276 TREATMENT OF SPECIFIC ANXIETY DISORDERS
respiration or cardiac functioning. As a result she became increasingly reluc-
tant to venture more than a few miles from a hospital for fear that she would
be trapped without access to medical facilities. Avoidance, reassurance seek-
ing and self- monitoring of physical symptoms (e.g., repeated pulse checking)
became the main coping strategies for her daily battle with panic attacks.
A structured diagnostic interview revealed that Helen met DSM-IV cri-
teria for panic disorder with agoraphobic avoidance of moderate severity. She
did not have any other current comorbid condition but did report two previous
episodes of major depression with suicidal ideation. Her pretreatment symp-
tom scores were BDI-II = 8, BAI = 22, PSWQ = 64, Agoraphobic Cognitions
Questionnaire (ACQ) = 33, and Body Sensations Questionnaire (BSQ) = 48.
Her main threat- related thoughts concerned “What if I can’t get my breath and
I suffocate?”, “Could this chest pain mean that I am having a heart attack?”,
“What if I can’t get to the hospital in time?”, “What if this builds into another
panic attack and it eventually drives me crazy?”, and “Is this ever going to
end?” In short, Helen revealed a pattern of anxious thinking and misinter-
pretation that reflected an intolerance of anxiety and reliance on maladaptive
avoidance and safety- seeking strategies in a desperate attempt to control her
anxiety and prevent the much dreaded panic attacks.Helen’s clinical state exemplifies a fairly typical presentation of panic disorder.
Twelve individual sessions of CBT followed by four booster sessions over an 8-month
period proved highly effective in reducing panic frequency, generalized anxiety, and
agoraphobic avoidance. Treatment focused on (1) psychoeducation in the cognitive ther-
apy model, (2) intentional activation of bodily sensations and underlying fear schemas,
(3) cognitive restructuring and reattribution of misinterpretations of bodily sensations,
(4) graded situational exposure homework, and (5) increased tolerance and acceptance
of anxiety, risk, and uncertainty with a corresponding reduction in intentional control
efforts. In this chapter we begin with a description of the phenomenology and diagnosis
of panic and agoraphobia, followed by a discussion of the cognitive model of panic, and
its empirical status. The remainder of the chapter discusses issues of assessment, case
formulation, the cognitive therapy treatment protocol, and its efficacy.
DiagnostiC ConsiDerations anD CliniCal featuresThe Nature of Panic
Panic attacks are discrete occurrences of intense fear or discomfort of sudden onset
that are accompanied by a surge of physiological hyperarousal. Barlow (2002) con-
siders panic the clearest clinical presentation of fear. In addition to strong autonomic
arousal, panic is characterized by a faulty verbal or imaginal ideation of physical or
mental catastrophe (e.g., dying, going insane), intense uncontrollable anxiety, and a
strong urge to escape (Barlow, 2002; Beck et al., 1985, 2005; Ottaviani & Beck, 1987).
So aversive is the panic experience that many patients have a strong apprehension about
having another attack and develop extensive avoidance of situations thought to trigger
panic. As a result panic and agoraphobia are closely associated, with most individuals
with panic disorder presenting with some degree of agoraphobic avoidance and 95% of