312 TREATMENT OF SPECIFIC ANXIETY DISORDERS
include interoceptive and experiential states (i.e., White et al., 2006), then the clinician
should take a wide- ranging perspective when describing the avoidance component of the
case formulation. As noted previously, Helen continued to use avoidance to manage her
anxiety so in vivo exposure was a critical component of her treatment plan.
Reappraisal Capacity
In the current cognitive model of panic disorder, loss of reappraisal capability is an
important factor in the persistence of panic attacks. Therefore it is important to assess
an individual’s ability to generate alternative, nonthreatening explanations for her phys-
ical sensations. The Symptom Reappraisal Form (Appendix 8.2) can be used to assess
critical components of reappraisal capability that might be present prior to treatment.
Three particular questions need to be addressed.
- Is the client able to offer a number of alternative non- threat explanations for the
physical sensations? - How much does he believe these explanations when anxious or panicky and
when not anxious? - Is the client able to recall these explanations when anxious and if so, what effect
does this have on the anxious state?
The weekly panic log can be a useful starting point for a discussion on possible alterna-
tive explanations for unpleasant or anxious physical sensations. Even if an individual is
unable to generate an alternative explanation to the catastrophic misinterpretation, this
will be valuable clinical information for treatment planning.
In our case illustration, Helen’s initial apprehensive thoughts after noticing an unex-
pected physical sensation were “What’s wrong with me?”, “Why am I feeling this way?”
She immediately generated a catastrophic misinterpretation such as “Could this be a
heart attack?” (i.e., if she felt chest pain), “What if I can’t catch my breath and then start
to suffocate?” (i.e., if she experienced a breathless sensation), or “Will I have a terrible
panic attack?” At pretreatment she was able to generate two less- threatening alterna-
tive explanations for the sensations (e.g., the sensation could be a symptom of anxiety
or stress that will eventually subside). Occasionally she could attribute the symptoms
to physical activity or a state of ill health (e.g., having a cold, flu symptoms). However,
she had difficulty believing these alternative explanations or even being able to access
them when she felt intense anxiety or panic. Also she became intolerant of anxiety, so
interpreting the sensations as symptoms of anxiety provided no relief for her. It was
clear from the assessment that strengthening her reappraisal capability would be an
important focus of treatment.
Perceived Panic Outcome
A final component of the case conceptualization is to determine the “natural” outcome of
panic attacks. It is expected that individuals will engage in escape, avoidance, and safety-
seeking behaviors in an effort to control the anxiety and panic. The clinician should
assess the perceived effectiveness of these strategies. To what extent is an individual able
to achieve a sense of safety after the occurrence of an anxiety or panic episode? How long