310 TREATMENT OF SPECIFIC ANXIETY DISORDERS
Important contextual and phenomenological information on panic can also be
obtained from the panic disorder module of the ADIS-IV. The Situational Analysis
Form (Appendix 5.2) is an alternative measure that can be used to gather data on the
situational triggers, primary symptoms, and anxious interpretation of panic. Whether
this form is used or the weekly panic log, arriving at a valid case formulation depends on
obtaining this “online assessment” of multiple instances of panic that occur in natural-
istic settings. Individuals who refuse to fill in the panic log or who provide insufficient
information will hamper treatment.
Helen, who was introduced at the beginning of this chapter, recorded one to two
daily panic and anxiety episodes on her weekly panic log at pretreatment. Only one to
two of these weekly episodes were considered full-blown panic attacks. The remain-
der were limited- symptom attacks or acute anxiety over physical symptoms associated
with a heightened degree of worry that a panic attack might occur. A variety of situa-
tions were identified that triggered anxiety and panic including public settings, staying
overnight away from home, driving alone in the car outside her community, being in
locations that were distant from medical facilities, and the like. Evidence of mild to
moderate agoraphobic avoidance indicated that in vivo exposure should be a prominent
feature of the treatment plan.
Interoceptive Hypersensitivity
Two issues are particularly important when assessing hypersensitivity to bodily sensa-
tions. What is the first physical or mental sensation experienced in the sequence of sen-
sations that leads to panic? And which physical or mental sensation is the focus of the
catastrophic misinterpretation?
Although the BSQ can be helpful in assessing responsiveness to bodily sensations,
the idiographic rating forms such as the Physical Sensation Self- Monitoring Form
(Appendix 5.3) or the Expanded Physical Sensations Checklist (Appendix 5.5) will have
the greatest clinical utility along with the weekly panic log. The cognitive therapist
should review completed forms with clients, extracting from the discussion the tempo-
ral order of the internal sensations and the primary sensation that is considered most
threatening. For example, a review of Helen’s panic logs revealed that the first sensation
she often noticed during a panic episode was a sense that maybe her breathing was a
little irregular followed by other sensations such as tension, weakness, restlessness, and
lightheadedness. This culminated very rapidly in the physical symptom that was the
focus of her catastrophic misinterpretation and the apex of the panic experience: short-
ness of breath. Based on this information we included symptom amplification exercises
in our treatment plan in order to increase Helen’s exposure to the breathlessness sensa-
tion and decatastrophize her interpretation of the sensations.
Catastrophic Misinterpretation
A critical part of the cognitive assessment is to identify the primary catastrophic misin-
terpretation of internal sensations. The clinician focuses on discovering the impending
immediate physical or mental catastrophe that underlies the panic episode (e.g., fear
of heart attack, suffocation, going crazy). Often a fear of anxiety or dread of future
panic attacks replaces the somatic catastrophe for those with a history of recurrent