Panic Disorder 315
strophic cognitions like “I’m not getting enough air, I’m going to die of suffocation,”
“What if I’m having a heart attack?”, or “If I don’t stop I’m going to have a full-blown
panic attack.” The catastrophic misinterpretation led to various control efforts such as
escape, reassurance seeking from others, controlled breathing, or distraction, which
together often ended in intense anxiety or panic attacks. After completing the Vicious
Cycle of Panic form, the therapist emphasized that catastrophic misinterpretations and
maladaptive control efforts were the main catalysts for panic rather than the real pos-
sibility of some imminent threat (e.g., possible heart attack). Helen was given a copy of
the completed Vicious Cycle of Panic form and asked to record her anxiety and panic
experiences over the next week with particular focus on whether the cognitive model
was a good explanation for her anxious experiences.
Clinician Guideline 8.10
Use the Vicious Cycle of Panic form (Appendix 8.3) to begin educating clients to the cogni-
tive model and highlight the central role of catastrophic misinterpretations in the persistence
of panic.Schema Activation and Symptom Induction
A critical feature of cognitive therapy for panic is the use of within- session exercises to
induce the client’s feared physical sensations (Beck, 1988; Beck & Greenberg, 1988; D.
M. Clark, 1997; D. M. Clark & Salkovskis, 1986). When cognitive therapy of panic was
first developed, patients were always given a 2-minute breathing hyperventilation exer-
cise followed by instruction in controlled breathing in order to introduce overbreathing
as a possible alternative explanation for the occurrence of intense physical sensations (D.
M. Clark & Salkovskis, 1986). However, it is now known that hyperventilation prob-
ably plays a less prominent role in panic, so controlled breathing is no longer recom-
mended in most cases of panic disorder (see discussion below). Furthermore, cognitive
therapists are more likely to use a variety of induction exercises repeatedly throughout
treatment based on the positive effects of interoceptive exposure on panic reduction (see
White & Barlow, 2002).
Symptom induction exercises are important in cognitive therapy of panic disorder
because they allow direct activation of threat schemas and opportunity to challenge
catastrophic misinterpretations of bodily sensations. Usually the intentional production
of symptoms like dizziness, heart palpitations, breathlessness, and so on in the presence
of the therapist is less intense and better tolerated by the patient than in real life. In this
way the client learns that certain physical sensations are not always frightening, that the
physical sensations do not lead to the catastrophic outcome, and that an exacerbation
of unwanted sensations can be due to other, more benign causes. Often the within-
session symptom induction is the first direct experiential evidence that challenges the
catastrophic misinterpretation. After engaging in symptom induction, the cognitive
therapist always reviews the experience with clients in terms of whether the experi-
ence confirms or disconfirms the catastrophic misinterpretation of bodily sensations.
Symptom induction exercises are introduced by the second or third session and they
are repeated often throughout treatment. Eventually symptom induction is assigned as