Mastery of Your Anxiety and Panic

--

David H. Barlow, PhD


 

Anne Marie Albano, PhD

Jack M. Gorman, MD

Peter E. Nathan, PhD

Paul Salkovskis, PhD

Bonnie Spring, PhD

John R. Weisz, PhD

G. Terence Wilson, PhD

Mastery of Your
Anxiety and Panic
FOURTH EDITION

T h e r a p i s t G u i d e

Michelle G. Craske • David H. Barlow

1

1
Oxford University Press, Inc., publishes works that further
Oxford University’s objective of excellence
in research, scholarship, and education.

Oxford New York

Auckland Cape Town Dar es Salaam Hong Kong Karachi
Kuala Lumpur Madrid Melbourne Mexico City Nairobi
New Delhi Shanghai Taipei Toronto
With offices in
Argentina Austria Brazil Chile Czech Republic France Greece
Guatemala Hungary Italy Japan Poland Portugal Singapore
South Korea Switzerland Thailand Turkey Ukraine Vietnam

Copyright ©  by Oxford University Press, Inc.

Published by Oxford University Press, Inc.

 Madison Avenue, New York, New York 
www.oup.com
Oxford is a registered trademark of Oxford University Press
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.

Library of Congress Cataloging-in-Publication Data

Craske, Michelle Genevieve, ‒
Mastery of your anxiety and panic : therapist guide / Michelle G. Craske
and David H. Barlow. —th ed.
p. cm.—(Treatments that work)
Includes bibliographical references.
ISBN- ----
ISBN ---X
. Panic disorders—Treatment. . Anxiety disorders—Treatment.
I. Barlow, David H. II. Title.
[DNLM: . Anxiety Disorders—therapy.
. Panic Disorder—therapy. . Agoraphobia—therapy.
. Psychotherapy—methods. WM  Cm ]
RC.B 
.⬘—dc 

        

Printed in the United States of America

on acid-free paper
About TreatmentsThatWork ™

Stunning developments in healthcare have taken place over the last sev-
eral years, but many of our widely accepted interventions and strategies
in mental health and behavioral medicine have been brought into ques-
tion by research evidence as not only lacking benefit but, perhaps, in-
ducing harm. Other strategies have been proven effective using the best
current standards of evidence, resulting in broad-based recommendations
to make these practices more available to the public. Several recent de-
velopments are behind this revolution. First, we have arrived at a much
deeper understanding of pathology, both psychological and physical,
which has led to the development of new, more precisely targeted interven-
tions. Second, our research methodologies have improved substantially, so
that we have reduced threats to internal and external validity, making the
outcomes more directly applicable to clinical situations. Third, govern-
ments, healthcare systems, and policymakers around the world have de-
cided that the quality of care should improve, that it should be evidence
based, and that it is in the public’s interest to ensure that this happens
(Barlow, ; Institute of Medicine, ).

Of course, the major stumbling block for clinicians everywhere is the ac-
cessibility of newly developed, evidence-based psychological interven-
tions. Workshops and books can go only so far in acquainting responsi-
ble and conscientious practitioners with the latest behavioral healthcare
practices and their applicability to individual patients. This new series,
TreatmentsThatWork™, is devoted to communicating these exciting
new interventions to clinicians on the frontlines of practice.

The manuals and workbooks in this series contain step-by-step, detailed

procedures for assessing and treating specific problems and diagnoses.
 But this series also goes beyond the books and manuals by providing an-
cillary materials that will approximate the supervisory process in assist-
ing practitioners in the implementation of these procedures in their
practice.

In our emerging healthcare system, the growing consensus is that

evidence-based practice offers the most responsible course of action for
the mental health professional. All behavioral healthcare clinicians
deeply desire to provide the best possible care for their patients. In this
series, our aim is to close the dissemination and information gap and
thus make that possible.

The Mastery of Your Anxiety and Panic, Fourth Edition (MAP–IV ), pro-
gram updates, extends, and improves on the previous program in nu-
merous ways. Among the major changes reflected in this revision is the
incorporation of treatment for agoraphobic behavior; agoraphobia was
addressed minimally in the previous Mastery of Your Anxiety and Panic,
Third Edition (MAP–III ), because clients with moderate to severe ago-
raphobia were directed to the accompanying Client Workbook for Agora-
phobia. First, in MAP–IV, the panic and agoraphobia workbooks have
been combined. Second, the structure of the workbook has changed, so
that each chapter represents a module of treatment rather than a session
of treatment. This was done because of the recognition that clients vary
dramatically in the pace at which they proceed through each part of the
treatment. Third, relaxation training has been dropped from this edition
since the evidence to date does not suggest that relaxation training as a
stand-alone treatment is effective for panic disorder and agoraphobia or
that it is more effective than breathing skills training. Fourth, breathing
skills and thinking skills (i.e., cognitive restructuring) are now framed as
skills to help clients move toward and face their fear and anxiety, as well
as anxiety-producing situations; they are not intended to reduce fear and
anxiety immediately. Fifth, the method by which exposure therapy is
conducted, either to feared interoceptive cues (i.e., physical sensations)
or feared external situations, is substantially changed, so that the focus is
no longer on immediate fear reduction but instead on learning to with-
stand and tolerate fear and anxiety. The reasons for this change are de-
tailed in later sections. Sixth, the chapter on medications and their in-
teractions with cognitive behavioral therapy (the type of therapy that is
described in MAP–IV ) is updated with the latest advances in issues per-

vi
taining to pharmacology. Finally, MAP–IV has been completely rewrit-
ten with a new and more accessible reading level to make it easier for all
clients to understand.
David H. Barlow, Editor-in-Chief,
TreatmentsThatWork™
Boston, Massachusetts

vii
This page intentionally left blank
Contents

Chapter  Introductory Information for Therapists 

Chapter  The Nature of Panic Disorder and Agoraphobia 

Chapter  Outline of Treatment Procedures and Basic Principles

Underlying Treatment 

Chapter  Introduction to the Program 

Chapter  Learning to Record Panic and Anxiety 

Chapter  Negative Cycles of Panic and Agoraphobia 

Chapter  Panic Attacks Are Not Harmful 

Chapter  Establishing a Hierarchy of Agoraphobia Situations 

Chapter  Breathing Skills 

Chapter  Thinking Skills 

Chapter  Facing Agoraphobia Situations 

Chapter  Involving Others 

Chapter  Facing Physical Symptoms 

Chapter  Medications 

Chapter  Accomplishments, Maintenance, and

Relapse Prevention 

Chapter  Modification for Primary Care Settings 

References 

About the Authors 

This page intentionally left blank
Chapter 1 Introductory Information for Therapists

Development of This Treatment Program and Its Evidence Base

Research on the efficacy of nonpharmacological treatments for the vari-

ous anxiety disorders has been ongoing for over two decades at our in-
stitutions, the Center for Anxiety and Related Disorders at Boston Uni-
versity and the University of California, Los Angeles, Anxiety Disorders
Behavioral Research Program. Developments in the conceptualization
of panic attacks and Panic Disorder (PD) in the s made possible sig-
nificant improvements in the psychological treatment of PD and the de-
velopment of panic control treatment (PCT ), a treatment for panic dis-
order with proven effectiveness. As a result, we received many requests
to inform mental health professionals of the ways in which the treatment
is conducted. After completing a series of workshops, we recognized the
value of a guide outlining the treatment procedures. Hence, the Mastery
of Your Anxiety and Panic, Workbook and Mastery of Your Anxiety and
Panic, Therapist Guide were written and have now been revised. Now in its
fourth edition, the revised client workbook is written in a style suitable
for the client’s direct use, under the supervision of a trained professional.

Efficacy of Panic Control Treatment

The PCT described has undergone many independent evaluations. Spe-

cifically, PCT is more effective than general relaxation training (Barlow,
Craske, Cerny, & Klosko, ) and typically yields panic-free rates in
the range of –% and high end-state rates (i.e., within normative
ranges of functioning) in the range of –% (e.g., see Barlow, et al.,
). Also, results generally maintain over follow-up intervals for as long
as  years (Craske, Brown, & Barlow, ). This contrasts with the higher

1
 relapse rates typically found with medication approaches to the treat-
ment of PD, particularly, high potency benzodiazepines (e.g., Gould,
Otto, & Pollack, ). One analysis of individual profiles over time sug-
gested a less optimistic picture in that one third of clients who were
panic free  months after PCT had experienced a panic attack in the
preceding year, and % had received additional treatment for panic
over that same interval of time (Brown & Barlow, ). Nevertheless,
this approach to analysis did not take into account the general trend
toward continuing improvement over time. Thus, rates of eventual thera-
peutic success may be underestimated when success is defined by con-
tinuous panic-free status since the end of active treatment.

The effectiveness extends to patients who experience nocturnal panic at-

tacks, panic attacks from out of sleep (Craske, Lang, Aikins, & Mystkow-
ski, ). Also, PCT is effective even when there is comorbidity and
some studies indicate that comorbidity does not reduce the effectiveness
of PCT for PD (e.g., Brown, Antony, & Barlow, ; McLean, Woody,
Taylor, & Koch, ). Furthermore, PCT results in improvements in
comorbid conditions (Brown, Antony, & Barlow, ; Tsao, Lewin, &
Craske, ; Tsao, Mystkowski, Zucker, & Craske, , ). In other
words, co-occurring symptoms of depression and other anxiety disorders
tend to improve after PCT for PD. However, one study suggests that the
benefits for comorbid conditions may lessen over time when they are as-
sessed two years after PCT (Brown et al., ). Nonetheless, the general
finding of improvement in comorbidity is significant since it suggests
the value of remaining focused on the treatment for PD even when co-
morbidity is present since the comorbidity will be benefited as well, at
least up to one year. In fact, there is preliminary evidence to suggest that
attempting to address PD simultaneously along with comorbidity using
cognitive-behavioral therapy (CBT ) tailored to each disorder may be
less effective in general than remaining focused on PD (Craske et al.,
), although this finding is in need of replication.

Also, applications of PCT have proven very helpful in lowering relapse

rates on discontinuation of high-potency benzodiazepines (e.g., Otto,
Pollack, Sachs, Reiter, & Rosenbaum, ; Spiegel, Bruce, Gregg, &
Nuzzarello, ). Procedures for benzodiazepine withdrawal are detailed
in Stopping Anxiety Medication: Panic Control Therapy for Benzodiazepine
Discontinuation, Therapist Guide (Otto, Jones, Craske, & Barlow, ),

2
 and Stopping Anxiety Medication: Panic Control Therapy for Benzodiazepine
Discontinuation, Patient Workbook (Otto, Pollack, & Barlow, ),
available as part of the TreatmentsThatWork™ series from Oxford Uni-
versity Press.

The efficacy of psychological treatments for panic has been demon-

strated in several other institutions around the world, using the same or
similar approaches, by clinicians and researchers such as Beck ();
Clark, Salkovskis, and Chalkley (); Clark, Salkovskis, Hackmann, et
al. (); and Ost (). Although they are derived from somewhat dif-
ferent theoretical perspectives, most of these treatments to some degree
involve: (a) re-education about the nature of panic attacks; (b) breathing
skills training or relaxation; (c) cognitive therapy directed at negative
cognitions associated with panic; and (d) exposure to interoceptive so-
matic cues. PCT highlights interoceptive exposure to feared bodily sen-
sations by providing a variety of unique methods of provoking these
sensations in a mild way in the office. In , the National Institute of
Mental Health published the results of a consensus conference recom-
mending that the treatments of choice for PD, based on research to date,
are cognitive-behavioral approaches, such as PCT; medications; or both.
Empirical studies since then continue to uphold the strong efficacy of
PCT for PD, leading to its classification as an empirically validated treat-
ment (Chambless et al., ). Two meta-analyses reported very large
effect sizes of . and . for CBT (including PCT ) for PD (Mitte,
; Westin & Morrison, ).

Efficacy of Cognitive-Behavioral Treatment for Agoraphobia

The CBT for agoraphobia typically incorporates cognitive restructuring,

some form of breathing skills training, and in vivo exposure to feared
agoraphobia situations. In this guide, these methods are combined with
strategies for deliberately facing feared somatic sensations in agorapho-
bia situations. Researchers since the s have established the efficacy
of this type of CBT, in one form or another, for agoraphobia. Random-
ized controlled studies that include an index of clinically significant
change yield the following average statistics: after an average of  treat-
ment sessions and a % rate of attrition, % of participants show

3
 some level of clinically significant improvement by posttreatment, as do
the same percentage by follow-up assessment. High end-state, meaning
normative levels of functioning, is attained by % by posttreatment
and by % by follow-up (see Craske, ). The trend for continuing
improvement over time is noteworthy in this regard. Furthermore, Fava,
Zielezny, Savron, and Grandi () found that only .% of their
panic-free clients relapsed over a period of five to seven years after expo-
sure-based treatment for agoraphobia. Some research suggests that the
trend for improvement after acute treatment is facilitated by the involve-
ment of significant others in every aspect of treatment (e.g., Cerny, Bar-
low, Craske, & Himadi, ). For this reason, our program describes
methods for involving significant others in the treatment process. As with
PCT, CBT for agoraphobia is considered an empirically validated treat-
ment (Chambless et al., ). Recently, an intensive, -day treatment,
using a sensation-focused PCT approach was developed for individuals
with moderate to severe agoraphobia, and initial results are promising
(Morissette, Spiegel, & Heinrichs, ).

Dismantling CBT for Panic and Agoraphobia

Attempts have been made to dismantle the different components of

PCT and CBT for agoraphobia. The results are somewhat confusing,
and they are dependent on the samples used (e.g., mild versus severe lev-
els of agoraphobia) and the exact comparisons made. It appears that the
cognitive therapy component may be effective (e.g., Williams & Falbo,
), even when conducted in full isolation from exposure and behav-
ioral procedures (e.g., Salkovskis, Clark, & Hackman, ), and is more
effective than applied relaxation (e.g., Arntz & van den Hout, ;
Beck et al., ; Clark et al., ). On the other hand, some studies
find that cognitive therapy does not improve outcome when added to in
vivo exposure treatment for agoraphobia (e.g., van den Hout, Arntz, &
Hoekstra, ; Rijiken, Kraaimaat, De Ruiter, & Garssen, ). Simi-
larly, one study found that for agoraphobia, breathing skills training and
repeated interoceptive exposure to hyperventilation did not improve
outcome beyond in vivo exposure alone (de Beurs, Lange, van Dyck, &
Koele, ), and we found that breathing skills training was slightly less
effective than interoceptive exposure when each was added to cognitive

4
 restructuring (Craske, Rowe, Lewin, Noriego-Dimitri, ). Clearly,
more dismantling research is needed.

Cost-Effective Treatments for Panic and Agoraphobia

Group formats appear to be as effective as individual-treatment formats

for PCT and behavioral treatment for agoraphobia (Neron, Lacroix, &
Chaput, ; Lidren et al., ). One possible exception is that indi-
vidual, one-on-one formats may be better in the long term with respect
to symptoms of generalized anxiety and depression (Neron et al., ).
However, more direct comparison between group and individual for-
mats is warranted before firm conclusions can be made.

Most of the studies described above averaged around – treatment

sessions. Four to six sessions of PCT (Craske, Maidenberg, & Bystrit-
sky, ; Roy-Byrne, Craske, Stein, Sherbourne, Bystritsky, Golinelli,
Katon, & Sullivan, ) seem effective also, although the results were
not as effective as those typically seen with – treatment sessions. On
the other hand, another study demonstrated equally effective results when
delivering CBT for PD across the standard  sessions versus approxi-
mately six sessions (Clark, Salkovskis, Hackmann, Wells, et al., ),
and a pilot study indicated good effectiveness with intensive CBT over
two days (Deacon & Abramowitz, ).

Computerized versions of CBT for PD now exist. Computer-assisted and

Internet-based versions of CBT are effective for PD (e.g., Richards, Klein,
& Carlbring, ). In one study, a four-session, computer-assisted
CBT for PD was less effective than a -session PCT at posttreatment,
although they were equally effective at follow-up (Newman, Kenardy,
Herman, & Taylor, ).

However, findings from computerized programs for emotional disorders

in general indicate that such treatments are more acceptable and suc-
cessful when they are combined with therapist involvement (e.g., Carl-
bring, Ekselius, & Andersson, ).

Finally, self-directed treatments, with minimal direct contact with a

therapist, are very beneficial to highly motivated and educated clients
(e.g., Ghosh & Marks, ; Gould & Clum, ; Gould, Clum, &

5
 Shapiro, ). Nevertheless, we generally recommend that a mental
health professional conduct and supervise this treatment because not all
clients are highly motivated, educated, or able to fully appreciate the nu-
ances of the cognitive and behavioral therapeutic strategies.

Pharmacological Treatments for Panic and Agoraphobia

Currently, serotonin-specific reuptake inhibitors (SSRIs) are the medi-

cation treatment of choice for PD, based on  positive, placebo-controlled,
randomized clinical trials (Roy-Byrne & Cowley, ). Meta-analyses
and reviews have reported medium to large effect sizes compared to
placebo (e.g., Mitte, ; Bakker, van Balkom, & Spinhoven, ).
The majority of trials have been short term, although several have ex-
amined and confirmed longer-term efficacy up to one year.

