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CBT for Panic Disorder
Transcript of CBT for Panic Disorder
PSY 694 Panic Disorder and Agoraphobia Contributing Factors Treatment Variables Session 1 Panic Attack: Goals: CBT for Panic Disorder Panic Disorder: Discrete episodes of intense dread or fear, accompanied by physical and cognitive symptoms Recurrent "unexpected" panic attacks, followed by at least 1 month of persistent concern about their recurrence and their consequences, or by a significant change in behavior consequent to the attacks Agoraphobia: Avoidance or endurance with dread of situations from which escape might be difficult, or help unavailable in the event of a panic attack, or in the event of developing symptoms that could be incapacitating or embarrassing. Not all people who panic develop agoraphobia! Conceptualization of Panic Disorder Acquired fear of bodily sensations, particularly sensations associated with autonomic arousal
AKA flight-fight response 1) Genetics and Temperament: Most associated temperament - neuroticism.
Tend to experience variety of negative emotions across a variety of situations.
Genetic analyses of human twin samples attribute 30-50% of variance in neuroticism to additive genetic factors. Interoceptive Awareness: Heightened awareness of, or ability to detect, bodily sensations of arousal may enhance probability of panic by increasing probability of perceiving sensations that may trigger an attack if perceived as dangerous Session 12 Case Studies Review the principles and skills learned
Provide the patient with a template of coping techniques for potential high-risk situations in the future
Agree to continue in vivo exposure practices over the next few months to consolidate learning Cameron was a 35 year old sales manager who's first panic attack occurred at work, in front of his coworkers. He began to feel weak, nauseous, and dizzy and asked a colleague to call a doctor because he was afraid he was having a heart attack since his father had recently died of one. In addition to his personal loss, Cameron was dealing with a lot of stress at work. Several months before his first attack, there were times when he was nervous and had shaky hands, but nothing compared to the attack. He had a physical exam and his doctor told him that it was stress and anxiety. The panic attacks kept happening, often they were out of the blue and sometimes woke him out of a deep sleep. Cameron felt anxious most of the time because he worried about having another attack. He started to avoid being alone whenever possible. He also avoided certain places, like shopping malls and theaters where he feared being trapped and embarrassed if he panicked.
Lynn was a 41 year old, married woman who was unemployed because of her panic attacks. She quit her job as a paralegal several years ago because it became harder and harder to leave her house. Her attacks involved feeling strong chest pains and feelings of pressure on her chest, numbness in her left arm, shortness of breath, and heart palpitations. She was terrified that she was having a heart attack, especially when these feelings woke her up from a deep sleep. Lynn lived with her extended family of Chinese descent and her grandmother convinced her that demons were descending on her and that she would die if she didn't wake up in time. Consequently, Lynn became very afraid of going to sleep, so instead, took several naps throughout the day when people were around. She only went outside, occasionally, as long as a friend or family member accompanied her. Although she had seen several doctors and had many stress tests to determine the health of her heart and nothing was detected, she remained convinced that she would have a heart attack or that she would die in her sleep.
Divide class in half
Develop a summarized treatment plan for one of the clients using the techniques discussed Psychoeducation:
Describe fear and anxiety
Help patients understand the cyclical influences among behavioral, physiological and cognitive responses
Understand panic attack symptoms are not harmful
Self-monitoring Components: Identify anxiety patterns and situations, internal triggers, negative verbal cognitions, catastrophic imagery and physical sensations Psychoeducation Triple Response System Purpose Understanding Physiology Feel, Think, Do
Discuss cognitive, physiological, and behavioral aspects to their responding Survival value or protective function of anxiety and panic
Physiological basis to various sensations
Role of specific learned and cognitively mediated fears of certain bodily sensations
Explain concepts of misappraisals and interoceptive conditioning Reduce anxiety and decrease uncertainty about panic attacks
Enhance credibility of subsequent treatment procedures Self-Monitoring Purpose Homework Clarify objective vs. subjective self-monitoring
Introduce handout Begin self-monitoring panic attacks, daily anxiety and mood
Re-read handout several times
Increased exposure should reduce distress levels Sessions 6 and 7 Goals: Review past week of in vivo exposure
Design new exposures
Review between-session practices of interoceptive exposure
Conduct repeated interoceptive exposure in session Components: Review in vivo exposure, focusing on avoidance
Reasons for avoidance may include continued misinterpretation of the dangers of bodily sensations
Continued practice of interoceptive exposure with the next item on hierarchy Session 2 Goals: Create hierarchy of agoraphobic situations
Introduce breathing retraining
Introduce cognitive restructuring Components: Develop hierarchy
Continued Self-Monitoring Breathing
Exercise Retraining Education During session, have patient hyperventilate voluntarily by standing and breathing fast and deep, as if blowing up a balloon, for 1.5 minutes
Then, sit, close their eyes, and breathe very slowly, pausing at the end of each breath.
