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Section 26
Cognitive Treatment of Panic Disorder

Question 26 | Test | Table of Contents

Exposure
A commonly observed progression for panic disorder is the subsequent development of agoraphobia (Michelson et al., 1990). The behavioral technique of exposure may play an important role in preventing panic disorder from escalating into panic with agoraphobia. This technique involves gradually exposing the individual to feared situations (Agras, 1993). Swinson et al. (1992) investigated the effects of exposure on the frequency of panic attacks and the development of avoidance associated with agoraphobia in panic disorder. They compared the effects of supportive therapy with supportive therapy and exposure combined. The exposure group revisited locations where panic attacks occurred. Significantly fewer panic attacks were reported by the exposure group. Furthermore, individuals in the supportive therapy only group were significantly more likely than were the combined group to develop agoraphobic avoidance during the follow-up time period. This suggests that exposure to the situation in which the panic attacks occurred may be a significant factor in the prevention of agoraphobia in individuals with panic disorder.

Biofeedback
The bodily sensations that occur during the onset of a panic attack have been explained as a positive feedback loop between bodily symptoms of anxiety and an individual's reactions to these symptoms (Ehlers, Margraf, Roth, Taylor, & Birbaumer, 1988). It has been postulated that the individual with panic disorder is sensitized to peripheral arousal and becomes preoccupied with these sensations as potential warning signs of an impending attack, creating anticipatory anxiety (Beck & Scott, 1987).

Several researchers have attempted to use biofeedback to uncover the etiology of panic disorder and help individuals reattribute those bodily sensations. Lynch, Bakal, Whitelaw, and Fung (1991) found that highly anxious participants with panic disorder exhibited significantly higher electromyography (EMG) activity than low anxious or controls. Beck and Scott (1988) found frequent panickers to have significantly higher elevations in trapezious EMG and muscle tension. Increased heart rate and EMG during the onset of panic attacks was a common finding in a number of studies (Beck & Scott, 1987; Cohen, Barlow, & Blanchard, 1985; Ehlers et al., 1988). No research was found that explored the efficacy of biofeedback in the treatment of panic disorder.

Cognitive Treatment
Considerable support exists for a cognitive component in the development and maintenance of panic disorder. Cognitive theory purports that panic attacks result from catastrophic misinterpretations of bodily sensations or psychological experiences. Panic symptoms escalate when an individual focuses on these symptoms and misreads them as dangerous while concomitantly blocking corrective information and reasoning (Sokol, Beck, Greenberg, Wright, & Berchick, 1989). These cognitive distortions have been found to be quite prevalent in panic disorder (Cloitre & Liebowitz, 1991; Harvey, Richards, Dziadosz, & Swindell, 1993; Holt & Andrews, 1989; Ottaviani & Beck, 1987; Sargent, 1990; Rapee, Mattick, & Murrell, 1986) Cognitive treatment consists of a combination of cognitive restructuring, focused cognitive therapy, imaginal coping, and panic education.

Cognitive restructuring. Cognitive restructuring is designed to assist these individuals in modifying specific aspects of their thinking by questioning the logical basis of their fears and by encouraging them to consider alternative ways of thinking (Clark, 1986). Research results indicate that this form of treatment is equal to or superior to interoceptive exposure, in which exposure to somatic cues occurs through visualization or symptom induction, relaxation training, or the use of imipramine.

Margraf and Schneider (1991) found cognitive restructuring to be as successful as interoceptive exposure alone, or a combination of cognitive and interoceptive exposure, with up to 93% of their participants panic-free at 3-month follow-up. The short interval of the follow-up may explain why no differences were found between experimental groups. Margraf et al. (1993) reported in their meta-analysis of panic disorder treatment that the cognitive component of assisting clients to reattribute their bodily sensations was found to be more important to recovery than simply habituating participants through exposure.

In a study by Clark et al. (1991), cognitive restructuring was found to be more effective in reducing panic and panic-related conditions then applied relaxation or imipramine. At a 12-month follow-up, the same pattern of results emerged. Waddell, Barlow, and O'Brien (1984) investigated the effectiveness of self-coping statements and progressive relaxation on panic symptoms. They found that significant decreases in panic attacks occurred with self-coping statements. The relaxation component did not add significantly to the participants' progress, although the gains made during the cognitive treatment were not reversed. This study suffers from a very small number of participants and no controls, but it is generally supportive of the results of the previous research on this technique.