Benzodiazepines are effective agents for PD. They work rapidly, within
days to one week, and are even better tolerated than the very tolerable
SSRI class of agents. However, they are limited by their risk of physio-
logic dependence and withdrawal and by the risk of abuse (Roy-Byrne
& Cowley, )

Numerous studies clearly show that discontinuation of medication re-

sults in relapse in a significant proportion of patients, with placebo-
controlled discontinuation studies showing rates between –% within
 months, depending on each study’s design. In addition, SSRIs, serotonin-
norepinepherine reuptake inhibitors (SNRIs) and benzodiazepines are
associated with a time-limited withdrawal syndrome (considerably worse
for the benzodiazepines), which itself may serve as an interoceptive stimu-
lus that promotes or contributes to PD relapse.

In terms of comparison between pharmacological and psychological

approaches to the treatment of PD, we compared the antidepressant
imipramine, CBT, placebo, a combination of CBT and placebo, and a
combination of CBT and imipramine in patients with PD uncompli-
cated by depression or significant agoraphobia (Barlow et al., ). This
landmark study showed that all four active treatments were equivalent
at the end of the acute (-month) phase and that the combination of
imipramine and CBT was marginally superior to either treatment alone

6
 at  months (consistent with prior reports of the superiority of com-
bined treatment in more complicated panic). Following discontinua-
tion, however, patients receiving the CBT plus imipramine combination
fared somewhat worse than those receiving CBT alone, suggesting the
possibility that state- or context-dependent learning in the presence of
imipramine may have attenuated the new learning that occurs during
CBT (Bouton, Mineka, & Barlow, ).

Findings from the combination of fast-acting anxiolytics—and, specifi-

cally, the high-potency benzodiazepines with behavioral treatments for
agoraphobia—are contradictory (e.g., Marks et al., ; Wardle et al.,
). Nevertheless, several studies reliably show detrimental effects from
chronic use of high-potency benzodiazepines on short-term and long-
term outcome from PCT and cognitive-behavioral treatments for ago-
raphobia (e.g., Otto, Pollack, & Sabatino, ; van Balkom, de Beurs,
Koele, Lange, & van Dyck, ; Wardle et al., ). Specifically, there
is evidence for more attrition, poorer outcome, and more relapse with
chronic use of high-potency benzodiazepines.

Therapist Variables

Therapist variables have been understudied with respect to cognitive-

behavioral treatments. Williams and Chambless () found that pa-
tients who rated their therapists as caring or involved and as modeling
self-confidence achieved better outcomes on behavioral-approach tests.
However, an important confound in this study is that client ratings of
therapist qualities may have depended on client responses to treatment.
Keijsers, Schaap, Hoogduin, and Lammers () reviewed findings re-
garding therapist-relationship factors and behavioral outcome. They
conclude that empathy, warmth, positive regard, and genuineness as-
sessed early in treatment predict positive outcome. Second, patients who
view their therapists as understanding and respectful improve the most.
Also, patient perceptions of therapist expertness, self-confidence, and
directiveness related positively to outcome, although not consistently. In
their own study of junior therapists who provided cognitive-behavioral
treatment for panic disorder and agoraphobia (PDA), Keijsers, et al. ()
found that therapists used more empathic statements and more ques-
tioning in the first session than in later sessions. In the third session,

7
 therapists became more active and offered more instructions and expla-
nations. In the tenth session, therapists employed more interpretations
and confrontations than previously. In fact, directive statements and ex-
planations in the first session predicted poorer outcome. Empathic lis-
tening in the first session related to better behavioral outcome, whereas
empathic listening in the third session related to poorer behavioral out-
come. Thus, they demonstrated the advantages of different interactional
styles at different points in therapy.

Finally, Huppert, Bufka, Barlow, Gorman, Shear, & Woods () demon-
strated that the experience of therapists positively influenced outcome,
seemingly because these therapists were more flexible in administering
the treatment and better able to adapt it to the individual being treated
(Huppert, et al., ).

Outline of This Treatment Program

It is our intention that the Mastery of Your Anxiety and Panic, Fourth
Edition (MAP–IV ), although written for the client, be carried out under
the supervision of a mental health professional. We recommend this
practice because many of the concepts and procedures are relatively
complex. The most effective implementation requires an understanding
of the principles underlying the different procedures. Therefore, the
mental health professional should be fully familiar with the therapist
guide and client workbook and aware of the conceptual bases for the di-
fferent techniques.

The following outline presents a recommended pace for working through

the chapters in the workbook. It is important to realize that the pace is
likely to shift based on the client’s own profile of panic, anxiety, and ago-
raphobia. For example, clients will spend much less time on chapter  if
they avoid only a limited number of agoraphobia situations.

Week  Chapter : Learning to Record Panic and Anxiety

Chapter : Negative Cycles of Panic and Agoraphobia

Chapter : Panic Attacks Are Not Harmful

Chapter , Section : Medications (Education)

8
Week  Chapter : Establishing Your Hierarchy of Agoraphobia
Situations

Chapter , Section : Breathing Skills (Diaphragmatic

Breathing)

Chapter , Sections  and : Thinking Skills (Basics; Realis-

tic Odds)

Week  Chapter , Section : Breathing Skills (Slow Breathing)

Chapter , Section : Thinking Skills (Putting Things Into

Perspective)

Week  Chapter , Section : Breathing Skills (Coping Application)

Chapter , Section : Thinking Skills (Review; Memories)

Chapter , Section : Facing Agoraphobia Situations

(Planning)

Chapter : Involving Others

Week  Chapter , Section : Breathing Skills (Review)

Chapter , Section : Facing Agoraphobia Situations

(Review and Planning)

Chapter , Section : Facing Physical Symptoms (Assess-

ment and Practice)

Week  Chapter , Section : Facing Agoraphobia Situations

(Review and Planning)

Chapter , Section : Facing Physical Symptoms (Review

and Practice)

Week  Chapter , Section : Facing Agoraphobia Situations

(Review and Planning)

Chapter , Section : Facing Physical Symptoms (Review

and Practice)

Week  Chapter , Section : Facing Agoraphobia Situations

(Review and Planning)

9
 Chapter , Section : Facing Physical Symptoms (Review
and Practice; Activities Planning)

Week  Chapter , Section : Facing Agoraphobia Situations

(Review and Planning)

Chapter , Section : Facing Physical Symptoms (Review

and Practice; Activities Planning)

Week  Chapter , Section : Facing Agoraphobia Situations

(Symptoms)

Chapter , Section : Facing Physical Symptoms (Review

and Practice; Activities Planning)

Week  Chapter , Section : Facing Agoraphobia Situations

(Symptoms)

Chapter , Section : Facing Physical Symptoms (Review

and Practice; Activities Planning)

Week  Chapter , Section : Medications (Stopping Medications)

Chapter : Accomplishments, Maintenance, and Relapse

Prevention

Ideally, clients will meet with their therapist to cover the material in the
introductory chapter and to review the principles of chapter  (“Learn-
ing to Record Panic and Anxiety”) of the workbook. The client is asked
to read chapter , begin to record panic and anxiety, and read chapters 
and , as well as chapter , section . At the second visit, the therapist
reviews the material in chapters  and  and chapter , Section, and
then assists clients in establishing a hierarchy of agoraphobia situations
and in beginning to use coping skills, and so on. At the end of each visit
with the therapist, we suggest that clients read the chapters relevant to
the material to be covered in the next visit with the therapist. If pre-
ferred, therapists may suggest that clients only read the relevant chapters
after the material is discussed in session.

This therapist guide provides session outlines, the concepts and prin-
ciples underlying the therapeutic procedures, the relevant therapist be-
haviors, vignettes depicting typical questions asked by clients, and prob-
lems that may arise in each chapter. Each chapter in this guide is

10
 structured as follows: (a) materials needed; (b) session outline; (c) ther-
apist behaviors; (d) main concepts and principles underlying the partic-
ular treatment procedures included in the chapter; (e) case vignettes that
reflect typical types of questions asked in each chapter and examples of
therapist responses; and (f ) atypical or problematic client responses. A
final chapter in the therapist guide discusses ways in which this treat-
ment is modified for primary care settings. A separate workbook for this
six-session program is available from Oxford University Press.

Who Will Benefit From This Program?

The MAP–IV workbook is geared toward people who suffer from panic
or anxiety attacks and agoraphobia. It is ideal for those who meet the cri-
teria for PD, with or without agoraphobia, according to the American
Psychiatric Association’s Diagnostic and Statistical Manual of Mental Dis-
orders (), fourth edition (DSM–IV ). However, it will be useful for
clients who suffer occasional panic attacks but who do not meet the
severity criteria for PD or who show only mild signs of agoraphobia. In
addition, it will be useful for people suffering from more discrete pho-
bias such as claustrophobia, fear of heights, or fear of driving. This is
because many of these phobias are associated with unexpected panic at-
tacks, although the avoidance behavior that develops is very circumscribed.
However, we also have a therapist guide and a workbook especially de-
signed for specific phobias: Mastery of Your Fears and Phobias, Therapist
Guide (Craske, Antony, & Barlow, ) and Mastery of Your Fears and
Phobias, Workbook (Antony, Craske, & Barlow, ) are available from
Oxford University Press.

What If Other Problems Are Present?

It is not at all uncommon for people with panic attacks and agorapho-
bia to be depressed, to have other anxiety disorders, or to exhibit features
of a variety of personality disorders. None of these problems precludes
treatment using MAP–IV. However, we have taken the approach that
the most severe and disabling problem should be the problem that is tar-
geted first for treatment. For example, if certain clients present with a

11
 major depressive episode that is clearly more severe than their panic at-
tacks, then the depression should be treated first, and they can perhaps
return to treating their panic and agoraphobia after the depressed mood
has alleviated. This would be our recommendation even if the depres-
sion developed secondary to, or as a consequence of, panic and agora-
phobia. On the other hand, if clients present with both conditions, but
the PD and agoraphobia are clearly equally or more severe than the de-
pression, then it is appropriate to proceed with our workbook. The same
is true for other comorbidities. Keep in mind that comorbid conditions
tend to improve, at least for some period of time, with successful treat-
ment of PD. That being said, our assumptions about which constella-
tion of symptoms should be treated first are based on clinical experience
and have not been empirically tested.

This program is not appropriate for clients who are generally anxious or
depressed without the complication of panic attacks and agoraphobia.
Different treatment protocols have been developed and evaluated for
people suffering from more generalized anxiety, stress, and associated de-
pression. On occasion, people with a broad pattern of hypochondriacal
complaints may think this program is appropriate. However, other ap-
proaches exist that are more suited to hyponchondriasis. Thus, it is im-
portant to distinguish people suffering from PD from those with a more
generalized anxiety, stress, depression, or somatoform disorder.

Finally, clients who are undergoing major life stressors, such as marital
or financial crises, may not have the time or energy to devote to this type
of treatment program and are best advised to postpone beginning such
a treatment until their other major problems are resolved.

Assessment

Mental health professionals may wish to screen clients using the Anxiety
Disorders Interview Schedule for DSM-IV (ADIS–IV), which was designed
for this purpose. Specifically, this semistructured interview provides a
very detailed analysis of the nature of the anxiety or panic, the ability to
determine if one or more anxiety and/or mood disorders is present, as
well as the ability to measure the relative severity of each disorder. A par-

12
ticular strength of this interview is that it helps to differentiate among
the different anxiety and somatoform disorders. ADIS–IV is available
from Oxford University Press.

Furthermore, a medical evaluation is generally recommended because

several medical conditions should be ruled out before assigning the di-
agnosis of PD. These include thyroid conditions, caffeine or ampheta-
mine intoxication, drug withdrawal, or pheochromocytoma (a tumor on
the adrenal gland which produces excess adrenaline). Fortunately, most
PD clients have had complete medical evaluations already. Furthermore,
certain medical conditions can exacerbate Panic Disorder, although PD
is likely to continue despite those conditions’ medical control. Mitral
valve prolapse, asthma, allergies, and hypoglycemia fall into this cate-
gory. These medical conditions exacerbate PD to the extent that they
elicit the types of physical sensations now feared by the individual. For
example, mitral valve prolapse can produce heart murmurs; asthma re-
sults in shortness of breath; and hypoglycemia causes dizziness and weak
feelings.

Several standardized self-report inventories provide useful information

for treatment planning, as well as being sensitive markers of therapeutic
change. The Mobility Inventory (Chambless et al., ) lists common
agoraphobia situations that are rated in terms of degree avoidance, both
when alone and when accompanied. This instrument is very useful for
establishing in vivo exposure hierarchies. The Anxiety Sensitivity Index
(Reiss, Peterson, Gursky, & McNally, ) has received wide acceptance
as a trait measure of threatening beliefs about bodily sensations. It has
good psychometric properties and tends to discriminate PD from other
types of anxiety disorders. More specific information about which partic-
ular bodily sensations are feared the most, and what specific misappraisals
occur most often, can be obtained from the “Body Sensations Ques-
tionnaire” and the “Agoraphobia Cognitions Questionnaire” (Chamb-
less et al., ).

Ongoing assessment throughout treatment is provided by the self-

monitoring procedures outlined in chapter  of the workbook.

13
Medication

Many people suffering from panic attacks and agoraphobia will be re-
ferred to mental health professionals while already on psychotropic
medication, most often prescribed by primary care physicians. In our ex-
perience, almost three quarters of our clients take low doses of benzo-
diazepines or minor tranquilizers, tricyclic antidepressants, or selective
SSRIs. Issues surrounding the combination of medications with CBTs
are complex and not fully understood. The most effective ways of com-
bining CBTs with an already-existing medication regimen are yet to be
empirically tested. Thus, we make no recommendation that already-
medicated clients decrease their medication before beginning our work-
book. Rather, we suggest that they continue with whatever dosage of
medication they are taking until they complete the workbook.

We do discourage clients from increasing dosages of medication, particu-

larly benzodiazepines, during the course of treatment because, as re-
viewed, there is some evidence that high dosages of benzodiazepines
may interfere with the effects of PCT. It is believed that high doses of
these drugs may have a number of negative effects; they may lessen the
motivation to practice cognitive-behavioral skills; result in such little
fear and anxiety that exposure-based treatments are no longer valuable;
generate a strong attribution of therapeutic improvement to the medi-
cation in a way that detracts from the development of self-efficacy; cause
medications to become safety signals that detract from learning to cor-
rect misappraisals of danger; or cause state dependency of learning, so
that skills learned under the influence of the drug may not generalize to
times when the drug is discontinued.

In our experience, a large proportion of clients successfully completing

the workbook stop all medication use on their own, without any en-
couragement to do so. Nevertheless, issues of medication withdrawal are
discussed in chapter  of the workbook. We have found it helpful to
use the MAP–IV program as an aid for discontinuing medication if
clients and prescribing physicians so desire. The program assists clients
in tolerating the withdrawal effects of certain medications, particularly,
the benzodiazepines. A modification of the MAP–IV program has been
developed as a tool for facilitating the discontinuation of high doses of

14
 benzodiazepines in clients who have become dependent on them (Otto,
Pollack, & Barlow, ). Stopping Anxiety Medication: Panic Control Ther-
apy for Benzodiazepine Discontinuation, Therapist Guide (Otto, Jones, et
al., ) and accompanying Patient Workbook (Otto, Pollack, & Barlow,
) are available from Oxford University Press.

Who Should Administer the Program?

The MAP–IV workbook is presented in sufficient detail, so that most

mental health professionals should be able to supervise its implementa-
tion. Efforts are underway to evaluate the issue of program leadership in
more detail; there are already studies in primary care settings showing
that these kinds of treatments can be delivered without years of special-
ized clinical expertise. However, we do have some recommendations for
minimal requirements. Of most importance is familiarity with the na-
ture of anxiety and panic; some basic information on these topics is pre-
sented in chapter . Familiarity with the basic principles of cognitive and
behavioral intervention is another recommended minimal requirement.
In addition, we believe it is important that therapists have sufficient
knowledge of the principles underlying the specific treatment in this
workbook to allow adaptation of the material to best suit each client.
Provision of this knowledge is the purpose of this therapist guide. (More
in-depth information can be found in the References and Additional
Readings sections.)

Should Former Clients Be Cotherapists?

Many programs, particularly those targeting agoraphobia avoidance be-

havior, utilize ex-clients as cotherapists or team leaders. These therapists
often act as supervisors during in vivo exposure exercises. The philoso-
phy behind this approach is that these ex-clients have struggled through
similar problems and can therefore act as good role models for clients
currently struggling with panic and associated problems. In addition,
these individuals tend to be very understanding and supportive during
the process. This is the positive side of the picture.

15
 On the other hand, some less positive aspects have been reported. Some-
times, ex-clients, because of their own success, believe that there is only
one correct way to accomplish various tasks. They may not understand
the reasons why a client does not wish to work in the same way that they
did or to work at the same speed. In other words, they may not be as
adept at tailoring the program to individual clients as is the fully trained,
professional therapist.

Therapists will have to decide whether the positive aspects of using ex-
clients outweigh the potential negatives. Obviously, this decision will
depend on the individual ex-client. To date, no research has determined
the effectiveness of working with ex-clients. What we do know is that
our workbook program has been evaluated and shown to be successful
when administered by mental health professionals without the help of
ex-clients.

