292 TREATMENT OF SPECIFIC ANXIETY DISORDERS
and still others may show a shift in which only certain physiological threat schemas
are dominant at any particular time (D. M. Clark, 1986a). Acquisition of particular
physiological threat schemas (e.g., “Heart palpitations are dangerous”) will depend on
prior learning history and the circumstances associated with the first panic attack (D.
M. Clark, 1997). For example, it is common for individuals who experience chest pain
to first go to emergency departments where they receive a full cardiac assessment. Such
experiences can reinforce beliefs that “chest pain represents a highly imminent danger
of heart attack and possible death.” It is obvious how such experiences can lead to
hypervalent schemas about the dangerousness of chest pain and the pathogenesis of
panic disorder.
In order to activate physiological and mental threat schemas, the corresponding
internal sensations must reach a certain threshold of intensity (Beck, 1988). For exam-
ple, Helen did not experience heightened anxiety until her sense of breathlessness was
sufficiently intense that she began to wonder if she was getting enough air. Furthermore,
once schematic activation occurs, the main consequence is the catastrophic misinterpre-
tation of the internal sensation. Once Helen’s beliefs about the danger of breathlessness,
suffocation, and lack of oxygen were activated by attention to her respiratory sensations,
she made a rapid, automatic catastrophic misinterpretation. “There is something wrong
with my breathing and I am not getting enough oxygen; I could suffocate to death.”
Thus the cognitive basis of the catastrophic misinterpretation of bodily sensations is
the activation of prepotent and enduring threat- oriented schemas about the imminent
danger associated with certain somatic or mental sensations.
Catastrophic Misinterpretation of Internal Sensations
The central cognitive process in the persistence of panic is the catastrophic misinter-
pretation of somatic or mental sensations (see Beck, 1988; Beck et al., 1985; D. M.
Clark, 1986a). Often the catastrophic outcome associated with physical sensations is
death caused by heart attack, suffocation, seizure, or the like. However, the imagined
catastrophe can also involve a loss of control that leads to insanity (i.e., “I’ll go crazy”),
or acting in an embarrassing or humiliating manner in front of others. In addition,
fear of panic attacks can be so intense that the catastrophe might be the possibility of
experiencing another severe full-blown panic episode. Whatever the actual nature of
the dreaded catastrophe, the sensations are misinterpreted as representing an imminent
physical or mental disaster (D. M. Clark, 1988). In order to precipitate panic, the cata-
strophic threat must be perceived as imminent; if the misinterpretation is merely exag-
gerated threat, then anxiety rather than panic will be roused (Rachman, 2004). The
occurrence of the catastrophic misinterpretation is the cognitive basis for the remaining
processes that contribute to panic disorder (see Figure 8.1). In cued or situational panic
attacks sensations associated with heightened anxiety are misinterpreted, whereas in
spontaneous (uncued) panic attacks the sensations arise from a variety of nonanxious
sources (e.g., exercise, stress, emotional reactions). D. M. Clark (1988) argued that the
catastrophic misinterpretation of bodily sensations is necessary for the production of
a panic attack and represents an enduring cognitive trait (vulnerability) that is evident
even when individuals with panic disorder are not anxious.
As a Phase I process that is elicited by activation of panicogenic schemas, the cata-
strophic misinterpretation is an involuntary, automatic, and rapid response to the detec-