ological or mental threat schemas, the catastrophic misinterpretation of bodily sensa-
tions, and the functional role of avoidance and safety seeking in the persistence of panic
attacks.
Table 8.7 summarized the main components of cognitive therapy for panic disorder.
Reduction in hypervigilance for feared bodily sensations, reversal of the catastrophic
misinterpretation of internal states, increased ability to produce more realistic and bal-
anced reappraisals of the feared symptoms of anxiety, reduction in avoidance and safety
seeking, and an increased sense of safety are the primary goals of cognitive therapy.
These are achieved using within- session symptom induction to activate threat schemas,
cognitive restructuring to weaken catastrophic misinterpretations and improve reap-
praisal capacity, and systematic situational and interoceptive exposure assignments in
a hypothesis- testing context. Over the last two decades a number of well- designed ran-
domized clinical trials have established cognitive therapy as a highly efficacious treat-
ment for panic disorder with or without agoraphobic avoidance.
There are a number of issues that remain for cognitive theory and therapy of panic
disorder. Panic disorder is characterized by increased responsiveness to changes in inter-
nal state, although the specific processes that contribute to this interoceptive hypersen-
sitivity are not well understood. It is still not clear whether a catastrophic misinterpreta-
tion of bodily sensations is necessary for the production of all panic attacks, whether it
is a cause or a consequence of repeated panic attacks, and whether the concept should
be broadened to include imminent social and emotional threats such as fear of further
panic attacks. Moreover, there is insufficient research on whether loss of reappraisal
capacity is a major determinant of recurrent panic attacks and the role played by panic
self- efficacy or perceived effectiveness in terminating panic episodes. In terms of treat-
ment effectiveness, comparative outcome studies of cognitive therapy versus the newer
SSRIs are needed as well as longer follow-up periods to determine the enduring benefits
of treatment. Nevertheless, cognitive therapy/CBT is now considered a well- established
and efficacious treatment for panic disorder with or without agoraphobia and should be
the first-line treatment choice in most cases of the disorder.