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Chapter 8
Cognitive Therapy of Panic Disorder
Of course, we were afraid and fear isn’t always a wise counselor,
let’s go back, for our greater safety we ought to barricade the
door of the wards....
—Jo s é sa r aM a g o (Portuguese novelist and 1998
Nobel Laureate in Literature, 1922– )Helen is a 27-year-old single woman who worked in the insurance industry and
presented with an 11-year history of panic disorder and moderate agoraphobic
avoidance. At the time of assessment she was experiencing approximately eight
full-blown panic attacks daily with elevated levels of generalized anxiety, con-
siderable apprehension about having panic attacks, and avoidance of routine
activities such as travel outside her community, not maintaining close prox-
imity to medical facilities, highway driving, air travel, and the like. The first
onset of panic occurred when she was 16 years old but the panic attacks were
few and far between until she took her first business trip to New York City at
age 22. She described 4 days of terrifying acute anxiety involving chest pain,
heart palpitations, tingling in the extremities, abdominal distress, and agita-
tion. These bodily sensations were accompanied by an intense fear that she
might die from a heart attack. However, she did not seek medical intervention
at the time but instead coped by resting, taking Gravol, and trying to remain
calm. Upon returning home the panic attacks continued. In the intervening 5
years she has been treated with citalopram, lorazepam, and relaxation training
with minimal effectiveness.
Pretreatment assessment revealed that heart palpitations, chest pain,
sweating, shortness of breath, feelings of choking, nausea, and hot flushes
were the main bodily sensations during her panic attacks. Although fears of a
heart attack or of going crazy were still present, her main misinterpretation of
threat had shifted to a focus on breathlessness, with a fear that she would stop
breathing and suffocate. Extensive reliance on safety seeking emerged such
that Helen became preoccupied with maintaining close geographic proximity
to medical facilities, frequently making trips to her family physician and hospi-
tal emergency department whenever she felt intense panic or concern about her