Compares degree of anxiety with panic attacks
Realizes similar symptoms, but is often confused due to safe environment and obvious cause
Most will rate less anxiety provoking than if same symptoms occurred naturally Educate on physiological basis of hyperventilation
Reduce misinterpretations of dangers of over breathing
Provide facts that challenge misinterpretations Teach diaphragmatic breathing more than chest muscles
Instruct patients to concentrate on their breathing, by counting on their inhalations, and thinking the word "relax" on exhalations.
May mistakenly view breathing retraining as a way of relieving symptoms
Goal: use breathing skills to encourage continued approach toward anxiety and anxiety producing situations. Homework Continue self-monitoring panic attacks, daily anxiety and mood
Practice diaphragmatic breathing for at least 10 minutes, two times a day in relaxing environment
Identify anxious thoughts in relation to items on hierarchy
Use session steps of examining the evidence and generating alternative explanations
Do this for every panic attack this week Hierarchy Develop hierarchy of agoraphobic situations over the following week
Items on hierarchy become basis of in vivo exposure
May be refined as a result of cognitive restructuring
Highlight specific features of situations that are most anxiety provoking
Hierarchy includes situations that range from mild to extreme anxiety Cognitive
Restructuring Introduction Types of Cognitive Errors Countering Overestimations Explaining distortions and errors in thinking and their adaptive functions
Treat thoughts as hypotheses and guesses rather than facts
Explanations of automatic thinking Anxious thoughts are usually labeled as "risk" or "valence"
Risk - overestimation, or jumping to conclusions by viewing negative events as being probable events, when in fact they are unlikely to occur Patient is asked to identify overestimations from anxiety and panic incidents.
Examine the evidence for probability judgments and generate alternative, more realistic predictions.
Use Socratic style to help patient arrive at conclusion after considering all the evidence Session 3 Goals: Develop breathing retraining
Continue active cognitive restructuring
Decatastrophizing Components: Breathing Retraining
Continued Self-Monitoring Decatastrophizing Catastrophic errors are seen as "dangerous" or "insufferable" when they are actually not
Key principle: events can be endured even though they are uncomfortable
Recognize finite nature of discomfort
Reinforce clients ability to tolerate discomfort Homework Continue self-monitoring panic attacks, daily anxiety and mood
Practice diaphragmatic breathing for at least 10 minutes, two times a day in relaxing environment
Identify errors of catastrophizing in relations to each item on hierarchy
Generate ways to cope Sessions 8 and 9 Goals: Continue in vivo exposure
Extend interoceptive exposure to natural activities Components: Review the week's practice of interoceptive exposure
Generate a naturalistic hierarchy Homework Continue self-monitoring panic attacks, daily anxiety and mood
In vivo exposure to an item from the hierarchy at least three times
Daily practice of interoceptive exposure Naturalistic
Interoceptive Exposure Exposure to daily tasks or activities that have been avoided or endured with dread because of associated sensations
This exercise is designed to be systematically graduated and repeated From a list of typically feared activities specific to the individuals own experience, a hierarchy is established.
Each item is then ranked in terms of anxiety ratings (0-10)
Identify maladaptive cognitions and rehearse cognitive restructuring before beginning each activity
Focus on and fully experience the sensations throughout w/out using coping skills Homework Practice two naturalistic interoceptivce exposures at least three times each before the next treatment session Sessions 10 and 11 Goals: Review the in vivo and naturalistic exposure exercises over the past week
Combine exposure to feared situations with feared sensations for maximum efficacy Components: Evaluate and correct tendencies to avoid naturalistic interoceptive exposure tasks by considering underlying misassumptions that are leading to avoidance Homework Continue self-monitoring
Practice in vivo exposure combined with interoceptive exposure
Continue naturalistic interoceptive exposure Introduction: Process: Patients Should: * Note: as with all exposures, it is important to identify and remove (gradually, if necessary) safety signals or protective behaviors (e.g. cell phones, lucky charms) Combining Internal and External Cues Combine exposure to feared and avoided agoraphobic situations with deliberate induction of feared sensations into those situations
Ex: Repeated practice walking through a shopping mall while dizzy is more effective than either situation alone
Patients choose an item from their hierarchy and also choose which symptom to induce and ways of inducing that symptom in that situation
Ex: Wearing heavy clothes in a restaurant to induce feelings of heat while exposing to restaurant Group Exercise Triple Vulnerability Theory: Psychological and biological predispositions enhance vulnerability to acquire fear of sensations associated with autonomic arousal. 2) Anxiety Sensitivity Anxiety and its associated symptoms may cause deleterious physical, social and psychological consequences that extend beyond any immediate physical discomfort during an episode of anxiety of panic
AKA "Fear of fear"
Primes fear reactivity to bodily sensations
Predicts subjective distress and reported symptomatology in response to procedures that induce physical sensations 3) Medical Illness and Abuse History of respiratory disturbance
Family history of asthma or emphysema
History of sexual and physical abuse Maintenance
Conditioning Catastrophic Misappraisals "Fear of fear" or anxiety focused on somatic sensations are maintained by two factors. Conditioned fear of internal cues
Internal cues are associated with intense fear, pain, or distress
Low-level sensations of arousal and anxiety become conditioned stimuli (CS), so early somatic CS elicits significant bursts of anxiety or panic. Misinterpretations of sensations as signs of imminent death, loss of control, etc.