Additional Training Opportunities

For more information on training opportunities, please visit the Treat-

mentsThatWork™ website (http://www.oup.com/us/ttw).

Group Versus Individual Sessions

We have administered this program in both individual and group for-

mats. As noted, there are few direct empirical evaluations of individual
versus group formats, but those that exist suggest that they are about
equally effective. Possible exceptions are that generalized symptoms of
anxiety and depression may be helped more by an individual format,
and rates of attrition may be higher from group than from individual
sessions.

The decision for group versus individual treatments should probably be

determined on a site-by-site basis in accord with therapist preferences.
Health maintenance organizations (HMOs) typically administer our pro-
gram in groups of six to eight to take advantage of the economies
afforded by this mode of administration. On the other hand, private
practitioners who do not wish to make clients wait until a group forms

16
 may find individual administration more convenient. When we deliver
group treatments, we limit the number of group members to no more
than eight because it is difficult to allocate individual attention to clients
during a -minute session in larger groups. However, other therapists
have reported successful use of this program in groups of  or more.

Frequency of Meetings

Usually, therapists meet with clients or groups once per week and assign
readings from the workbook and exercises to be conducted during the
week before the next meeting. Some therapists speed treatment by offer-
ing two sessions per week, thus cutting the length of treatment in half.

Does Every Person Require the Entire Program?

It is strongly recommend that each client complete the entire workbook

(aside from the few chapters that may not be directly relevant because
they concern medication issues or involvement of significant others),
even if he or she feels considerably better after fewer sessions. It has been
our experience that people who stop early because they feel better (a not
infrequent occurrence) may be subject to higher rates of relapse than
those who complete the entire program.

Benefits of Using a Manual

The first “revolution” in the development of effective psychosocial treat-

ments was the manualization of these treatments. Because these are struc-
tured programs for specific disorders, they can be written in sufficient
detail to allow trained therapists to administer them in roughly the same
manner in which they were proven effective. This does not, however,
imply that therapeutic skills are no longer required.

The second phase of this revolution is the preparation of the structured

program in a manner suitable for direct distribution to clients working
under therapeutic supervision. The MAP–IV workbook is one of a few

17
 examples of a scientifically sound guide written at the client’s level which
can be a valuable supplement to programs delivered by professionals
from a number of disciplines. There are several advantages to this.

Self-Paced Progress

Clients can move at their own individual pace. As stated previously, some
therapists or clients may wish to shorten the program by scheduling
more frequent sessions. Other clients may choose to move more slowly,
due to conflicting demands such as travel schedules. Having the client
workbook available between irregularly scheduled sessions for review
and rereading can be quite beneficial.

Ready Reference for Clients

Although concepts may be perfectly clear to the therapist, clients who

seem to understand material during the session often become confused
after leaving. One of the greatest benefits of the client workbook is the
opportunity for clients to review relevant conceptualizations, explana-
tions, and instructions between sessions. The authors have found that
during treatment, the MAP–IV workbook frequently becomes the client’s
“bible.” Many clients take the client workbook with them wherever they
go for handy reference and have found this availability extremely useful.
Certainly, research in memory stresses the importance of such repetition
and rehearsal for the consolidation of newly acquired information.

Availability to Family Members and Friends

We have demonstrated a significant advantage from having family mem-

bers, particularly spouses or other partners, be aware of and involved in
treatment (e.g., Barlow, O’Brien, & Last, ; Carter, Turovsky, & Bar-
low, ; Cerny et al., ). For example, clients whose partners were
included in treatment did better at a -year follow-up than did those
clients whose partners were not included. Family participation can be
beneficial in several ways. First, attempts to sabotage the program, either

18
 purposely or unwittingly, are offset if family members become familiar
with the nature of the disorder and the rationale underlying treatment.
Second, family members can be helpful in overcoming some of the avoid-
ance behavior that often accompanies panic. Of course, some clients
prefer that their partners or family members remain unaware of their
problem. In these cases, we attempt to persuade clients of the advantage
of sharing the problem with their partners and thereby to allay any con-
cerns. Typically these concerns revolve around worries that family mem-
bers will think they are insane or will be openly hostile to their efforts.
These reactions almost never happen. Nevertheless, occasionally, there
may be clear signs that it is inappropriate to involve the significant other
(e.g., severe marital discord), in which case we do not encourage the sig-
nificant other’s involvement. When the decision is made to incorporate
the significant other, we usually bring the partner into treatment ses-
sions, either initially or throughout the entire treatment.

Clients Can Refer to the Manual After the Program Ends

The MAP–IV workbook will help clients deal effectively with occasional
recurrences of panic attacks or agoraphobia after treatment is over. This
kind of recurrence is most likely under particularly stressful situations.
The client workbook can be a source of great comfort during these pe-
riods and can often prevent escalation of panic attacks into a full-blown
relapse. The final chapter of the workbook, chapter , outlines ways of
maintaining progress and dealing with occasional recurrences of panic
and agoraphobia. In addition to the availability of useful information
and prompts to use the skills learned during treatment, having the client
workbook available in and of itself seems to be anxiolytic. In fact, the
workbook may function as a cue or reminder that simply by its presence
increases the recall of information and skills learned during treatment.

Full Workbook Versus Installments

Some therapists who have been using the MAP–IV program since its in-
ception in  report that they prefer to distribute the chapters in in-
stallments. In this way, they prevent clients from skipping ahead and thus

19
 encourage better concentration on one chapter at a time. These thera-
pists have adopted loose-leaf binders or other mechanisms of putting the
client workbook together.

Based on this feedback, we considered supplying the workbook in such

formats but ultimately decided against it. The downside of this practice
is that individual chapters are more likely to be misplaced, so, when the
program ends, clients will have incomplete workbooks. This causes diffi-
culties in later months, when clients wish to refer to specific chapters.

In addition, we are not particularly concerned if clients do a little skip-

ping around. In general, we find that the more time clients spend re-
viewing the workbooks, the deeper their understanding, and the greater
their benefit. During the sessions, if clients mention material that they
have read in future chapters, the therapist can simply refocus the clients’
attention to the current assignments. Nevertheless, we do not discour-
age therapists from distributing the client workbooks in installments if
they prefer that practice.

Fees for the Workbook

Different therapists and programs will obviously have their own fee
structures. The cost of the workbooks is typically incorporated into this
fee structure in one of two ways. First, client workbooks can be pur-
chased in bulk by the program or therapist, and these costs are then in-
corporated into the costs of the therapy session or program. Alterna-
tively, some therapists and programs, particularly those with rather
inflexible rate structures, have the clients themselves assume the cost of
purchasing the client workbook. In these cases, workbooks may be pur-
chased in bulk for resale at the beginning of treatment.

20
Chapter 2 The Nature of Panic Disorder and Agoraphobia

Diagnostic Criteria for Panic Disorder

A. Both  and :
. Recurrent unexpected panic attacks.
. At least one of the attacks has been followed by one month
(or more) of one (or more) of the following:
a. a persistent concern about having additional attacks;
b. worrying about the implications of the attack or its con-
sequences (e.g., losing control, having a heart attack,
going crazy insane);
c. a significant change in behavior related to the attacks.

B. The panic attacks are not due to the direct physiological effects
of a substance (e.g., a drug of abuse, a medication) or a general
medical condition (e.g., hyperthyroidism).

C. The panic attacks are not better accounted for by another mental
disorder, such as social phobia (e.g., occurring on exposure to
feared social situations), specific phobia (e.g., on exposure to a
specific phobia situation), obsessive-compulsive disorder (OCD)
(e.g., on exposure to dirt in someone with an obsession about con-
tamination), posttraumatic stress disorder (PTSD) (e.g., in re-
sponse to stimuli associated with a severe stressor), or separation
anxiety disorder (e.g., in response to being away from home or
close relatives).

Panic Disorder (PD) is divided into categories of with or without ago-

raphobia.

21
Diagnostic Criteria for Agoraphobia

A. Anxiety about being in places or situations from which escape might

be difficult (or embarrassing) or in which help may not be available
in the event of having an unexpected or situationally predisposed
panic attack or panic-like symptoms. Agoraphobic fears typically
involve characteristic clusters of situations that include being out-
side the home alone; being in a crowd or standing in a line; being
on a bridge; and traveling in a bus, train, or automobile.

B. The situations are avoided (e.g., travel is restricted), or else are

endured with marked distress or with anxiety about having a
panic attack or panic-like symptoms, or require the presence of a
companion.

C. The anxiety or phobic avoidance is not better accounted for by

another mental disorder, such as social phobia (e.g., avoidance
limited to social situations because of fear of embarrassment), spe-
cific phobia (e.g., avoidance limited to a single situation like eleva-
tors), OCD (e.g., avoidance of dirt in someone with an obsession
about contamination), PTSD (e.g., avoidance of stimuli associated
with a severe stressor), or separation anxiety disorder (e.g., avoid-
ance of leaving home or relatives).

Diagnostic Criteria for a Panic Attack

The diagnostic criteria for a panic attack include a discrete period of in-
tense fear or discomfort in which four (or more) of the following symp-
toms develop abruptly and reach a peak within  minutes:

. heart palpitations, pounding heart, or accelerated heart rate;

. sweating;

. trembling or shaking;

. sensations of shortness of breath or smothering;

. feeling of choking;

. chest pain or discomfort;

22
 . nausea or abdominal distress;

. feeling dizzy, unsteady, lightheaded, or faint;

. derealization (feelings of unreality) or depersonalization (being de-

tached from oneself );

. fear of losing control or going insane;

. fear of dying;

. paresthesias (numbness or tingling sensations);

. chills or hot flushes.

Features of Panic Disorder and Agoraphobia

Panic Disorder is characterized by recurrent panic attacks (or, sudden

rushes of intense fear or discomfort). A panic attack is defined by a clus-
ter of physical and cognitive symptoms, including heart palpitations,
shortness of breath, derealization, paresthesia, trembling, and fears of
dying, going insane, or losing control. Panic attacks are common to all
anxiety disorders. PD is distinguished by unexpected attacks, that is, at-
tacks that occur without an obvious trigger; and at least one month of
persistent apprehension about the recurrence of panic or its conse-
quences; or a significant behavioral change.

Agoraphobia refers to avoidance or endurance with dread of situations

from which escape might be difficult or help unavailable in the event of
a panic attack, or panic-like symptoms, such as loss of bowel control.
Typical agoraphobia situations include shopping malls, waiting in lines,
being at movie theaters, traveling by car or bus, being in crowded restau-
rants and stores, and being alone.

The National Comorbidity Survey-Replication (NCS-R) provides preva-

lence estimates of -month and lifetime PD as .% and .%, respec-
tively (Kessler, Chiu, Demler, Merikangas, & Walters, ; Kessler,
Berglund, Demler, Jin, Merikangas, & Walters, ). Conservative
estimates suggest that an additional .–.% experience nonclinical
panic (or, occasional panic attacks). The level of anxiety about the re-

23
 currence of panic and catastrophic cognitions during panic seem to
differentiate nonclinical panic from PD.

Epidemiological studies report relatively high rates for agoraphobia

without a history of PD: .% in the last  months and .% in a life-
time (Kessler, Berglund, et al., ). In contrast, individuals with ago-
raphobia who seek treatment almost always report a history of panic
which preceded development of their avoidance (Wittchen, Reed, &
Kessler, ). There are at least two explanations for the contrast be-
tween population-based and clinic-based data. First, epidemiological data
may vastly overestimate the prevalence of agoraphobia due to misdiag-
nosis of specific phobias, generalized anxiety, or “normal” cautiousness
about certain situations (e.g., walking in unsafe urban districts) as ago-
raphobia. Second, individuals who panic are more likely to seek help.

Rarely does the diagnosis of PD, with or without agoraphobia, occur in

isolation. Commonly co-occurring Axis I conditions include specific
phobias, social phobia, dysthymia, generalized anxiety disorder, major
depressive disorder, and substance abuse. From  to % of persons
with PD also meet criteria for a personality disorder, mostly avoidant
and dependent personality disorders (see Roy-Byrne, Craske, Stein, Sul-
livan, Bystrisky, & Katon, et al., ).

The modal age of onset is late teenage years and early adulthood (Kessler,
Chiu, et al., ), although treatment is usually sought at a much later
age, around  years. A large percentage (approximately %) report the
presence of identifiable stressors around the time of the first panic at-
tack. Finally, PD and agoraphobia tend to be chronic conditions with se-
vere financial and interpersonal costs. That is, only a minority of patients
remit without subsequent relapse within a few years (%), although a
similar number experience notable improvement, albeit with a waxing and
waning course (%) (Roy-Byrne & Cowley, ). Fortunately, PD re-
sponds well to specifically targeted treatments, described in our workbook.

Psychobiological Conceptualization

For a full presentation and original citations for psychobiological con-

ceptualization, see Barlow () and Craske ().

24
Biological Factors

From a genetic perspective, it is believed that PD, like other psychiatric

disorders, is a complex disorder with multiple genes conferring vulnera-
bility through as-yet-undetermined pathways. Either there is substantial
genetic heterogeneity with multiple etiologically distinct forms of the
disorder, or the superficially similar phenotype actually reflects a more
unified, broad genetic vulnerability to panic and anxiety. Studies involv-
ing multivariate genetic analyses of large samples of subjects tend to
support the latter model, to suggest the existence of relatively broad or
nonspecific genetic factors that influence the vulnerability to panic and
anxiety. Thus, the workbook educates the reader to think of certain bio-
logical factors that may be inherited or passed on through genes and thus
may lead some people to be more likely to panic. Many believe that what
is inherited is overly sensitive parts of the nervous system which increase
the likelihood of all negative emotions, including anger, sadness, guilt,
and shame, as well as anxiety and panic. However, inheriting vulnera-
bilities to experience negative emotions does not guarantee panic attacks
or PD. In other words, panic is not inherited in the same way that eye
color is inherited.

Biological factors (whatever they might be) probably help explain why
panic disorder tends to run in families. In other words, if one family
member has PD, then another person in the same family is more likely
to have PD than are others in the general population. That is, whereas
–% of the American population has PD and/or agoraphobia, –%
of first-degree relatives (parents, siblings, children) of someone with
panic disorder themselves develop PD.

Psychological Factors

The psychological conceptualization of panic disorder emphasizes fear

of bodily sensations, characterized by tendencies to misappraise these
sensations in a catastrophic manner or to misappraise them as being
much more dangerous than they really are. Usually, the misappraisals are
of impending physical or mental danger, such as believing that a feeling
of breathlessness as evidence of impending breathing cessation and death,

25
 viewing palpitations of the heart as evidence of an impending heart at-
tack, thinking that lightheadedness is evidence of an impending loss of
consciousness, or viewing shakiness as evidence of impending loss of
control and insanity.

The trait of anxiety sensitivity, a set of beliefs that anxiety is harmful

along social, physical and mental domains, is believed to predispose to-
ward the fear of bodily sensations. In support, several longitudinal stud-
ies find that high scores on a measure of anxiety sensitivity are predictive
of the development of panic attacks in nonclinical groups and of the
maintenance of panic disorder in untreated PD groups.

We believe that anxiety sensitivity is acquired insidiously from a lifetime

of direct aversive experiences (such as a personal history of significant
illness or injury), vicarious observations (such as exposure to significant
illnesses or death among family members or to family members who dis-
play a fear of body sensations through hypochondriasis), and/or infor-
mational transmissions (such as parental warnings or overprotectiveness
regarding physical well-being).

Also associated with anxiety sensitivity is an enhanced attentional selec-

tivity toward, or interoception for, physical cues. Individuals with panic
disorder have heightened awareness of, or ability to detect, bodily sensa-
tions of arousal, although discrepant findings exist as to whether they are
more accurate in their detection. Ability to perceive one’s heartbeat, in
particular, appears to be a relatively stable individual difference variable.
Thus, along with anxiety sensitivity, the ability to detect interoceptive
cues may predispose an individual toward PD.

Many (%) panic clients report similar but less intense or less frighten-
ing panic-like sensations prior to their first panic attack. Also, previous
experiences of cardiac symptoms and shortness of breath predict later
development of panic attacks and PD. Perhaps such prior experiences
reflect a state of autonomic vulnerability which only develops into full-
blown panic when instances of autonomic arousal occur in threatening
contexts or under stressful conditions (i.e., when the sensations are more
likely to be perceived as harmful).

Earlier theorists emphasized separation anxiety as a specific precursor for

agoraphobia and panic. Bowlby () suggested that abnormal parent-

26
 child bonding induces a specific form of anxious attachment in children,
resulting in enduring separation anxiety, which in turn leads to agora-
phobia when the individual is confronted with personally threatening
situations as an adult. Some retrospective findings support the link be-
tween separation anxiety and agoraphobia. However, there is also reason
to believe that separation anxiety is a vulnerability for all anxiety disorders,
as well as for depression. Thus, separation anxiety may be best viewed as
a component of a broader vulnerability.

Initial Panic Attacks

The large majority of initial panic attacks occur outside of the home,
while driving, walking, or simply being at work or at school, in public
in general, and on a bus, plane, subway, or in social evaluative situations.
Furthermore, settings for initial panic attacks often are rated retrospec-
tively as somewhat difficult to escape. Situations that block escape behavior,
the natural action tendency associated with panic, intensify the urgency
to escape, as well as the associated fear and panic. Furthermore, initial
panic attacks may be most likely to occur in situations in which feared
physical sensations are perceived as particularly threatening due to pos-
sible impairment (e.g., driving), entrapment (e.g., air travel, elevators),
negative social evaluation (e.g., job, formal social events), or distance
from safety (e.g., unfamiliar locales).

