318 TREATMENT OF SPECIFIC ANXIETY DISORDERS
8.2) can be used to focus the client on alternative explanations for fearful sensations.
Most clients have considerable difficulty generating alternative explanations for their
most feared sensations so this will take a considerable amount of guided discovery. A
variety of alternative explanations for the symptoms can be raised such as (1) response
to heightened anxiety; (2) reaction to stress; (3) product of physical exertion; (4) fatigue;
(5) side effects of coffee, alcohol, or medication; (6) heightened vigilance of bodily sensa-
tions; (7) strong emotions like anger, surprise, or excitement; (8) random occurrence of
benign internal biological processes; or (9) other context- specific possibilities.
Another aspect of the alternative explanation that is emphasized is the role that cata-
strophic thoughts and beliefs play in exacerbating symptoms (D. M. Clark, 1996). For
example, “Is an underlying cardiac condition your problem so that chest pains could signal
a heart attack (catastrophic interpretation) or is your problem that you believe there is
something wrong with your heart and so you are preoccupied with your heart rate” (alter-
native cognitive explanation)? At this point the therapist simply raises these alternative
explanations as possibilities or hypotheses and invites the client to investigate the valid-
ity of each explanation by gathering confirming and disconfirming evidence. This can be
done by using information recorded on the Weekly Panic Log (Appendix 8.1) or one of the
cognitive forms provided in Chapter 6 (e.g., Appendices 6.2 or 6.4). The goal of cognitive
rest r uc t u ri ng is for i nd ividuals w it h pa n ic to reali ze t hat t hei r a n x iet y a nd pa n ic sy mptoms
are due to their erroneous beliefs that certain physical sensations are dangerous. Although
patients may find it difficult to accept this alternative because of their heightened anxiety,
they are repeatedly encouraged to focus on the evidence, not on how they feel.
A major part of Helen’s cognitive therapy for panic was the gathering of evidence
for alternative explanations for her symptoms of breathlessness, which had become the
primary dreaded physical sensation. Gradually, with accumulating evidence based on
repeated experiences, she began to accept that her sense of breathlessness was most
likely due to excessive monitoring of her breathing and the possibility that she was
actually suffocating was entirely remote at best. Over time she found evidence that
other physical sensations were probably due to stress, anxiety, fatigue, or alcohol con-
sumption was much more compelling than the automatic catastrophic interpretation. At
this point therapy shifted away from challenging the catastrophic interpretation toward
increasing her tolerance of anxiety and its physical manifestations.
Clinician Guideline 8.12
In panic disorder cognitive restructuring focuses on gathering evidence (1) that the client
automatically generates a highly unlikely and exaggerated misinterpretation of unwanted
physical or mental sensations, and (2) that alternative, benign explanations are more plau-
sible. The role of catastrophic thoughts and beliefs in perpetuating anxiety and panic symp-
toms is emphasized throughout treatment.Empirical Hypothesis- Testing Experiments
Behavioral experiments play a particularly important role in the treatment of panic.
They often take the form of deliberate exposure to anxiety- provoking situations in
order to induce fearful symptoms and their outcome. The outcome of the experiment