May accompany panic attacks because they are a natural part of the constellation of responses that go with panic
May be sufficient to elicit conditioned panic attacks, but not necessary Patient Variables Comorbidity Other Factors Comorbidity with other anxiety disorders and depressive disorders
High co-occurence with avoidant, dependent, and histrionic personality disorders
Medical conditions such as cardiac arrhythmias or asthma Lower education/income associated with higher rates of attrition
Between 80 and 100% of patients undergoing these treatments will be panic free at the end of treatment and maintain these gains for up to two years. Therapist Variables Interactional Styles Considerations Empathy, warmth, positive regard and genuineness early in treatment.
i.e. empathetic statements in session 1
More active and offer more instructions and explanations by session 3
By session 10, employ more interpretations and confrontations
Although this treatment seems highly structured, we must not forget that all techniques described require careful adaptation to the individual case. Session 4 Goals: Use breathing training as coping tool
Review cognitive restructuring skills
Begin in vivo exposure to the first item on hierarchy Components: Cognitive Restructuring Feedback
Breathing training with in-vivo exposure
In Vivo exposure plan
Continued self-monitoring Homework Continue self-monitoring panic attacks, daily anxiety and mood
Continued use of cognitive restructuring and breathing retraining in event of elevated anxiety or panic
Practicing the first item on agoraphobic hierarchy at least 3 times Cognitive Restructuring
Feedback Generate realistic probabilities
Facing the worst
Generating ways of coping with each item on the hierarchy
Feedback for "lack of specificity"
Encourage detailing specific anxieties or worries In vivo exposure Specificity Schedule Goal: learn something new as a result of exposure. NOT immediate reduction in fear and anxiety
Examine previously failed attempts at exposure
In particular, ones that were haphazard, brief, spaced too far apart, or attempts without a sense of mastery Delineate exposure task as concretely as possible
Ensures clear understanding
Reduces uncertainty Regular schedule of repeated in vivo exposure practices at least three times per week
Conduct practices regardless of internal or external factors that may prompt postponement.
Emphasize: copkin skills are not intended as means to reduce fear and anxiety, but to tolerate it.
Client should use breathing and thinking skills to complete assigned task Session 5 Goals: Review in vivo exposure
Design another exposure task
Begin interoceptive exposure Components: In vivo exposure feedback
Create next in vivo exposure task
Induce interoceptive exposure
Compare interoceptive exposure and naturally occurring anxiety and panic
Continued self-monitoring In vivo feedback Objectively evaluate performance
Address any prematurely terminated practice, focus on contributing factors or precipitating factors
Emphasize goal to repeatedly face situations despite anxiety and tolerate fear
If anxiety does not decline over a few days, there may be too much emphasis on immediate fear and anxiety reduction
Interoceptive Exposure Procedure Standard Exercises Additional Exercises Next steps Homework Practice interoceptive items conducted in session 3 times daily.
Consider safety signals in clinic setting or from counselor.
Emphasize gradated exposure homework.
Continue in vivo exposure.
Assess patient's response to a series of standard exercises.
Help achieve confidence in their ability to tolerate symptoms of anxiety. Therapist models each exercise first
After client has completed each exercise record:
Anxiety Level (0-10)
Sensation intensity (0-10)
Similarity to naturally occurring panic sensations (0-10) Shake head from side to side for 30 sec
Place head between the legs for 30 secs and lift head to an upright position quickly
Running in place or using steps for 1 minute
Holding one's breath for as long as possible
Complete body muscle tension for 1 minute or holding a push-up position for as long as possible
Spinning in a swivel chair for 1 minute
Hyperventilating for 1 minute
Breathing through a narrow straw (with closed nasal passages) or breathing as slowly as possible for 2 minutes
Staring at a spot on the wall or at one's mirror image for 90 secs
If none of the standard exercises produced sensations at least moderately similar to those that occur naturally, other, individually tailored exercises are generated.
Tightness around chest - deep breath before hyperventilating
Heat - induced by wearing heavy clothing
Choking sensations - induced with tongue depressor, high-collared sweater, or a necktie No anxiety for the patient because of the therapist's presence? The client should attempt exercises alone at home.
Exercises that rate at least 3 out of 10 on similarity to naturally occurring panic are selected for repeated exposure.
Use a graduated approach, beginning with lowest item on hierarchy.
For each trial, client begins induction and indicate sensations experienced.
Continue induction for 30 secs to permit learning.
After termination, rate anxiety and apply cognitive and breathing coping skills
Review induction experience. Emphasize experiencing sensations fully, concentrating objectively on sensations, and identifying specific cognitions and challenging them by considering evidence.