In addition to a vulnerability to instances of elevated autonomic arousal,

an array of factors may explain surges of physiological sensations on the
occasion of an initial panic attack. These include benign physiological
events (ranging from normal variations in bodily state to illnesses), dis-
tal and proximal stress (e.g., impending divorce, rushing to an appoint-
ment, meeting a deadline), stimulants (e.g., caffeine, hallucinogenic
drugs, prescription medications), environmental conditions (e.g., heat
and humidity), and anticipatory anxiety about the immediate situation
or an upcoming event (e.g., receiving a work evaluation).

A stress-diathesis interaction seems to account for initial panic attacks. In

other words, the initial panic attack is viewed as a false alarm that is
prone to activation under stressful conditions. Just as some people expe-
rience irritable bowel syndrome, others experience panic attacks in re-

27
 sponse to stressful events. Certainly, the majority of individuals associ-
ate their initial panic attacks with stressful events. Typical stressful life
events include the unexpected loss of a significant other, illness, or aver-
sive drug experiences.

Maintenance Factors

Acute “fear of fear” (really, anxiety about fear or panic) that develops
after initial panic attacks refers to fear of specific bodily sensations asso-
ciated with panic attacks (e.g., racing heart, dizziness, paresthesia). This
anxiety is attributed to two factors. The first is interoceptive conditioning
(i.e., learned anxiety focused on internal states via aversive associations—
such as learning to be anxious about elevated heart rate because of a pre-
vious association between elevated heart rate and a panic attack). The
second factor is the misappraisal of bodily sensations (i.e., misinterpre-
tation of sensations as signs of imminent death, loss of control, and so
forth). “Fear of fear” can be construed as the sensitization of the predis-
posing trait of anxiety sensitivity due to the experience of panic attacks.

In support of the notion of “fear of fear,” clients with panic disorder

have strong beliefs and fears of physical or mental harm arising from
bodily sensations that are associated with panic attacks, and these clients
are more likely to interpret bodily sensations in a catastrophic fashion.
Also, persons with PD are more likely to be anxious about procedures
that elicit bodily sensations similar to the ones experienced during panic
attacks, including benign cardiovascular, respiratory, and audiovestibu-
lar exercises, as well as more invasive procedures, such as carbon dioxide
inhalations. Furthermore, these individuals become anxious about sig-
nals that ostensibly reflect heightened arousal, even in the absence of ac-
tual height-ened arousal, as shown through false physiological feedback
paradigms. Not only is misappraisal associated with anxiety, but reap-
praisal lessens anxiety. For example, persons with PD and nonclinical
panickers report significantly less anxiety and panic during laboratory-
based panic provocation procedures, such as hyperventilation and car-
bon dioxide inhalation, when they perceive that the procedure is safe
or controllable, when accompanied by a safe person, or after successful
cognitive-behavioral treatment.

28
The pattern of learned anxiety to certain somatic sensations typically re-
sults in an acute sensitivity to otherwise normal bodily sensations. Hence,
different daily activities that elicit sensations similar to the sensations ex-
perienced during panic may trigger panic attacks. Examples include a rac-
ing heart from exercise; sweating from hot weather conditions; excitement
from suspenseful movies, arguments, or sexual arousal; trembling from
ingestion of caffeine; and feelings of floating or heaviness from deep re-
laxation. Note, however, that anxiety focused on sensations is moderated
by occasion setters, which vary greatly across individuals. For example,
elevated heart rate may be anxiety provoking while sitting but not while
running, depending on the individual. Furthermore, if the bodily sen-
sation occurs in association with an established safety signal or a safe
context, anxiety will be diminished. For example, a racing heart may be
anxiety provoking when an individual is alone but not anxiety provok-
ing when that person is in close proximity to others and, especially, to
medical help.

Several features distinguish anxiety focused on bodily sensations from

anxiety triggered by external stimuli. First, autonomic arousal generated
by anxiety from sensations in turn intensifies the sensations, thus creat-
ing a reciprocating cycle of anxiety and sensations. The cycle is sustained
until physiological arousal is exhausted or perceptions of safety are
achieved. In contrast, anxiety triggered by external stimuli does not in-
tensify the object of fear. Second, cues that trigger panic attacks (i.e.,
bodily sensations) are not always immediately obvious, thus generating
the perception of unexpected or “out of the blue” panic attacks. Fur-
thermore, even when interoceptive cues are identifiable, they tend to be
less predictable than external stimuli. Third, bodily sensations are more
difficult to escape, on average, than external objects; that is, sensations
are relatively uncontrollable. Unpredictability and uncontrollability ele-
vate anxiety about upcoming aversive events, in general, and panic at-
tacks, in particular. Consequently, the unpredictable and uncontrollable
nature of panic attacks is hypothesized to contribute to high levels of
chronic anxious apprehension and to maintaining anticipatory anxiety
about the recurrence of panic. In turn, anxious apprehension increases
the likelihood of panic by directly increasing the availability of sensa-
tions that have become conditioned cues for panic or by increasing at-
tentional vigilance for these bodily cues. Thus, a maintaining cycle of
panic and anxious apprehension develops.

29
 Also, anxiety develops over specific contexts in which the occurrence of
panic would be particularly troubling (i.e., situations involving impair-
ment, entrapment, negative social evaluation, or distance from safety).
These anxieties contribute to agoraphobia. Note, however, that agora-
phobia is predicted by other variables as well, as described in the next
section.

Finally, subtle avoidance behaviors are believed to maintain negative be-

liefs about feared bodily sensations. Examples include holding on to ob-
jects or persons for fears of fainting, sitting and remaining still for fears
of heart attack, and moving slowly or searching for an escape for fears of
acting foolish.

Development of Agoraphobia

Not all persons who panic develop agoraphobia, and the extent of ago-
raphobia that emerges is highly variable. Agoraphobia tends to increase
as an individual’s history of panic lengthens; however, a significant pro-
portion of persons panic for many years without developing agorapho-
bic limitations. Nor is agoraphobia avoidance related to age of onset or
frequency of panic. Some researchers report more intense symptomatol-
ogy during panic attacks in individuals who are more agoraphobic. Oth-
ers fail to find such differences. Agoraphobic individuals may be more
concerned with social consequences of panicking, and the anticipation
of panic in specific agoraphobia situations predicts agoraphobia avoid-
ance. Whether the latter two variables are precursors or are secondary to
agoraphobia remains to be determined.

Occupational status predicts agoraphobia avoidance, accounting for

% of the variance: the more one is forced to leave the house by means
of employment, the less one is likely to suffer from agoraphobia. Perhaps
the strongest predictor of agoraphobia, however, is gender. Females in-
creasingly predominate the sample as agoraphobia worsens. Sex-role ex-
pectations and behaviors may contribute to these effects.

30
 Generalized Generalized
psychological vulnerability biological vulnerability

Stress due to life events

False alarm
Associated with somatic sensations
(interoceptive cues, e.g., pounding heart)
Learned alarm

Specific psychological vulnerability

(unexplained physical sensations are dangerous)

Anxious apprehension Development of agoraphobia

(focused on somatic sensations) (determined by cultural, social, and pragmatic
factors, and moderated by presence or
absence of safety signals)

Panic Disorder PDA

Figure 2.1.
Model of the etiology of panic disorder and agoraphobia

Nocturnal Panic

The psychobiological model described above applies equally to noctur-

nal panic, that is, waking from sleep in a state of panic (a recent review
is provided by Craske & Tsao, ). Nocturnal panic does not refer to
waking from sleep and panicking after a lapse of waking time, nighttime
arousals induced by nightmares or environmental intrusions, night ter-
rors, sleep paralysis, sleep seizures, or flashbacks to traumatic events.
Nocturnal panics occur without apparent reason and are similar symp-
tomatically to daytime panic attacks. They tend to occur in non-REM
sleep and, particularly, during the transition between late Stage  and
early Stage  sleep. While epidemiological studies have not been con-
ducted, surveys of select clinical and nonclinical groups suggest that
nocturnal panic is a relatively common phenomenon. From  to %
of PD clients report having experienced nocturnal panic at least once,
and from  to % have regular and frequent occurrences.

We believe that fears of bodily sensations contribute directly to noctur-

nal panic. In support of this claim, we find that individuals who are re-

31
 assured that episodes of physiological arousal during sleep are safe and
expected are less fearful of signals of such arousal than individuals who
are not reassured and who do not expect episodes of arousal to occur.
In other words, we found that the latter group awoke with more self-
reported distress, panic, and symptoms in response to these signals of
arousal.

We propose that, like daytime panic attacks, nocturnal panics are trig-
gered by changes in an individual’s physiological state during sleep
through a process of interoceptive conditioning, whereby low-level so-
matic sensations of arousal or anxiety become conditional stimuli, so
that early somatic components of the anxiety response come to elicit
anxiety or panic. In addition, interoceptive conditional responses are not
dependent on conscious awareness of triggering cues such that, once
acquired, these responses can be elicited under anesthesia, even in hu-
mans. Consequently, changes in relevant bodily functions which are not
consciously recognized due to sleep or sleep-like states may elicit condi-
tional fear due to previous pairings with panic. The role of precipitating
physiological events has received some support from reports of short
muscle twitches, increased EEG frequency, body movements, breathing
irregularities, and increases in heart rate and skin conductance in the
minutes and seconds preceding panicky awakenings. It may be necessary
for these physiological events to co-occur with Stage  or Stage  sleep,
as one shifts from semivigilance to nonvigilance; a shift that may be par-
ticularly anxiety provoking for individuals who have frequent nocturnal
panic attacks.

Fortunately, as mentioned earlier, panic control treatment modified

slightly for sleep is effective for nocturnal panic attacks (Craske, Lang,
Aikins, & Mystkowksi, ).

32
Chapter 3 Outline of Treatment Procedures and Basic
Principles Underlying Treatment

Procedure Outline

There are four main sections to the Mastery of Your Anxiety and Panic,
Fourth Edition (MAP–IV ), Workbook. The first is Basics, and it involves
(a) information and education designed to correct misinformation and
misinterpretations of somatic sensations and of panic and anxiety; and
(b) self-recording, which is intended to enhance objective self-awareness
and a personal scientist approach to panic and anxiety.

The second is Coping Skills, which involves (a) breathing skills training
(called Breathing Skills), which is designed to teach slow and diaphrag-
matic breathing; and (b) cognitive restructuring (called Thinking Skills),
which has been designed to identify and replace anxious, biased thoughts
with more realistic, evidence-based thinking.

The third section is Exposure, which involves (a) in vivo exposure to

situations where panic attacks or panic-like symptoms are anticipated
to occur. Examples include movie theaters, restaurants, shopping malls,
and waiting in lines. Integral to the method of in vivo exposure is the
removal of all unnecessary safety behaviors (e.g., holding on for support)
and safety signals (e.g., empty medication bottles) that inadvertently re-
inforce fear. Exposure also involves (b) interoceptive exposure, designed
to elicit, in a systematic, controlled manner, the salient somatic sensations.
Through repeated exposures and increasing tolerance of the sensations
without engaging in overt, covert, subtle, or obvious avoidance, indi-
viduals eventually learn to be less afraid of the sensations. Interoceptive
exposure extends from simulation exercises (e.g., spinning, forced hyper-
ventilation) to naturalistic activities (e.g., exercise classes, driving in hot
weather conditions). Again, the removal of all safety behaviors and safety

33
 signals is critical to interoceptive exposure. In addition, interoceptive ex-
posure is incorporated into in vivo exposure.

The fourth section is Planning for the Future, which involves (a) dis-
cussion of medications and ways to wean from medications; and (b) re-
lapse prevention.

Therapeutic Mechanisms of Exposure Therapy

We believe that there are multiple mechanisms accountable for thera-

peutic change. The most relevant mechanisms are reviewed briefly be-
cause knowledge of these mechanisms facilitates the design of treatment
in the most effective way possible.

Habituation

The term habituation refers simply to reduction in response strength

with repeated stimulus presentations. Thus, fear declines as feared ob-
jects are faced over and over again. Excessively high levels of arousal are
likely to impede habituation. In addition, habituation is impeded by
lengthy intervals between each occasion of exposure. However, habitua-
tion is unlikely to account for long-term fear reduction since it is a non-
learning process, and habituated responses dishabituate over time.

Extinction

Extinction refers to decrements in responding through repetition of un-

reinforced responding: repeated encounters with feared stimuli (condi-
tioned stimulus, CS) without aversive consequences (unconditioned stimu-
lus, US). Thus, the person who is fearful of heights learns by repeated
exposures that he or she does not fall. Extinction accounts are supported
by the finding that a single lengthy exposure session is generally more
effective than a series of short exposures for the same total duration, as
lengthy exposure provides sufficient time to learn that aversive outcomes

34
do not occur. It is for this reason that the workbook recommends ex-
tending interoceptive exposure well beyond the point at which the bod-
ily sensations are first noticed; and it also recommends lengthy in vivo
exposures to feared agoraphobic situations.

Wolpe () attributed extinction to counterconditioning or reciprocal

inhibition. Specifically, when a response antagonistic to anxiety can be
made to occur in the presence of anxiety-provoking stimuli, and this re-
sults in a complete or partial suppression of the anxiety response, then
the bond between the stimulus and the anxiety response is weakened.
However, his model was criticized because exposure can proceed effec-
tively without including specific antagonists to anxiety. The response by
Wolpe () to this criticism was that there are many unintended re-
ciprocal inhibitors, including the presence of the therapist, that work to
compete with anxiety during exposure therapy. However, this awaits
empirical examination.

Recent conditioning models maintain that extinction involves the learn-

ing of new, inhibitory CS-US associations, as opposed to the unlearning
of original CS-US associations. Thus, Bouton and colleagues (see Bou-
ton, ) propose that the original excitatory meaning of the CS is not
erased during extinction but, rather, that an additional inhibitory mean-
ing is learned. The resulting dual meaning of the CS creates an ambigu-
ity that is resolved only by the current context of the CS. Bouton uses
the analogy of an ambiguous word. That is, reaction to the word “fire”
depends largely on the context in which it occurs; “fire” may elicit a
panic reaction in a crowded theater, but it will probably elicit very little
reaction in a carnival shooting gallery. Thus, the context determines
which meaning is expressed at any given time. In terms of anxiety treat-
ments, bodily sensations may mean “sudden death” when experienced in
a context that reminds the person of intense panic attacks before treat-
ment, whereas the same sensations may mean “unpleasant but harmless”
when experienced in a context that reminds a person of their success
with treatment. The main implication from this theory is that exposure
is best conducted in as many contexts as possible to minimize context
specificity of fear reduction and to enhance the likelihood of inhibitory
or nonfearful meanings in whatever context the stimulus is encountered
once treatment is over.

35
Self-Efficacy and Control

According to self-efficacy theory, therapeutic gains are dependent on the

degree to which self-efficacy, that is, confidence to perform a certain task,
is generated (Bandura, ). Self-efficacy is theoretically distinct from
outcome expectancies, which refer to the perceived likelihood and valence
of negative events. Efficacy expectations are claimed to influence the
choice of activities and settings, and they determine the degree of effort
expended and persistence in the face of obstacles or aversive experiences.
In other words, self-efficacy is believed to influence coping in threaten-
ing situations. Self-efficacy judgments are posited to derive from four
main sources of information: performance accomplishment, verbal per-
suasion, vicarious experience, and physiological arousal. The strongest
source is the first, as it is through performance accomplishment that one
obtains most evidence for personal achievement and skills.

Related to self-efficacy is the notion that fear declines as perceived con-

trol increases (Barlow, ). In particular, a reversal of the fear action
tendency, or reduction of escape urges or behaviors, leads to a sense that
events or emotions are no longer proceeding uncontrollably, which in
turn lessens fear and anxiety. This process can be set in motion by pre-
venting the fear action tendency or by introducing specific competing
tendencies, such as those characteristic of positively valent emotional states
(e.g., humor).

Emotional Processing

The concept of emotional processing, first introduced by Rachman ()

and extended by Foa and Kozak (), combines the concepts of ha-
bituation and cognitive modification. They hypothesized two necessary
conditions for fear reduction: full activation of fear; and incorporation
of new material that is incompatible with fear memories, so that new
memories are formed. The most effective method for activating fear is
direct exposure to feared stimuli. With repeated exposure, the model
states that incompatible information is derived from short-term physio-
logical habituation that dissociates stimulus and response (i.e., recognition
that the stimulus can occur in the absence of arousal). Between-session

36
 habituation is attributed to changes in the meaning of the stimulus and
response (i.e., risk of harm is lowered, and the affective valence becomes
less negative). So, outcome expectancies are altered. Thus, there are
three indicators of emotional processing: evidence of initial physiologi-
cal arousal and self-report distress (i.e., fear activation); reactions gradu-
ally reduce during exposure (i.e., within-session habituation); and initial
reactions to the stimulus reduce across exposures (i.e., between-session
habituation).

