294 TREATMENT OF SPECIFIC ANXIETY DISORDERS
This loss of reappraisal capability is clearly illustrated in a young man with panic
disorder who was fearful of sudden increases in his heart rate. On some occasions, such
as sitting at his computer, he would perceive an increase in heart rate that elicited the
apprehensive thought “Why is my heart racing?” His underlying physiological threat
schemas were “I am vulnerable to heart attacks,” “If I let my heart rate get too high,
I could have a heart attack,” and “After all, I do have a cardiac condition” (he had a
diagnosed congenital cardiac condition that was benign). Once activated, he generated a
catastrophic misinterpretation (“My heart is racing, I might be having a heart attack”).
At this point he was unable to generate an alternative explanation for this increased
heart rate, and so he became panicky. On other occasions, such as when working out
at the gym (as recommended by his physician), he would notice his heart rate increase,
wonder if it could be a sign of a cardiac problem, but immediately reappraised the sensa-
tions as due to the demands of his physical activity. One of the main objectives of cog-
nitive therapy for panic is to improve the patient’s ability to reappraise fearful internal
sensations with more realistic, plausible, and benign alternative interpretations.
Other Secondary Elaborative Processes
As illustrated in Figure 8.1 there are a number of other secondary cognitive and behav-
ioral processes that occur as a result of the dissociation of elaborative reasoning from
the automatic catastrophic threat appraisals. Beck et al. (1985) noted that a striking
characteristic of panic attacks is the experience of anxiety as an overwhelming and
uncontrollable state. The individual with recurrent panic attacks thinks of anxiety as a
rapidly escalating and uncontrollable experience that she learns to dread.
A second cognitive process at the elaborative phase is apprehension and worry about
mounting anxiety and the recurrence of panic attacks. The worry in panic disorder is
focused almost exclusively on panic attacks and the intolerance of heightened states of
anxiety. After a number of CT sessions, Helen’s panic attacks remitted. However, her
apprehension and worry over a possible relapse remained high. For example, she was
considering a change of jobs and a move to a new city but was very reluctant to make
any changes for fear it would heighten her anxiety and trigger a new round of panic
attacks.
With elaborative information processing dominated by perceptions of uncontrol-
lable and escalating anxiety, constant apprehension and worry about panic, and loss of
higher order reflective reasoning to counter the domination of catastrophic thinking,
it is little wonder that the person with panic disorder deliberately turns to avoidance
and other safety- seeking strategies to exert better control over his negative emotional
state. However, there is now considerable evidence that agoraphobic avoidance actu-
ally contributes to the persistence and increased severity of panic disorder (see previous
discussion). Moreover, reliance on safety- seeking behaviors such as carrying anxiolytic
medication in case of emergency, being accompanied by a family member or friend, or
suppressing strong emotions and unwanted thoughts, can actually contribute to the per-
sistence of panic by maintaining the person’s belief that certain internal sensations are
dangerous (D. M. Clark, 1997, 1999).
As can be seen from Figure 8.1, there is a strong reciprocal relationship between the
panic- relevant cognitive processes that occur early at the automatic, catastrophic inter-