320 TREATMENT OF SPECIFIC ANXIETY DISORDERS
Clinician Guideline 8.14Graded in vivo exposure is important in the treatment of agoraphobic avoidance and in dis-
confirming the catastrophic thoughts and beliefs pathogenic to panic attacks and their fear.Symptom Tolerance and Safety Reinterpretation
As stated earlier, cognitive therapy seeks to increase the panic individual’s tolerance
of unexpected physical sensations and discomfort as well as subjective anxiety and to
instill a greater sense of safety and coping ability. This can be accomplished by inten-
tionally focusing on the client’s ability to tolerate the physical symptoms of anxiety
during within- session and between- session behavioral exposure exercises. For example,
a client who is anxious about chest tightness and heart palpitations could be asked to
monitor his physical sensations while doing a cardio workout in the gym. Not only
would repeated experiences of physiological activation provide evidence that physical
symptoms can be tolerated, but the panic-prone individual will be learning that mere
occurrence of physical symptoms is not dangerous. However, for these experiences to be
therapeutic the cognitive therapist must repeatedly emphasize the idea that “clearly you
are able to tolerate these physical sensations just like everyone else.”
Therapy must also focus on increased tolerance for physical discomfort and anxiety.
Clients could be asked to keep a diary of their experiences of physical discomfort that
are not associated with anxiety such as episodes of headaches, sore muscles, fatigue, and
the like. Individuals can be asked to rate the degree of discomfort associated with these
symptoms and their level of anxiety. The point of this exercise is for the panic-prone
individual to learn that she is capable of tolerating discomfort without feeling anxious.
By reinforcing this observation, the therapist can strengthen the client’s beliefs in her
ability to cope with the physical discomfort associated with anxiety. Moreover, toler-
ance of anxiety can be improved through graded in vivo exposure exercises in which
the therapist gradually increases the level of anxiety so individuals learn they can cope
with even high anxiety states.
The cognitive therapist can increase the client’s sense of safety by helping him rein-
terpret anxiety- provoking situations encountered during homework assignments. At
every opportunity, the therapist redirects the client’s attention by asking questions such
as “What aspects of this situation suggested safety?”, “Was there anything about this
situation that made you think it was less dangerous and more safe than you initially
thought?”, or “As you look back on the situation, what safety cues were present that
you just didn’t notice at the time?” An important goal of cognitive therapy is to “train”
the individual with panic disorder to intentionally reconsider the safety features of an
anxiety- provoking situation in order to counter his automatic catastrophic interpreta-
tion. The Symptom Reappraisal Form (Appendix 8.2) can be used for this purpose. In
addition it is helpful to have clients rate the “realistic” level of danger associated with
the situation (e.g., 0–100 rating scale) as well as the “realistic” level of safety after
recording danger and safety features on the panic log (Appendix 8.1). It is important to
ensure that clients’ ratings are based on a “realistic” assessment rather than on “how
they feel” because emotion-based ratings will always be distorted because of a height-
ened anxiety state.