Violation of Expectancies and Fear Toleration

However, given the recent advances in research, showing that neither

physiological habituation nor the amount of fear reduction within an
exposure trial is predictive of overall outcome (see Craske & Mystkow-
ski, ), and given that self-efficacy through performance accom-
plishment is predictive of overall phobia reductions (e.g., Williams, )
and that toleration of fear and anxiety may be a more critical learning
experience than the elimination of fear and anxiety (see Eifert & Forsyth,
), the focus now is on staying in the phobic situation until the spec-
ified time at which clients learn that what they are most worried about
never or rarely happens or that they can cope with the phobic stimulus
and tolerate the anxiety. Thus, the length of a given exposure trial is not
based on fear reduction but on the conditions necessary for new learn-
ing, which eventually leads fear and anxiety to subside across trials of ex-
posure. Essentially, the level of fear or fear reduction within a given trial
of exposure is no longer considered an index of learning but, rather, a
reflection of performance; learning is best measured by the level of anxi-
ety which is experienced the next time the phobic situation is encoun-
tered, or at some later time.

This is also the reason why it is essential to replace escape and avoidance
behavior, including safety behaviors and reliance on safety signals, with
toleration of fear and anxiety. Active escape is central to the construct of
fear. Indeed, the autonomic discharge associated with states of intense
fear or panic is interpreted as a survival mechanism (i.e., the fight-flight
reaction), the primary purpose of which is to prepare the body to engage
in protective behaviors of fleeing, fighting, or freezing. Preparatory avoid-

37
 ance in anticipation of danger (i.e., agoraphobia avoidance) is more
variable and influenced by individual differences in learned methods of
approach and avoidance. Nevertheless, almost every client with Panic
Disorder (PD) engages in some type of preparatory avoidance, whether
it be relying on safety signals (e.g., remaining in close proximity to medi-
cal facilities, carrying anxiolytic medication at all times), using safety
behaviors (such as keeping one’s mind preoccupied to avoid thinking
about panic, maintaining steady body movements to prevent the expe-
rience of strange sensations, standing close to walls in order to prevent
falling, attempting to prevent arguments or other sources of emotional
arousal), or avoiding specific situations. The workbook outlines ways of
weaning from active escape and preparatory avoidance.

Case Example

When she presented for treatment, S. was a -year-old married woman

with two children, aged  and  years. S. had experienced her first panic
attack approximately one year prior to the time of initial assessment.
Her father had died  months before her first panic attack; his death was
unexpected, the result of a stroke. In addition to grieving for her father,
S. became extremely concerned about the possibility of herself having a
stroke. S. reported that she had never experienced anything similar to
panic attacks before her father’s death, nor did she report being overly
concerned about her health in general. Apparently, the loss of her father
produced an abrupt change in the focus of her attention, and a cycle of
anxiety began.

The unexpected nature of her father’s death led S. to increase her aware-
ness of the imminence of her own death, given that “nothing in life was
predictable.” Hence, from the time of her father’s death to the time of her
first panic attack, S. became increasingly aware of her own bodily sensa-
tions. Following her first panic attack, S. was highly vigilant for tingling
sensations in her scalp, pain around her eyes, and numbness in her arms
and legs, especially on her left side. She interpreted all of these symp-
toms as indicative of an impending stroke. Moreover, her concerns be-
came more generalized, so that she began to fear other physical symp-
toms as well, such as shortness of breath and heart palpitations.

38
Her concerns led to significant changes in her lifestyle, although her pat-
tern of avoidance was not severely agoraphobic. She continued to func-
tion at home and at work in her roles as a mother and clerical worker.
Nevertheless, as a result of being anxious about panicking, S. began to
avoid having unstructured time in the event that she might dwell on
“how she felt” and, by so doing, panic. In fact, S. became involved in as
many committees and activities as time allowed, distracting herself from
her feelings. S. had difficulty falling asleep and developed a pattern of
doing so while watching television. Physical exercise was limited because
of the symptoms it brought on, although S. had previously been an avid
jogger. She avoided checkups because she was afraid that the doctor
would find evidence of minor strokes or an impending major stroke.
Emotional arousal was kept at a minimum, so S. avoided stressful situa-
tions, interpersonally and at work, for fear of such arousal bringing on a
panic. She avoided caffeine because of the symptoms it elicited. Also,
she avoided thinking about the loss of her father because the grief would
quickly turn into fear and panic.

S. felt that her life revolved around preventing the experience of panic
and stroke. Although the concerns about stroke were most salient in the
midst of panic attacks, her worries about having a stroke were present at
other times as well. S. was healthy (a medical evaluation revealed no
physical abnormalities) and was not taking any medication. Over the
year since her first attack, the frequency of panic had varied but never
remitted completely. Her high level of anxiety about the recurrence of
panic and its associated threat continued throughout the year. Interview
and self-monitoring measures showed that S.’s most severe panic symp-
toms were numbness, tingling, difficulty breathing, a racing heart, and
fear of dying. In addition to concerns about a stroke, S. also was very
concerned about the way in which her family would be affected if she
died, leaving her children without a mother. This concern seemed to
arise in direct relation to the suffering that she experienced following her
father’s death.

S. underwent our treatment program. She initially responded very well

to the corrective information and cognitive restructuring because she
was able to counter her thoughts of stroke by examining the medical evi-
dence and the actual risk. She realized that she was vastly overestimating
the chance of stroke and misinterpreting physical symptoms as an im-

39
 pending stroke. However, as sometimes occurs, S. used this information
in a reassuring way without fully understanding the role of anxious
thinking. That is, the information reassured her but was not fully inte-
grated into a new way of thinking. She continued to be sensitive to signs
of impending panic, such as rapid heartbeat or shortness of breath,
which were elicited by physical activities or which resulted from normal
fluctuations in her bodily state. It was not until the interoceptive expo-
sure phase of treatment was implemented that her sensitivity to physical
symptoms and her concerns about suffering a stroke truly diminished.
S. was taught breathing skills training and used it successfully to help
herself continue in whatever activity she was involved in at the moments
of being anxious rather than retreating to “safety.” Initially, she used
breathing skills training to prevent more negative experiences, such as
panic or stroke. However, S. learned to apply breathing skills training as
an adaptive strategy for facing her fears rather than as a way of trying to
prevent a dire consequence from occurring.

S. found the following interoceptive exercises to elicit sensations most

similar to her naturally occurring experiences: hyperventilation, holding
her breath, straw-breathing, and step-ups. These also produced the most
anxiety. Initially, the exercises increased S.’s vigilance to bodily sensa-
tions, and she panicked more frequently than she had in the preceding
months. However, her sensitivity eventually reduced with repeated prac-
tice. Activities that produced bodily symptoms included lying in bed
without the television on and letting herself simply think about her bod-
ily sensations objectively, walking alone quickly, drinking coffee, reading
information about strokes, thinking about her father’s death, and swim-
ming. Some of these activities were more difficult because S. was unable
to rid herself quickly of the physical sensations. However, the impor-
tance of tolerating the sensations and not connecting their presence with
evidence for physical risk was pointed out, and eventually, S. was less
anxious.

S. experienced few panic attacks in the first few weeks of treatment and
experienced more panics when interoceptive exposure began, after which
the panic attacks declined. Her belief in the possibility that she was hav-
ing a stroke and her concerns about the well-being of her children re-
duced along with the reduction of general anxiety and panic. By the end
of treatment, several other aspects of her life had changed without direct

40
instruction from the therapist. S. reported that she was engaging in
work-related and family-related activities no longer as distractions but
rather for the direct involvement and enjoyment. In addition, S. under-
went an ophthalmological exam, which she had avoided for the previous
 or  months for fear that evidence of mini-strokes would be found. At
the end of the program, S. was reevaluated and found to experience very
little evidence of PD. Her status was maintained for  months after
treatment completion, when she was reassessed.

41
This page intentionally left blank
Chapter 4 Introduction to the Program

(Corresponds to chapter  of the workbook)

There are no materials needed.

Outline

■ To provide information about panic attacks, Panic Disorder, and

agoraphobia

■ To describe the treatment program

Therapist Behaviors

The therapist is to review the main points of this chapter for the client,
who will read the chapter over the time before the next visit with the
therapist. The therapist is to be fully informed about the phenomenology,
etiology, and maintenance model of Panic Disorder (PD) and, therefore,
be able to informatively answer clients’ questions and provide clarification,
where necessary. In other words, the therapist is primarily an information
giver in this introductory chapter.

Questions asked on initial therapeutic contact most often are reassur-

ance seeking in nature, as clients ask about particular experiences that
seem most inexplicable or frightening to them. At this initial stage of
treatment, it is appropriate to provide direct information and correct
misconceptions. However, giving reassurance is rarely an effective strat-
egy in the long term and, therefore, is not continued once the education
phase of treatment is completed (after chapter ). Questions in the fu-

43
 ture which obviously reflect seeking reassurance may be deflected by ask-
ing clients to refer back to what their own experience tells them.

Information on Panic Attacks, Panic Disorder, and Agoraphobia

Overall, the information presented in this introductory chapter is in-

tended to clarify the purposes of the workbook and provide corrective
information that assures clients that they are neither insane nor atypical
and that there is a good chance of successful treatment. Hence, cogni-
tive modification is begun through provision of a model for under-
standing panic attacks and anxiety which is more objective and less vic-
timizing than the client’s own perspective.

By describing the phenomenology of PD and the particular clustering

of symptoms which characterizes PD, clients are informed that they are
not alone in their experiences; some reassurance derives from recogniz-
ing that their problem is a known entity.

Similarly, the psychobiological conceptualization of panic is presented

to demystify the experience of panic and provide a conceptual frame-
work within which the treatment makes sense. By understanding the na-
ture and likely causes of panic and anxiety, a personal scientist perspec-
tive is being encouraged; a perspective that is a core element for the
entire treatment.

At the same time, the psychobiological model introduces the notion that
panic attacks themselves are not the main issue; more important is the
anticipation of and behavioral avoidance of panic attacks since these are
the features that distinguish PD from the occasional panic attacks expe-
rienced by a substantial number of the population.

The various unhelpful ways of coping with panic attacks (i.e., avoid-
ance, alcohol, and so forth) are presented as understandable, given the
level of anxiety experienced, but also as contributory to PD and agora-
phobia in the long term. Hence, the treatment is designed to replace
these unhelpful coping methods with more adaptive methods of coping.

Clients learn that they might have inherited an emotional sensitivity

that predisposes them to PD. From the research conducted to date, high

44
 levels of emotionality, particularly negative emotionality, appear to con-
tribute to the likelihood of developing an anxiety disorder. Furthermore,
some evidence indicates that the propensity to respond to stressful events
with a panic attack, as opposed to other manifestations of anxiety (such
as ulcers, headaches, or depression) also may be somewhat physiologi-
cally based. It is important that clients understand that the predisposi-
tional variables do not mean that they are destined to have PD for the
rest of their lives because emotional vulnerabilities can be regulated in
the ways described in this treatment.

Similarly, the psychological vulnerabilities—tendencies to interpret bod-

ily sensations as harmful—do not mean being destined always to suffer
from PD. The treatment assumes that the beliefs can be lessened with
the right experience and generation of competing and more evidence-
based beliefs.

Finally, by recognizing that while stress contributes to the onset of panic,

it does not typically explain the perpetuation of panic attacks and PD, the
client is steered away from stress reduction as a treatment option. Instead,
the goal of this treatment is to target the processes that perpetuate fear
and anxiety, those being the anxious thinking and avoidant behaviors.

Case Vignettes

Case Vignette 1

C: Does anyone ever faint when they panic?

T: Fainting as a result of panic is very rare, although it does occur in some

cases. Panic attacks are associated predominantly with sympathetic ner-
vous system activation, whereas fainting involves an overactivation of
the parasympathetic nervous system. That is, panic and fainting have
opposing physiological processes. In addition, fainting is very familial,
and if you have never fainted before, it is unlikely that you will faint
now. Fainting is most common in people who become nervous when
exposed to blood and injury. But even if you faint when you see blood
or injury, chances are that you will not faint when you panic, because

45
 blood and injury have a very specific effect on the parasympathetic
nervous system which is different from the effect of panic.

Case Vignette 2

C: I only experience one or two of the symptoms you mentioned (see the
DSM–IV checklist). Does that mean that I do not have panic disorder?

T: Have you ever experienced four of those symptoms at one time?

C: Yes, but it was a long, long time ago.

T: Are you worried about having more panic attacks?

C: Well, I avoid going to shopping malls and driving because I think that
I might have a really bad panic attack.

T: Then whether you currently experience four or more or less than four
symptoms, it is the same problem. That is, you are anxious about hav-
ing panic attacks, and that anxiety places a restriction on your activities.

Case Vignette 3

C: You said that panic attacks are acute episodes of fear which are typi-
cally short-lived. My panic attacks last for weeks.

T: Do you mean that the peak of panic lasts for weeks or that you are
highly anxious for weeks?

C: Well, I feel like I’m constantly on the edge of having another panic
attack; and, in fact, I do have more of them. After the first one, I’m
really anxious, and they keep recurring until somehow I am exhausted,
and they stop. This whole thing takes several weeks.

T: In other words, the panic attack itself is a relatively short event, but it
is followed by a high level of anxiety, which is most likely contributing
to the recurrence of panic attacks. So, there is a fluctuation between
brief episodes of intense fear (i.e., panic) and long-lasting anxiety.

C: Yes, that’s the way it feels.

46
Case Vignette 4

C: I have noticed that I panic more than usual just before my menstrual
period. Why does that happen?

T: A combination of factors may lead to an increased frequency of panic

before your period. For example, hormonal changes might lead you to
experience various sensations that are not typical, and these sensations
may make you anxious. Also, you may be attending very closely to
your bodily sensations at those times, given your expectation of pan-
icking. Or, maybe you are more emotional in general and, therefore,
more likely to panic.

Case Vignette 5

C: I wake out of sleep in a panic attack. How can that happen?

T: We will go into much more detail about the reasons why panic attacks
occur at different times. However, let me just mention at this point
that nocturnal panic is quite common. Approximately % of people
who experience PD report at least one occasion on which they have
woken from sleep in a panic. Nocturnal panic seems to involve
processes similar to those that occur during daytime panic attacks.

Case Vignette 6

C: Does this mean that my children will have Panic Disorder?

T: It is true that panic attacks run in families. This means that the chance
of children having panic attacks is increased if their parents have expe-
rienced panic attacks. Learning ways by which to regulate your panic
attacks will help buffer the risk for your children.

47
Atypical and Problematic Responses

Given the physical sensations experienced during panic and anxiety, a

medical or chemical explanation of panic attacks is often more credible
to clients than is an explanation that takes into account psychological
variables. In addition, a medical or chemical account may be perceived
as less stigmatizing than a psychological account. For these reasons,
clients may be unwilling to give full consideration to the information
discussed in the first few chapters, despite the absence of medical evi-
dence (following extensive testing) of abnormality. Clients may attrib-
ute their panic attacks either to a physical disease process that “the
doctors have overlooked” or to a “chemical imbalance” that cannot be
tested. Furthermore, many clients have been told by physicians that they
do indeed have a chemical imbalance. As described in the workbook,
however, there are no definitive data to show that such chemical imbal-
ances cause PD.

We suggest the following ways of dealing with the situation described

above.

. Validate the “real” nature of symptoms of panic, and understand

that these symptoms are not all “in your head.” Reiterate that bio-
chemical changes are indeed most likely occurring during panic
attacks.

. Examine the evidence. What evidence does the client have from
medical testing to assume a medical or chemical abnormality?
Usually, there is none, or at least the panic continues despite con-
trol of the medical abnormality (e.g., thyroid medication for hy-
perthyroidism, diet changes for hypoglycemia, heart medication
for cardiomyopathy). Educate the client more fully about the evi-
dence to date. Specifically, evidence confirms the presence of defi-
nite biochemical processes during anxiety and panic (i.e., reassure
clients that the sensations are not “all in their head” or imagined).
However, the main question of why panic attacks develop in the
first place cannot as yet be answered from a biochemical perspec-
tive. That is, there is no conclusive evidence yet to suggest a speci-
fic biochemical dysregulation that causes panic attacks.

48
. Present the notion that even if biochemical or medical abnormali-
ties are present and do at least partly explain panic, there is no rea-
son to assume that the Mastery of Your Anxiety and Panic (MAP )
treatment will not be effective in treating panic. In other words,
biologically based disorders can be managed effectively with psy-
chological treatments. The evidence concerning the efficacy for the
treatment described in the workbook can be highlighted.

. A medical or biochemical explanation may seem more viable when

clients are unable to associate their panic attacks with discernible
triggers. Thus, inform clients that once they are able to recognize
the triggers to their anxiety, which is one of the first components
of this treatment program, then the psychological model may
seem more understandable or relevant to their own experiences.

49
This page intentionally left blank
Chapter 5 Learning to Record Panic and Anxiety

(Corresponds to chapter  of the workbook)

Materials Needed

■ Panic Attack Record

■ Daily Mood Record

■ Progress Record

Outline

■ Emphasize the importance of objective record-keeping

■ Distinguish generalized anxiety from panic

■ Introduce monitoring forms

■ Have client complete a Panic Attack Record and Daily Mood Record
in session

■ Provide corrective feedback, and answer any questions the client

may have

■ Assign homework

Therapist Behaviors

The therapist is to provide corrective feedback and answer questions as

the client completes (in session) a Panic Attack Record for a recent panic
attack. Aid clients in recording their thoughts and behaviors by helping
them to consider what it was that they were most worried about hap-

51
 pening in the panic attack, and what they did as a result. In addition,
provide feedback to clients as they complete the ratings on the Daily
Mood Record for today and yesterday.

