314 TREATMENT OF SPECIFIC ANXIETY DISORDERS
Educating Clients into the Cognitive Therapy Model of Panic
The first treatment session focuses on educating the client into the cognitive explana-
tion for recurrent panic attacks. If the cognitive assessment strategy has been followed,
then the therapist already has much of the critical information available for educat-
ing the client such as the situational triggers for panic, distressing physical sensations,
catastrophic misinterpretations, and maladaptive avoidance/safety- seeking responses.
Normally clients have started keeping a weekly panic log (see Appendix 8.1) and so
a typical panic episode can be selected from the log. Using Socratic questioning, the
cognitive therapist explores the client’s experience during this panic episode and his
interpretation of the symptoms. The therapist and client collaboratively complete the
Vicious Cycle of Panic form found in Appendix 8.3. It is important that the therapist
records specific thoughts and feelings associated with the panic episode and that the
cognitive explanation is presented as “one possible explanation of the origins of panic
that needs to be tested.”
At this initial stage of treatment it is unlikely the client is ready to abandon her
catastrophic misinterpretation and embrace the cognitive explanation. Instead the goal
of the educational session is to merely introduce an alternative explanation for panic
that provides a treatment rationale. The session normally ends with a homework assign-
ment in which clients continue with their panic logs but this time they examine whether
their anxiety and panic experiences are consistent or not with the cognitive explanation.
When reviewing homework in the subsequent session, it is important that the therapist
deal with anxiety experiences that appear contrary to the model and reinforce the cli-
ent’s observations that are consistent with the cognitive explanation.
In our case illustration a Vicious Cycle of Panic form (see Appendix 8.3) was com-
pleted at the outset of cognitive therapy. Helen identified a number of triggers from her
panic log such as being at a work meeting and sitting beside the guest speaker, not being
in close proximity to a hospital, flying, and driving alone some distance from home.
Her initial physical sensations were feeling lightheaded, sensing that her breathing was
a little irregular, and experiencing an unusual feeling of pressure in her chest. This was
followed by some initial anxious cognitions such as “What’s wrong with me?”, “Why
am I feeling this way?”, “Something is not right,” “I don’t like this,” “I am beginning to
feel anxious,” “I feel trapped,” and so on. These anxious thoughts often led to an esca-
lation in a few physical sensations such as feelings of suffocation or heart palpitations.
Once these intense physical sensations occurred, Helen identified a number of cata-
table 8.7. main treatment Components of Cognitive
therapy for panic
••Education into the cognitive therapy model of panic
••Schematic activation and symptom induction
••Cognitive restructuring of catastrophic misinterpretation
••Empirical hypothesis testing of alternative explanation
••Graded in vivo exposure
••Symptom tolerance and safety reinterpretation
••Relapse prevention
••Breathing retraining (optional)