Focused cognitive therapy. Focused cognitive therapy is a specific technique designed for use in the treatment of panic disorder that has received recent attention in the literature. Using this technique, specific panic-related symptoms are reproduced in the therapy session through verbal means, hyperventilation, imagery, or brief rigorous exercise. Individuals are encouraged to test the validity of their pathological misattributions and consider noncatastrophic interpretations instead (Salkovskis, Clark, & Hackmann, 1991). Overall, preliminary studies with focused therapy have been promising.

Using focused cognitive treatment, Salkovskis et al. (1991) were able to show a significant reduction in the frequency of panic attacks and in the misinterpretations of bodily symptoms. This method was effective after only two sessions of focal cognitive therapy. No reduction in symptomatology was reported in the cognitive restructuring group. These results support the use of focused cognitive treatment in treating panic disorder, but the small sample size, the brief therapy model, and the lack of a control group makes any definitive statements premature.

Sokol et al. (1989) also found focused cognitive therapy to be successful. Individual weekly meetings, ranging from 10 to 40 sessions, were able to bring the number of panic attacks to zero in all participants. These gains were maintained at 1-year follow-up, but this study suffers from a lack of control and experimental comparison groups, and the results must be interpreted with caution.

Similar results with focused cognitive therapy were found by Beck et al. (1992) when compared with brief supportive therapy. Nearly half of all participants were on benzodiazepines. After 8 weeks, the cognitive therapy participants improved significantly more on all measures of panic and anxiety. Furthermore, these therapeutic gains were stable at the 1-year follow-up, when the majority of those on benzodiazepines had either reduced or eliminated their medication.

A study by Black et al. (1993) reported the use of fluvoxamine to be more effective than focused cognitive therapy. They found that at the 8-week endpoint of their study, 81% of the fluvoxamine participants were panic-free, compared with 53% of the cognitive participants. They concluded that cognitive therapy showed some promise, but was not superior to fluvoxamine in treating panic disorder. Nonetheless, no follow-up data was reported, and studies have demonstrated that gains made in psychological interventions with panic are longer lasting than those made with pharmacological interventions (Beck et al., 1992; Clum, 1989; Shear et al., 1991; Sokol et al., 1989). Because of the lack of follow-up data, it is unclear whether the fluvoxamine remained a superior treatment.
- Beamish, P. M., Granello, P. F., Granello, D. H., Mcsteen, P. B., Bender, B. A., & Hermon, D. (1996). Outcome Studies in the Treatment of Panic Disorder: A Review. Journal of Counseling & Development, 74(5), 460-467. doi:10.1002/j.1556-6676.1996.tb01893.x
The box directly below contains references for the above article.

 

Current Diagnosis and Treatment of Anxiety Disorders

- Bystritsky, A., MD, PhD, Khalsa, S. S., MD, PhD, Cameron, M. E., PhD, & Schiffman, J., MD, MA, MBA. (january 2013). Current Diagnosis and Treatment of Anxiety Disorders. P&T, 38(1), 32-57.

Personal Reflection Exercise #12
The preceding section contained information about exposure, biofeedback and cognitive treatment of panic disorder.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
CBT treatment delivery formats for panic disorder: a systematic review
and network meta-analysis of randomised controlled trials

Papola, D., Ostuzzi, G., Tedeschi, F., Gastaldon, C., Purgato, M., Del Giovane, C., Pompoli, A., Pauley, D., Karyotaki, E., Sijbrandij, M., Furukawa, T. A., Cuijpers, P., & Barbui, C. (2023). CBT treatment delivery formats for panic disorder: a systematic review and network meta-analysis of randomised controlled trials. Psychological medicine, 53(3), 614–624. https://doi.org/10.1017/S0033291722003683


Peer-Reviewed Journal Article References:
Hourani, L., Tueller, S., Kizakevich, P., Strange, L., Lewis, G., Weimer, B., Morgan, J., Cooney, D., & Nelson, J. (2018). Effect of stress inoculation training with relaxation breathing on perceived stress and posttraumatic stress disorder in the military: A longitudinal study. International Journal of Stress Management, 25(S1), 124–136. 

Lange, J., Goerigk, S., Nowak, K., Rosner, R., & Erhardt, A. (2021). Attachment style change and working alliance in panic disorder patients treated with cognitive behavioral therapy. Psychotherapy, 58(2), 206–218.

Schwartz, R. A., Chambless, D. L., Milrod, B., & Barber, J. P. (2021). Patient, therapist, and relational antecedents of hostile resistance in cognitive–behavioral therapy for panic disorder: A qualitative investigation. Psychotherapy, 58(2), 230–241.

QUESTION 26
What is designed to assist clients experiencing panic attacks in modifying specific aspects of their thinking by questioning the logical basis of their fears and by encouraging them to consider alternative ways of thinking? To select and enter your answer go to Test.

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