Clients are expected to continue to record their panic and daily mood
for the remainder of the program. At the start of each session, the thera-
pist should spend a few minutes reviewing the monitoring forms for the
past week and reinforce their continued use.

Record-Keeping

During this session, explain to the client that recording panic and anxi-
ety objectively is a necessary first step to therapeutic change. Keeping
records offsets the anxiety-inducing effects of avoidance, subjective mon-
itoring, and recall biases. The goal is for clients to begin to become ob-
servers rather than victims of their anxiety.

The importance of understanding panic attacks in a matter-of-fact man-

ner, as opposed to focusing on subjective distress, is emphasized because
the latter tends to maintain fear and anxiety. In contrast, objective aware-
ness provides a way of moving out of the role of victim and into the role
of being an active participant in understanding one’s own panic and
anxiety. The distinction between subjective and objective recording is
especially important to point out to clients who are resistant to record-
ing because they believe that they are already constantly aware of their
symptoms (that is, point out their reliance on a subjective monitoring
style, and promote the value of a different, objective style).

Panic attacks are always cued; but sometimes, the cue or trigger is not
obvious. Recording will facilitate the detection of specific triggers and
conditions under which panic attacks occur. This in turn contributes to
a greater objective understanding and begins the process of identifying
relevant cues for exposure therapy.

52
Anxiety Versus Panic

Educate the client about the differences between panic and anxiety. Panic
is described as an acute episode of intense fear, whereas the state of anxi-
ety centers on future-oriented worries and tends to develop more gradu-
ally, without a discrete onset. States of generalized anxiety may increase
the likelihood of experiencing panic attacks as a function of chronic ten-
sion which elicits somatic cues and intensified attentional vigilance for
somatic cues. Education about the differences between panic and anxi-
ety again contributes to an objective, personal scientist model for the
client.

Panic Attack Record

Introduce the client to the Panic Attack Record. Clients should use this
form whenever they experience a panic attack or a sudden rush of fear.
A blank record is included in the workbook, and multiple copies can be
downloaded from the TreatmentsThatWork™ website (http://www.oup
.com/us/ttw).

During the session, ask the client to complete a Panic Attack Record for
a recent panic attack.

An example of a completed Panic Attack Record is shown on page .

Daily Mood Record

Introduce the client to the Daily Mood Record. This form should be com-
pleted at the end of each day. It uses a -point scale to rate daily levels of
anxiety, depression, and worry about having a panic attack. A blank record
is included in the workbook, and multiple copies can be downloaded from
the TreatmentsThatWork™ website (http://www.oup.com/us/ttw).

During the session, ask the client to complete a Daily Mood Record as
practice. Once again, provide corrective feedback, and answer any ques-
tions the client may have.

An example of a completed Daily Mood Record is shown on page .

53
Panic Attack Record

Date: 2/16/06 Time began: 5:20 p.m.

Triggers: Home alone and shortness of breath.

Expected: X Unexpected:

Maximum Fear
----------------------------------------------------------------------
None Mild Moderate Strong Extreme

Check all symptoms present to at least a mild degree:

Chest pain or discomfort

Sweating

Heart racing/palpitations/pounding

Nausea/upset stomach

Shortness of breath

Dizzy/unsteady/lightheaded/faint

Shaking/trembling

Chills/hot flushes

Numbness/tingling

Feelings of unreality

Feelings of choking

Fear of dying

Fear of losing control/going insane

Thoughts: I am going crazy, I will lose control.

Behaviors: Called my mother.

Figure 5.1.
Jill’s Panic Attack Record ()

54
Daily Mood Record for Jill

Rate each column at the end of the day, using a number from the –-point scale below.
----------------------------------------------------------------------
None Mild Moderate Strong Extreme

Average Average Average Worry

Date Anxiety Depression About Panic

Monday 7 5 7
16th

Tuesday 5 4 5
17th

Wednesday 4 4 5
18th

Thursday 4 3 4
19th

Friday 4 4 5
20th

Saturday 2 1 1
21th

Sunday 2 2 2
22th

Figure 5.2.
Jill’s Daily Mood Record

Progress Record

The last monitoring form that the client will use is the Progress Record.
Clients should use this chart at the end of each week to record their
progress throughout the course of treatment. It will allow clients to see
how they are doing and help them to put things into perspective. A
blank record is included in the workbook, and multiple copies can be

55
 downloaded from the TreatmentsThatWork™ website (http://www.oup
.com/us/ttw).

It is not necessary for the client to complete a Progress Record during this
initial session. The chart becomes more useful as treatment progresses.

An example of a completed Progress Record is shown below.

Progress Record

For each week, plot the number of panic attacks you experienced and your average anxiety level
for that week.

10
9
8
7
6
5
4
3
2
1
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Week
NumberNumber of Attacks
of Panic Panic Attacks
per Week
AverageAverage
AnxietyAnxiety per Week
per Week

Figure 5.3.
Example of completed Progress Record

56
Case Vignettes

Case Vignette 1

C: What am I supposed to record if I successfully avoid panics by never

putting myself in the situations that could make me panic?

T: If you are not panicking at all, just record your daily mood and anxiety.

Case Vignette 2

C: I can always find an explanation for my panic attacks when I think

about it afterward. Doesn’t that mean that they are all expected?

T: When we categorize attacks as expected or unexpected, we actually

mean how it felt at the moment of the panic: was it a complete sur-
prise at the moment, or was it something that you were anticipating or
waiting for? So, you could have a completely unexpected panic attack,
but you are later able to explain it once you consider possible con-
tributing factors. For the Panic Record, consider what it was that you
felt at the moment of panic.

Case Vignette 3

C: Should I record every time I notice symptoms? If so, I’ll be spending

all of my time recording.

T: Only record those times when you experience a sudden increase in

symptoms and distress.

Case Vignette 4

C: I’m afraid that this kind of recording will make me more anxious.

T: Do you typically try to avoid thinking about how you feel because you
are concerned that it will lead you to panic?

57
 C: Yes.

T: So, the recording forms will force you to face the things that frighten
you. However, the more you face these things by recording your expe-
riences, especially using the objective method of recording, the easier it
will get. In other words, your anxiety will lessen. It is the same with
almost everything we do: at first it is hard, but with repetition, it gets
easier.

Atypical and Problematic Responses

Sometimes clients claim that they do not have time or energy to com-
plete the recording forms. If lack of time or energy is due primarily to
lack of motivation, then you might assume that the client’s level of mo-
tivation for conducting the entire treatment program is relatively low. If
so, you might question whether now is the best time for the client to
begin this type of program.

On other occasions, as reflected in Case Vignette , recording may be

avoided because it elicits anxiety or fear. In this situation, the possibility
of becoming more anxious or fearful, at least initially, can be recognized,
but the usual decline in anxiety or fear should be emphasized, especially
when recording is objective.

If clients state that they know how they feel and that recording is there-
fore redundant, point out times at which panic attacks seem to occur un-
expectedly, and discuss the benefit of close monitoring in order to identify
precipitants for those unexpected occasions. Again, the objective nature
of the self-recording should be emphasized, as it may be quite different
from ways in which clients have been preoccupied with their symptoms
up until now. Furthermore, the records will provide concrete evidence
for the purposes of later comparisons (i.e., to see change over time).

Finally, some clients may require continuing corrective feedback in terms

of the method of recording due to a lack of understanding of the pro-
cedures or the forms. Compliance with recording will be increased by
spending a few minutes at the beginning of each subsequent session to
review their recording forms for the preceding interval.

58
Homework

✎ Instruct clients to record panic attacks and daily mood levels for at
least one full week using the Panic Attack Record and the Daily Mood
Record.

✎ Clients should read chapters , , , and chapter , section , in the

workbook

59
This page intentionally left blank
Chapter 6 Negative Cycles of Panic and Agoraphobia

(Corresponds to chapter  of the workbook)

Materials Needed

■ Step-by-Step Analysis of Panic Attack form

Outline

■ Help the client understand the negative cycles that contribute to panic
attacks and agoraphobia

■ Illustrate how this treatment interrupts the panic and agoraphobia cycles

Therapist Behaviors

The therapist is to review the main principles of the material in this

chapter, tying the concepts to the client’s panic and anxiety wherever
possible. In addition to being informative, the therapist is to give cor-
rective feedback and facilitate the client’s discovery of the pattern of in-
fluences across thoughts, behaviors, and physiology, as well as the se-
quence of events that typify panic attacks and episodes of anxiety. That
is, the therapist should assist the client in describing a recent panic at-
tack and prompt the client to think of what happened at each step of the
chain of reactions, from the first sensation, to the thought to the behav-
ior, and so on.

61
Cycles of Panic and Agoraphobia

The main goals of this chapter are to provide an understanding of the

ways in which thoughts, feelings, and behaviors influence each other in
ways that perpetuate fear and anxiety. By so doing, this chapter contin-
ues to reinforce an objective self-awareness and behavioral scientist model.
In addition, understanding these perpetuating influences provides a ra-
tionale for the treatment.

A theme that is introduced here and that is central to the entire treat-
ment is that anxiety and fear are not “all bad.” The purpose of fear and
anxiety is to prepare the body and mind to deal with threat. In other
words, they are designed to protect us from danger. Some level of anxi-
ety is constructive and conducive to performance and, in some situa-
tions, necessary for survival. The goal of the treatment program is to re-
duce the expression of anxiety at times when it is not warranted, as
opposed to removing all anxiety.

By learning to differentiate between anxiety and panic on the basis of ac-

curate descriptions of the response components (physiological, cogni-
tive, and behavioral) that typically exemplify the respective states, clients
acquire even more objective self-awareness and enhance their role as a
behavioral scientist of their own reactions.

Anxiety and fear are conceptualized as reactions, as opposed to entities

over which the individual has no control (despite the perception of being
out of control). Emphasis is given to the ways in which thoughts, be-
haviors, and physiology influence each other, in cycles, so that clients are
able to view their anxiety and panic as reactions. In addition, detailed
description of the cycles through step-by-step analyses emphasizes to
clients the role of reactions to thoughts and to physical sensations as cru-
cial elements to target in treatment. In other words, learning to replace
a threatening interpretation of physical sensations with a nonthreaten-
ing interpretation, or learning to replace an avoidant response to physi-
cal sensations or to negative thoughts with a nonavoidant response, is
central to overcoming fear and anxiety.

The links between response components and treatment components

is intended to demystify treatment and encourage a problem solving

62
 approach to treatment; that there exists a logical way of treating this
disorder.

Step-by-Step Analysis of a Panic Attack

Introduce the client to the Step-by-Step Analysis of Panic Attack form.

Step-by-step analysis is a method of identifying response components
and the ways in which they cycle and influence each other. For example,
noticing a heart-rate fluctuation may be followed by thoughts of a po-
tential heart attack, which may be followed by increased heart rate,
which serves to confirm the possibility of heart attack, and so forth. A
blank form is included in the workbook, and multiple copies can be
downloaded from the TreatmentsThatWork™ website (http://www.oup
.com/us/ttw).

An example of a completed Step-by-Step Analysis is shown on page .

Case Vignettes

Case Vignette 1

C: How can a short-term program cure me after I have experienced these

panics for so long? I could understand if the onset were recent, but this
has been going on for so long that I feel that there is no way it can
change so quickly.

T: There are several things to keep in mind. First, it has been found that
the duration of panic disorder does not predict response to treatment.
Rather, it is the amount of practice and engagement you have in the
treatment which is most important to the outcome and the benefit
that you receive. Second, as we mentioned last time, this program is
skills oriented, and learning can take place relatively quickly. Third,
during this short-term program, you will acquire skills that you can
apply on your own. You may continue to experience some anxiety
when you finish the treatment, but you will have principles and skills
to deal with the anxiety that remains. Finally, the rate of success with

63
Step-by-Step Analysis of Panic Attack

Where were you and what was going on when the panic attack first started? At home, watching

television, just relaxing, really tired from a late night.

What happened first? A physical symptom, negative thought, or a behavior? I noticed that my

heart skipped a couple of beats.

What happened next? How did you react to the first physical symptom or negative thought?
Did you notice more physical symptoms, more negative thoughts, or did you do something,
such as seek help, lie down, or exit wherever you were?

I was terrified that something was wrong with my heart, I thought that maybe I did some

damage the night before by exhausting myself, and immediately put a cool cloth on my

forehead and lay down.

What happened next? Did the physical symptoms get worse, did you become even more scared
about negative things happening?

My heart rate sped up, and I began to sweat. I thought of calling my husband or 911. I

thought I was having a heart attack.

What was next? The feelings got worse and worse—I felt weak and dizzy, and my heart

was racing very fast, and I sweated and felt sick to my stomach. I really thought I was

dying. I was too afraid to move, so I just lay on the couch, praying that I would not die.

How did it end? Eventually, the feelings subsided, although I felt very weak and out of it

for about an hour afterward.

Figure 6.1.
Example of completed Step-by-Step Analysis of Panic Attack form

64
 this type of treatment is very high, and that in itself is reason for you
to give it your best effort, or you should at least forestall a judgment
until you have tried it.

Case Vignette 2

C: I understand how thinking about something anxious might produce a

panicky feeling, but why do I panic when I’m not thinking of any-
thing? Sometimes it comes right out of the blue. Sometimes when I’m
watching TV and feeling relaxed, I can all of a sudden panic, and I
don’t know why.

T: The “out of the blue” panic attack is a hallmark feature of panic dis-
order. Next time, we will discuss the reasons why a panic attack may
occur seemingly out of the blue. In brief, it has to do with the triggers
being so subtle that you are not fully aware of them. You will soon
learn to become more aware of them.

Case Vignette 3

C: I don’t spend time worrying about panicking because I don’t confront

any of the situations that make me panic. As long as I can stick with
my familiar places, then I am okay. So, my worry ratings on the Daily
Mood Record will be zeros.

T: What would happen if you had to go outside of your familiar places—

if you knew that tomorrow you had to take a long trip to a new place?

C: I would not do it.

T: But let us just say that you had to. What would happen?

C: I would become a mess—terribly anxious.

T: So that illustrates that your avoidance behavior is based on being very

worried and anxious about panicking. In your case, the avoidance be-
havior is the same as worrying about panicking.

65
Case Vignette 4

C: The feeling of panic just hits me. It is so sudden that it is impossible

for me to know what is happening. I don’t know what I am thinking—
all I know is that I can’t stand the feeling.

T: I understand that the feeling terrifies you and that it is hard to think
about it objectively, especially at the moment it is happening. How-
ever, if you thought it was normal to feel the rush of adrenaline in
your body, then you would not be terrified, and you would know that
you could tolerate it. The goal of this treatment is to help you realize
that you can tolerate these feelings.

Atypical and Problematic Responses

In most cases, clients understand the interaction among the three re-
sponse components, and it seems credible. Occasionally, however, it is
difficult for clients to relate this model to their own experiences due to
the sudden onset of panic and the frequent absence of specific danger
cognitions. That is, the “out of the blue” panic attack is initially difficult
to explain according to the three-response-component model. In this
case, it is helpful to explain that the reciprocal influences among the re-
sponse components can occur not only on a conscious level but also on
a very direct, subconscious level, so that an individual may almost auto-
matically become afraid. This is explained in more detail in the next
chapter.

Occasionally, clients report that because they have panicked so many

times, they are no longer concerned about fainting, having a heart at-
tack, or being embarrassed. That is, they report having no danger-laden
cognitions. Nevertheless, they still panic. In these cases, it is helpful to
ascertain what they think might happen if the feelings of panic were to
continue longer than ever before or to become more intense than ever
before. This probing usually leads to recognition of concerns about dan-
ger or to concerns about being out of control. Both imply threat, and
therein, the danger-laden cognition is revealed.

66
 Sometimes clients report that they no longer panic but they are con-
stantly anxious and always have physical symptoms. Unless they are ex-
periencing bursts of arousal or peaks of fear in addition to the general
anxiety, these individuals are technically not panicking. However, it is
possible that their levels of anxiety and chronic symptomatology are
functions of extreme anxiety about the recurrence of panic. Therefore,
the same treatment procedures are appropriate.

Homework

✎ The client should continue to record anxiety and panic for one week
using the Panic Attack Record and Daily Mood Record.

✎ The client should read chapters  and , and chapter , section , in
the workbook.

67
This page intentionally left blank
Chapter 7 Panic Attacks Are Not Harmful

(Corresponds to chapter  of the workbook)

There are no materials needed.

Outline

■ To provide the client with information about panic attacks

Therapist Behaviors

The therapist reviews the major material and concepts in the chapter,
tying them to clients’ panic and anxiety wherever possible. The therapist
is to be informed so as to be able to fully address questions raised or to
provide clarifications. This is the last of the series of chapters in which
the focus is primarily information-giving.

Objective Understanding of Panic

Overall, the informational model of panic attacks builds on the previous

chapters in providing an alternative conceptual framework that is non-
threatening and contributes to a personal scientist perspective, whereby
clients can gain an objective understanding of their panic and anxi-
ety. This objective perspective is believed to be critical to the treatment
process.

