Panic Disorder 327
patient’s catastrophic interpretation of physical symptoms produced significant reduc-
tion in panic frequency in six out of seven patients, whereas nonfocal treatment had
little effect on panic symptoms. In a more recent multivariate time series single-case
analysis both cognitive restructuring with empirical hypothesis testing versus expo-
sure alone produced equivalent changes in dysfunctional beliefs and self- efficacy that
preceded improvements in panic apprehension (Bouchard et al., 2007). The authors
concluded that the findings add to growing empirical evidence that cognitive changes
precede improvement in panic symptoms whether treatment is primarily cognitive or
behavioral. Other studies have found that exposure alone is as effective as exposure
plus cognitive restructuring (Bouchard et al., 1996; Öst, Thulin, & Ramnerö, 2004),
although Van den Hout, Arntz, and Hoekstra (1994) found that cognitive therapy alone
reduced panic attacks but not agoraphobia. In a recent study of group CBT for panic,
20% of patients experienced a sudden gain (i.e., rapid symptom reduction) after two
sessions and this predicted better symptom outcome at posttreatment (Clerkin, Teach-
man, & Smith-Janik, 2008). Overall, these studies indicate that CBT can produce rapid
and effective symptom reduction in panic disorder and that cognitive restructuring is an
important component of the treatment package.
The therapeutic effects of cognitive restructuring suggest that targeting the cata-
strophic misinterpretations of bodily sensations is a central mechanism of change in
cognitive therapy of panic disorder. In their clinical trial D. M. Clark at al. (1994) found
a significant correlation between BSIQ scores at 6 months and panic symptoms and
relapse rates at 15 months. This relation between a continued tendency to misinterpret
bodily sensations and worst outcome at follow-up was supported in the authors’ out-
come study of brief cognitive therapy (D. M. Clark et al., 1999). However, comparison
of standard cognitive therapy that focused on interpersonal beliefs relevant to general-
ized anxiety versus focused cognitive therapy that targeted catastrophic misinterpreta-
tions of bodily sensations showed that both were equally effective in reducing panic
symptoms, although reduction in panic- related cognitions and beliefs was correlated
with changes in panic frequency at termination (Brown, Beck, Newman, Beck, & Tran,
1997). In their descriptive and meta- analytic review of 35 CBT studies on panic disor-
der, Oei, Llamas, and Devilly (1999) concluded that the therapy is effective for panic
disorder and does produce change in cognitive processes, although it is unclear whether
change in catastrophic misinterpretations is the central change mechanism in CBT for
panic disorder. Overall it would appear that change in catastrophic misinterpretations
of the physical symptoms of anxiety is an important part of the treatment process in
panic but whether a specific focus on these symptoms is necessary remains unclear.
Clinician Guideline 8.18
Cognitive therapy involving cognitive restructuring, symptom induction, and empirical
hypothesis- testing exposure exercises is a well- established empirically based treatment for
panic disorder with or without agoraphobic avoidance. Cognitive strategies and exposure-
oriented homework are both central ingredients in the treatment’s efficacy for panic
attacks.