Panic is construed as an alarm reaction, the primary function of which

is to protect the organism. It is a survival mechanism that misfires. Clients

69
 learn that this misfiring is not dangerous, but because the reaction is per-
ceived as dangerous, it becomes a source of anxiety.

The sensations experienced are often based on physiological processes.

Understanding the connections between different sensations experi-
enced, their physiological basis, and their survival value engenders a
greater sense of safety. Furthermore, it reassures clients that their sensa-
tions are not all imagined. By the same token, however, thoughts play a
crucial role in intensifying and prolonging sensations. Moreover, it is
sometimes possible to perceive bodily sensations in the absence of any
real physiological change. In the case of severe panic attacks, however,
perceptions of physical sensations are almost always accompanied by an
array of actual physiological changes.

A panic attack is presented as a learned fear of internal sensations. Un-

like fear of an external object, fear of internal sensations generates posi-
tive feedback loops. That is, fearing an internal sensation (e.g., “I am
having a heart attack”) increases arousal, which in turn increases the in-
tensity of the physical sensation (e.g., chest pain) that is feared. Experi-
encing more intense physical sensations may then confirm the subjective
fear (e.g., “I really am having a heart attack”), and, hence, a spiraling
effect occurs. Crucial to the model of panic attacks is the role of anxiety
about the recurrence of panic. Because the panic attack itself is feared as
a dangerous event, it makes sense to anticipate the next time it will occur
and to be very vigilant for signals of its next occurrence. Such vigilance
and apprehension result in escalations of generalized arousal. Increased
generalized arousal may produce more physical sensations that trigger a
fear reaction. In addition, the attentional vigilance for signals of danger
which accompanies anxiety tends to lead to a selective attention to bod-
ily sensations. This selective attention leads to a heightened awareness of
sensations that might not have been noticed in the past. Thus, a combi-
nation of more arousal and more attention to arousal sensations is con-
sidered central to the maintenance of panic.

70
Case Vignettes

Case Vignette 1

C: If panic is an adaptive response, why do I feel unreal? What is the

adaptive value of unreality?

T: It is not necessarily the sensations that are adaptive for survival but the
physiological processes that underlie the sensations. One might experi-
ence various sensations as a by-product of high levels of arousal. The
feeling of unreality is often related to hyperventilation because in
preparation for fight or flight, the body reacts by breathing faster be-
cause oxygen is a source of energy. Similarly, a tightness around the
throat or chest may be the by-product of increased muscle tension and
a slowing down or retardation of the digestive process, both of which
are part of the survival reaction.

Case Vignette 2

C: If the crux of the problem is that I am afraid of physical sensations,

how do you explain a panic attack that occurs from sleep? I’m not
thinking when I am asleep.

T: There are several things to keep in mind about nocturnal panic attacks.
First of all, natural fluctuations in physiological arousal occur during
sleep. For example, we experience peaks and valleys in heart rate as we
sleep, and individuals who are more anxious in general during the day
typically experience more arousal peaks during the course of sleep. If
you are particularly sensitive to or afraid of arousal, it is conceivable
that the peak of arousal may cause you to wake in a panic. In contrast,
someone who is not afraid of their bodily symptoms may experience
the same amount of physiological arousal during sleep but react with
restlessness or a disturbed sleep pattern instead of panic.

Think of yourself in a large crowd. You are unlikely to hear all of the
conversations going on around you. However, you may hear your

71
 name if it is mentioned. Similarly, you may not hear the sounds of
traffic while you are sleeping, but you hear the sound of your baby cry-
ing, even though the sound itself is fainter. Cues that you think mean
danger will, of course, be very meaningful. Therefore, you may be
likely to awaken in response to physical changes happening in your
body which scare you.

Case Vignette 3

C: Why did I start to worry about the symptoms in the first place?

T: It seems that certain life experiences affect how people understand am-
biguous signs of arousal. For example, the unexpected death of a sig-
nificant person may prime anyone to misinterpret ambiguous arousal
symptoms as harmful. Or, negative personal experiences, such as a bad
reaction to drugs or surgeries or an asthma attack, may have the same
effect.

Case Vignette 4

C: Once I have a panic attack, the feeling stays around for weeks after-
ward. That seems to be different from your description of short-lived,
intense sympathetic activation.

T: The actual panic attack generally is very brief, as sympathetic nervous

system exacerbation is counterbalanced by parasympathetic nervous
system activation. However, after a panic attack, you probably experi-
ence a lot of general arousal and vigilance for signals of another panic
attack. That state of general anxiety can be accompanied by various
symptoms that may be similar to, although usually slightly less intense
than, some of the symptoms experienced during panic, except that
they are present more chronically as opposed to acutely.

72
Case Vignette 5

C: I don’t think of the sensations as being dangerous but, rather, as just

uncomfortable. Nobody would want to feel those kinds of sensations.
So I don’t understand why I continue to experience them if I don’t
think of them as being dangerous.

T: When you experience the symptoms more intensely, do you typically

try to stop them from occurring and hope that they will go away, or do
you notice their presence and continue with whatever else you were
doing?

C: I try to get rid of them as quickly as I can—I try to distract onto

something else.

T: What do you think will happen if you focus on the sensations?

C: They might get worse and worse, and then I might really lose it.

T: So, actually, there is a threat in the back of your mind, although your
immediate reaction is one of discomfort.

C: Yes, I guess so.

Case Vignette 6

C: If I understand you correctly, you’re saying that my panic attacks are

the same as the fear I experienced the time we found a burglar in our
house. But it doesn’t feel the same at all.

T: Yes, those two emotional states—an unexpected panic attack and fear
when confronted with a burglar—are essentially the same. However,
in the case of the burglar, where were you focusing your attention: on
the burglar or on the way that you were feeling?

C: The burglar, of course, although I did notice that my heart was racing
a mile a minute.

T: And when you have a panic attack, where are you focusing your atten-
tion: on the people around you or on the way that you are feeling?

73
 C: Well, mostly on the way that I’m feeling, although it depends on
where I am at the time.

T: Being most concerned about what is going on inside you—on the feel-
ings that you are having—can lead to a very different type of experi-
ence than being concerned about a burglar, even though basically the
same physiological reaction is occurring. For example, remember our
description of the way in which fear of physical symptoms can inten-
sify the physical symptoms.

Atypical and Problematic Responses

Often, clients continue to be perplexed about the repeated occurrence of

certain physical sensations that they never experienced prior to their first
panic. Indeed, the very questioning of the source for the somatic expe-
riences reflects their anxiety over their recurrence. The following sce-
nario may be useful.

Imagine yourself walking through a dark alley, and you have reason to
believe that somewhere in the darkness lurks a killer. Under those con-
ditions, you would be extremely attentive to any sign, any sound, or
any sight of another person. If you were walking through the same
alley and were sure that there were no killers, you might not hear or
detect the same signals that you picked up on in the first case. Now, let
us translate this to panic: the killer in the dark alley is the panic at-
tack; and the signs, sounds, and smells are the physical sensations that
you think signal the possibility of a panic attack. Given the acute de-
gree of sensitivity to physical symptoms that signal a panic attack, it
is likely that you are noticing normal “noises” in your body that you
would otherwise not notice and, on occasion, immediately become
fearful because of those “noises.” In other words, the sensations are
often noticeable because you attend to them.

Some clients may understand the concept of panic as a fight-flight re-

sponse in general and yet not accept this as an explanation for their own
panic attacks, because they judge the sensations experienced during
panic to be very different from sensations experienced during a fear re-
action to a known stimulus (such as narrowly escaping a car accident).

74
 The difference between these two experiences can be explained as due to
different foci of attention. The focus on sensations triggered by an obvi-
ous external stimulus is quite different from the focus on sensations for
which no stimulus is perceived, as in panic. The inward focus of atten-
tion which occurs during panic thus changes the experience of the sen-
sations, so that they feel qualitatively different than those resulting from
an external trigger. The physiological basis of these sensations, however,
remains the same in both cases.

Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

✎ The client should read chapter , section , in the workbook over the
course of the week.

✎ You may instruct the client to continue to chapter  in the workbook

once the client has completed at least one week of recording panic at-
tacks and moods and has read workbook chapters –, and chapter ,
section .

75
This page intentionally left blank
Chapter 8 Establishing a Hierarchy of
Agoraphobia Situations

(Corresponds to chapter  of the workbook)

Materials Needed

■ List of typical agoraphobia situations

■ Agoraphobia Hierarchy

Outline

■ Review client’s records from the past week

■ Work with the client to generate a hierarchy of agoraphobia situations

■ Help the client identify unhelpful ways of coping (e.g., superstitious

objects and safety signals)

Therapist Behaviors

The therapist is to play an active role in reviewing the week’s worth of

Panic Attack Records and Daily Mood Records and in brainstorming
ways to facilitate such monitoring in the case of noncompliance. Thera-
pists are to remind clients to enter their week’s worth of data in the
Progress Record in the workbook.

In addition, therapists will help clients to generate a hierarchy and to list

their superstitious objects, safety signals, safety behaviors, and distrac-
tions. Both of these tasks are best done in session, although clients may
review and modify their choices over the following week. The therapist
can suggest possible moderators of the level of anxiety (e.g., the presence

77
 of others) in order to generate a hierarchy that covers a range of anxiety
and to help clients identify safety behaviors and safety signals that con-
tribute to anxiety in the long term, from which clients are to be weaned
during treatment.

Also, this chapter will allow the therapist to make an assessment of the
degree of agoraphobia avoidance, which in turn will determine how
much time is to be devoted to in vivo exposure in chapter  and, thus,
the overall length of treatment.

Records Review

The first section of this chapter addresses what was learned from the past
week of self-recording, such as patterns of anxiety in relation to panic
attacks and the conditions under which panic attacks are most likely to
occur. Ways of enhancing compliance with self-recording are suggested.

Establishing a Hierarchy of Agoraphobia Situations

The major focus of this chapter is the development of an individualized

hierarchy of agoraphobia situations for the client in preparation for in
vivo exposure. A hierarchy composed of situations that range in anxiety
level from mild to moderate, and all the way up to extremely anxious,
will form the basis of a graduated approach to in vivo exposure. Al-
though exposure exercises are not scheduled to take place for the next
couple of weeks, it is important to introduce the hierarchy now. Before
beginning exposures, the client will need to practice the thinking skills
from chapter  in relation to each situation on his hierarchy. This will
help prepare the client for the upcoming in vivo exposure exercises.

Work with clients to identify the specific situations that they avoid by
using the following list as a guide. Have clients review the list in the work-
book and put a check next to the situations they avoid or are anxious
about. Instruct clients to add as many “others” as necessary.

Have each client select up to  of the items on the list with a check
mark. This will form the basis for the client’s individualized agorapho-
bia hierarchy.

78
Typical Agoraphobia Situations

Check those that apply

Situations You Avoid or Are Anxious About

Driving

Traveling by subway, bus, taxi

Flying

Waiting in lines

Crowds

Stores

Restaurants

Theaters

Long distances from home

Unfamiliar areas

Hairdressers

Long walks

Wide-open spaces

Closed-in spaces (e.g., basements)

Boats

At home alone

Auditoriums

Elevators

Escalators

Other

Figure 8.1.
Blank Typical Agoraphobia Situations form

79
Individualized Agoraphobia Hierarchy

After the client has reviewed and checked off his or her items on the list of
Typical Agoraphobia Situations, work with the client to develop a hierar-
chy by using the Agoraphobia Hierarchy form in the workbook. The sit-
uations on this list are the ones that the client will face over and over again
during in vivo exposure. It is important to take into account the various
conditions that moderate levels of anxiety, such as distance, being accom-
panied or being alone, the time of day, proximity to an exit, and so forth.

Your client’s completed hierarchy may look something like the com-
pleted Agoraphobia Hierarchy on page .

Unhelpful Ways of Coping

In this chapter, clients’ reliance on safety signals (such as a brown paper

bag in the event of hyperventilation or an empty medication bottle),
safety behaviors (such as driving only in the right-hand lane of traffic),
and distractions (such as a radio) are restated as other forms of avoidance
which will interfere with corrective learning and contribute to anxiety in
the long term. Thus, the goal of treatment is to learn to face agorapho-
bia situations without these forms of avoidance.

Case Vignettes

Case Vignette 1

C: You said that treatment involves repeatedly facing my feared situation,

but I’ve done that already: I have to drive every day to get to work, and
my anxiety just seems to get worse each time.

T: If you look over the list of unhelpful coping methods, do you see any
that might apply to driving to work?

C: Well, I do play my radio really loud so that I have something else to

focus on, so I guess that could be distraction. And I call my mother
whenever I get anxious, and that could be a safety behavior.

80
Agoraphobia Hierarchy

Anxiety and/or
Situation Avoidance (0–10)

Walk to the store alone (10 blocks) 3

Wait in long line at the post office 4

Shop at the mall during peak hours 5

Drive to sister’s place with family member 6

Drive to sister’s place alone 7

Attend live performance at the theater 8

Stay overnight in another town 9

Travel long distance by plane 10

Figure 8.2.
Example of a Completed Agoraphobia Hierarchy

T: So those are two big differences already between the exposures you
have done on your own and the way in which we will do them in treat-
ment. Also, we will be facing situations much more systematically,
with specific preparation for the thoughts and feelings that you might
experience. Have you done that before leaving for work?

C: No, not really.

Case Vignette 2

C: I get very stressed at work, so let’s put that on my hierarchy.

T: What is it that you are most worried about happening at work?

C: That my boss won’t approve of my work, and I will be fired.

T: How does that relate to your fears of panicking?

81
 C: It doesn’t relate to my fears of panicking. I just worry about being
fired.

T: Okay, so even though the work situation is stressful, it seems as if that

is different from worrying about having panic attacks. For this hierar-
chy, we want to list only the situations that are relevant to your worries
about panicking.

Atypical and Problematic Responses

Clients who have had severe agoraphobia for a number of years may find
it difficult to develop a hierarchy because everything seems intensely
anxiety provoking. In these cases, it may be helpful to initially include
safety behaviors or safety signals in the description of situations so as to
generate a few less-anxious hierarchy items. Of course, these hierarchy
items will be practiced without those safety signals or safety behaviors in
the future.

The hierarchy developed at this stage is a tool that can be adjusted as

necessary throughout treatment. For example, a client might initially be-
lieve that elevators should be ranked higher than shopping lines but then
realize, in preparing for exposures, that the elevators are in fact less fright-
ening. The hierarchy can then be adjusted to reflect this new awareness.

Some clients may have very limited or no avoidance of agoraphobia sit-

uations. Continue to search for safety behaviors, distractions, safety sig-
nals, or superstitious objects (e.g., clients may report not avoiding any
situation on the list of agoraphobia situations and yet, on further ques-
tioning, reveal what they would avoid if they did not have their empty
medication bottle on hand).

Some clients may have no avoidance of agoraphobia situations and no

reliance on safety behaviors or safety signals. In this case, you may as-
sume that the client has panic disorder without agoraphobia, and you
may skip this chapter.

82
Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

✎ The client should read chapter , section , of the workbook.

83
This page intentionally left blank
Chapter 9 Breathing Skills

(Corresponds to chapter  of the workbook)

This chapter is divided into four sections.

Materials Needed for All Sections

■ Breathing Skills Record

SECTION 1 Education and Diaphragmatic Breathing

Outline

■ Educate the client about overbreathing

■ Conduct a forced hyperventilation test

■ Introduce diaphragmatic breathing skill

Therapist Behaviors

After reviewing the basic concepts of respiratory physiology and over-

breathing, the therapist may model the method of hyperventilation be-
fore asking clients to hyperventilate, or the therapist may hyperventilate
along with the client. This type of participant modeling is especially
helpful for clients who are self-conscious or highly anxious about the ex-
ercise, and it can be used to validate the normalcy of symptoms experi-

85
 enced as a result of hyperventilation (i.e., therapists can indicate the
symptoms that they experience from the exercise). Also, the therapist may
demonstrate the diaphragmatic breathing techniques for the client to imi-
tate. Then, the therapist can observe the client practice the exercise of
diaphragmatic breathing and give corrective feedback. Of course, gen-
eralization from the clinic to the home setting occurs by having clients
practice the exercises on a regular basis in their own environments.

Overbreathing

The main goals of this section are to introduce the physiology of over-
breathing as something that may contribute to the physiological sensa-
tions during panic attacks and to recognize that hyperventilatory sensa-
tions are not harmful. It is important that the client not misconstrue the
discussion of overbreathing as an indication that panic and fear are a di-
rect result of primarily physiological irregularities. That is, the role of
hyperventilation is placed within the context of the interactions that
occur among the three response components (i.e., behavioral, physio-
logical, and subjective). The experience of overbreathing in isolation
from catastrophic misinterpretations of bodily sensations or from learned
fear of bodily sensations is unlikely to result in a panic attack.

Breathing Skills

In this treatment, breathing skills training is intended to regulate breath-

ing, but more importantly, it is also intended to interrupt the panic cycle
and provide a tool to help clients face their fear, anxiety, and anxiety-
producing situations. Although breathing skills training may result in a
reduction in symptoms of overbreathing, this is not the primary goal.
The goal is to use breathing skills training to encourage the client’s con-
tinued approach toward anxiety and anxiety-producing situations. It is
important that clients do not attempt to use breathing skills to prevent
dire consequences from occurring (e.g., to prevent oneself from fainting
or dying) and that they do not view the skills as “magical” cures.

86
 The breathing skills are first practiced in relaxing environments for two
reasons: first, as a way of enhancing skill development and to permit con-
centration on the breathing; second, to deemphasize the use of breath-
ing skills as an immediate tool for the reduction of fear or symptoms.

Diaphragmatic Breathing Exercise

The purpose of this exercise is to teach clients a method of regulating

breathing that will help them to directly deal with the physical symp-
toms and situations that currently make them anxious. Diaphragmatic
breathing has two components: (i) a breathing component, in which
clients learn to slow their breathing and to breathe using their dia-
phragm muscles as opposed to their chest muscles; and (ii) a meditation
component. Detailed instructions for diaphragmatic breathing are in-
cluded in the workbook (chapter , section ). The client should prac-
tice this skill twice a day for  minutes each time and record the exer-
cises on the Breathing Skills Record. A blank record is included in the
workbook, and multiple copies can be downloaded from the Treatments
ThatWork™ website (http://www.oup.com/us/ttw).

An example of a completed Breathing Skills Record is shown on page .

Case Vignettes

Case Vignette 1

C: Will I pass out if I hyperventilate?

T: It is rare to pass out from hyperventilating for short periods of time.

Even hyperventilating for long periods of time rarely leads directly to
loss of consciousness. You may stop the hyperventilating exercise when
you wish, although I would encourage you to go for the specified pe-
riod of time.

87
Breathing Skills Record

Rate your concentration on breathing and counting during the exercise and your success with rely-
ing mostly on your diaphragm for breathing, on –-point scales (where  ⫽ none and  ⫽ excel-
lent), after each practice (twice per day).
----------------------------------------------------------------------
None Mild Moderate Strong Extreme

Concentration on
Date Practice Breathing and Counting Success With Breathing

2/16/06  4 4

 3 4

2/17/06  4 4

 4 5

2/18/06  5 5

2/19/06  4 4

 5 6

2/20/06  5 6

 4 4

2/21/06  5 7

 6 7

2/22/06  6 8

 6 7

Figure 9.1.
Example of completed Breathing Skills Record

88
Case Vignette 2

C: The symptoms are similar to what I experience when I panic, but

somehow, it feels different because you are here.

T: Do you mean that the symptoms are less anxious for you when we do
the exercise together?

C: Yes, it feels as if the symptoms won’t get any worse, and they are not as
intense as when I panic.

T: This shows the influence of your thinking; that is, my presence is leading
you to think differently about the symptoms. Remember our panic cycle?

Atypical and Problematic Responses

The breathing skills exercise may, for some clients, become a form of ex-
posure to feared sensations (as described in chapter ) because the ex-
ercise either forces attention on bodily sensations or induces new, un-
familiar bodily sensations. Clients who become anxious during breathing
skills training for these reasons should be encouraged to continue with
the exercises in the same way as would occur during interoceptive expo-
sure practices.

Notably, the research on the role of breathing skills training within cog-
nitive behavioral therapy for panic disorder is not clear. There is some
indication that it does not add significantly to the effect of exposure
alone and that the combination of cognitive restructuring, in vivo ex-
posure, and breathing skills is slightly less effective than the combination
of cognitive restructuring, in vivo exposure, and interoceptive exposure.
However, the studies to date have not clearly framed breathing skills as
a tool for continuing to face anxious situations and instead have em-
phasized breathing skills as a way of reducing symptoms. As noted ear-
lier, the program in this workbook focuses away from the immediate re-
duction in symptoms and fear and toward toleration of symptoms and
fear. Thus, if breathing skills training is done in the way framed above,
it may have more beneficial effects than when it is used as a means for
controlling symptoms. If it appears that a client is using breathing skills
as a control strategy, consider minimizing their use.

89
 Some clients find that the breathing exercises lack credibility. They point
out that if they could simply tell themselves to breathe slowly or to relax,
they would have no need for treatment, and thus, the exercise seems like
a gimmick. Remind clients that the goal of breathing skills training is
not to relax or calm down but to facilitate movement forward to face
fear, anxiety, and anxious situations.

Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic at-
tacks and daily average anxiety to the Progress Record.

✎ Instruct the client to practice the diaphragmatic breathing exercise

twice a day,  minutes each time, for seven days and to record prac-
tices on the Breathing Skills Record form.

✎ The client should read chapter , section , in the workbook.

SECTION 2 Slowed Breathing

Outline

■ Review the client’s practice of breathing skills over the past week

■ Introduce slowed diaphragmatic breathing technique

Therapist Behaviors

The therapist is to review the client’s practice of breathing skills over the
past week and brainstorm ways of overcoming problems with the breath-
ing skills practice (e.g., noncompliance or anxiety). In addition, the thera-

90
 pist can model slowed diaphragmatic breathing and then provide cor-
rective feedback as the client practices this skill.

Slowed Breathing

The purpose of this exercise is to teach clients how to slow their breath-
ing rate by matching their breathing to their counting. Detailed in-
structions for slowed breathing are included in the workbook (see chap-
ter , section ). The client should practice this skill twice a day for 
minutes each time and then record the exercises on the Breathing Skills
Record.

Case Vignettes

Case Vignette 1

C: I feel really dizzy when I focus on the breathing, and I feel as if I have
to take a deep breath.

T: This suggests that you may habitually overbreathe—that is, your nor-
mal style is to overbreathe—and, therefore, trying to institute a new
method of breathing is exacerbating some of your hyperventilation
tendencies. However, it is important that you continue the exercise,
because it will gradually get easier. If you really feel like you have to
take in a deep gulp of air, hold the air in a little bit longer after you in-
hale and before you exhale.

Case Vignette 2

C: I haven’t had time to practice. It seems like an extra burden to have to

do these exercises.

T: In a sense, you are right, because there is a definite time and effort
commitment involved. Does it help to realize that you are probably ex-

91
 erting as much effort trying to ward off feeling anxious and panicky as
you would in practicing these exercises?

Case Vignette 3

C: Should I be taking big breaths?

T: What you are trying to change during these exercises is not the
amount of air but, rather, the rate and depth at which you breathe.
Breathe in the normal amount, but do it slowly, and draw the air
deeply into your lungs.

Atypical and Problematic Responses

Occasionally, clients view these exercises as “magic pills” that they must
use in order to prevent dire consequences from happening. For example,
“I could pass out if I don’t slow down my breathing.” This is when cog-
nitive restructuring is so essential in helping clients to realize that no
calamity will result, even if their breathing cannot be slowed.

Breathing skills training can be very hard for the true chronic hyperven-
tilator, the person whose typical breathing pattern is shallow and rapid,
who sighs and yawns frequently, who experiences chronic chest tightness,
and who is very vulnerable to shortness of breath and paresthesia. Such
a client may feel short of breath after the -minute exercise and take
deep gulps of air between the slow breaths during the exercise. Our ex-
perience tells us that learning breathing skills takes a lot longer with
these individuals, but it can still be a valuable tool for them.

As mentioned above, breathing skills exercises may elicit panic. In these

cases, the panic is occurring in response to a heightened focusing of at-
tention on feared sensations (in contrast to the typical pattern of trying
to keep one’s mind occupied to avoid noticing the sensations), an in-
creased experience of atypical sensations, or both. Under these condi-
tions, help clients understand the reasons why they panicked, and in-
struct them to continue to practice. In this way, repeated practice of
breathing becomes an exposure.

92
Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic at-
tacks and daily average anxiety to the Progress Record.

✎ Instruct the client to practice the slowed breathing exercise twice a day,
 minutes each time, for  days and to record practices on the Breath-
ing Skills Record form.

✎ The client should read chapter , section , of the workbook.

SECTION 3 Breathing Skills as a Coping Technique

Outline

■ Teach the client to use breathing skills in distracting environments

Therapist Behaviors

Now that slow and diaphragmatic breathing have been practiced suffi-
ciently in relaxing environments, these skills are now ready to be used in
distracting environments and in anxious situations. It is time to practice
in different places. The therapist could have the client practice the breath-
ing skills in session while providing a deliberate distractor (such as a noise).
Also, the therapist can encourage the client to role play the use of breath-
ing skills as a coping tool in an imagined anxiety-provoking situation.

Coping Application

Encourage clients to use breathing skills as a coping technique to help

them face fear, anxiety, and anxiety-provoking situations. A coping tem-
plate is provided for use of breathing skills in combination with think-

93
 ing skills as tools for facing fear and anxiety rather than avoiding or
retreating.

Case Vignettes

Case Vignette 1

C: When I panicked during the week, I tried to use the breathing, but it
didn’t work. It made me feel worse.

T: It sounds as if you might have attempted to use the breathing exercise

as a desperate attempt to control the feelings that you were experiencing.

C: Yes, that’s right.

T: Remember that the breathing skills training is not only intended to

regulate your breathing but, more importantly, is to encourage you to
face whatever it is that is making you anxious. This means that you
do not have to control your anxious feelings or your symptoms; in-
stead, you have to learn to continue in your activities despite the symp-
toms and the feelings, because these symptoms are not dangerous.

Atypical and Problematic Responses

As noted before, the biggest problem is when clients begin to use breath-
ing skills as a safety signal or a safety behavior. In other words, they be-
lieve that they will be at risk for some mental, physical, or social calamity
if they do not breathe correctly. For clients who are using breathing skills
in this way, discontinuation of the breathing skills may be the most effec-
tive choice. That is, design exposure exercises without the use of breath-
ing skills so that clients learn that what they are most worried about hap-
pening either does not happen or can be managed without using the
breathing skills.

94
Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic at-
tacks and daily average anxiety to the Progress Record.

✎ Instruct the client to practice breathing skills in different distracting

environments and when anxious.

SECTION 4 Review of Breathing Skills

Outline

■ Review breathing skills as a way of facing anxious feelings and

situations

Therapist Behaviors

Therapists are to inquire about the way in which the breathing skills are
being implemented in anxious situations and to provide corrective feed-
back and encouragement. If appropriate, therapists can have clients role
play their use of breathing skills in an anxious situation.

Atypical and Problematic Responses

As noted above, overreliance on breathing skills as a means for immedi-

ate fear reduction or immediate symptom alleviation, or to prevent a
“catastrophe,” indicates that breathing skills are being used as a safety be-
havior. In these situations, remind clients of the purpose of breathing
(i.e., a tool for regulating breathing and a tool for facing fear and anxi-
ety despite physical symptoms and despite anxiety).

95
Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic at-
tacks and daily average anxiety to the Progress Record.

✎ Instruct the client to continue practicing breathing skills techniques.

96
Chapter 10 Thinking Skills

(Corresponds to chapter  of the workbook)

This chapter is divided into four sections.

Materials Needed for All Sections

■ Negative Thoughts list

■ Copy of completed Hierarchy of Agoraphobia

■ Changing Your Odds form

■ Realistic Odds Pie Chart

■ Changing Your Perspective form

SECTION 1 Thoughts Influence Emotions

Outline

■ Present a reciprocal model of anxiety and negative thinking

■ Help the client identify negative thoughts

Therapist Behaviors

The therapist should use Socratic questioning to help clients identify

their own anxious thoughts. The downward arrow technique is a useful
method of questioning to find out the details of what the client is most

97
 worried about happening in any given situation. The downward arrow
questions are as follows.

■ If you panicked, what would happen?

■ What would it mean if . . . ?

■ What do you picture happening if . . . ?

■ What do you see happening next?

It is important that the questioning does not stop at the thought of

having anxiety or suffering a panic attack but, rather, that it extends to
discover what it is that the person is most worried about which leads
them to feel anxious or to panic or to ascertain what it is that they are
most worried about if they did become anxious or panic. Clients may
be encouraged to use behaviors or behavioral urges (e.g., “I wanted to
leave”; “I had to leave”) as a cue to ask: “What was I thinking that mo-
tivated that behavior—what did I think would have happened had I
stayed?”

Anxiety and Negative Thinking

Present the client with a reciprocal model of anxiety and thinking. Ex-
plain that anxiety increases negative thinking, and in turn, negative
thinking increases anxiety. These reciprocal patterns are tied to adaptive
processes (e.g., it is natural for anxiety to lead to magnification of the
perception of danger and for perceived danger to lead to anxiety).

Recognizing Negative Thoughts

The main goal of this first section is to help clients recognize that the way
they think is critical to their level of fear or anxiety at any given moment
and that recognizing negative thinking at a specific and detailed level is
necessary before developing different, less negative ways of thinking.

Thinking skills do not simply represent positive self-statements but,

rather, a skill for understanding distortions and errors in one’s own think-

98
 ing and for the development of alternative ways of thinking which are
not biased by such distortions.

Emotional responses vary across situations as a result of different inter-

pretations. For example, heart palpitations experienced when home alone
may be interpreted very differently than similar palpitations experienced
while driving a car with passengers. These variations are very idiosyn-
cratic because of each individual’s own set of concerns. For some, the
palpitations may be perceived as more dangerous when driving, due to
the thought that an accident will ensue. For others, heart palpitations
that occur when the client is home alone seem more dangerous because
of the thought that no one will be there to help if necessary. This speci-
ficity in thinking highlights the value of identifying the specific predic-
tions that are being made in any given situation.

Negative Thoughts List

Ask clients to identify negative predictions for each item on their agora-
phobia hierarchy and each panic attack that they recorded over the past
week, and then have them document these on the Negative Thoughts
list in the workbook. Identifying specific predictions, hypotheses, or in-
terpretations in any given situation is emphasized as the first step in cog-
nitive restructuring.

Case Vignettes

Case Vignette 1

C: I am afraid of feeling panicky.

T: What would happen if you felt panicky in that situation?

C: It would be terrible.

T: What do you imagine happening that would be so terrible?

C: I would lose control.

99
 T: What would it mean if you lost control? What do you picture
happening?

C: I would collapse.

T: And if you collapsed, then what would happen?

C: I would never recover, and I would be hospitalized forever.

Case Vignette 2

C: I don’t want to feel those feelings.

T: What would happen if you felt those feelings?

C: I couldn’t handle it.

T: What do you imagine happening?

C: I would get up and go home.

T: What would happen if you couldn’t leave, and you had to stay?

C: The feelings would get worse.

T: And then what would happen?

C: I don’t know, it scares me to think about it. Maybe I would faint.

T: And if you fainted, then what?

C: I might die.

Atypical and Problematic Responses

Sometimes, clients express reluctance to identify their negative thoughts

because they worry that focusing on the thoughts will raise their anxiety.
In response, acknowledge the possibility that identifying negative thoughts
may initially increase anxiety. However, also stress that identifying the
thought in detail is necessary to challenge it effectively. We have often
found a golf analogy to be helpful in illustrating this point. The identi-
fication of negative thoughts is analogous to locating the flags in the

100
 holes on a golf course. While successfully locating the flag does not
guarantee that the golfer will get the ball in the hole, the golfer does not
have a chance without it: the golfer might not even know in what direc-
tion to go! Similarly, while identifying an automatic thought does not
guarantee anxiety reduction, the client does not have a chance without
doing so.

(Note: There is no homework, as clients are expected to go directly to

section  after completing section .)

SECTION 2 Jumping to Conclusions and Realistic Odds

Outline

■ Teach the client how to evaluate negative thoughts and generate

alternative, evidence-based thoughts

■ Teach the client to examine the evidence and develop realistic

odds

Therapist Behaviors

During cognitive restructuring, the therapist becomes a coach who asks

appropriate questions rather than simply providing direct reassurance.
This approach is called Socratic questioning, and it enables clients to
develop their own set of skills for dealing with anxious thoughts. For
example, therapists should ask clients what their most recent medical ex-
amination revealed as opposed to telling them that they will not have a
heart attack. Similarly, therapists should ask clients how many times oth-
ers have commented on how insane they look as opposed to telling them
that people do not think that they are deranged. Therapists can also
make contrasting statements to highlight the principles of jumping to
conclusions. For example, therapists may respond to clients’ statements
that they believe they will have a heart attack when they panic with, “So,
you must have had several heart attacks already.” (Or if a strong alliance

101
 has not already been established, the therapist might respond with, “So,
what evidence do you have that this will happen?”) By modeling the
method of asking appropriate questions, therapists help clients learn to
question the evidence for themselves.

When thinking skills are first introduced, the therapist will probably
need to be quite active, not only asking relevant questions but some-
times supplying alternative, balanced thoughts or sources of evidence
when the client draws a blank or overlooks important sources of evi-
dence. Over the course of the remaining sessions, however, therapists
should gradually fade out their contributions to the rethinking and ex-
plicitly encourage the patient to internalize the skills. For example, over
time, therapists can begin to ask, “Can you imagine what questions I
might ask you to consider about this?” rather than “What is the evidence
for that?” or “What is an alternative to that thought?”

Evaluating Negative Thoughts

The main goal of this section is to begin teaching a set of skills for eval-
uating negative thoughts by looking at the evidence and generating al-
ternative, more evidence-based thoughts.

Anxious thoughts tend to be regarded as if they were fact. For example,

clients may emotionally respond to the thought of a potential heart attack
as if they were actually about to have a heart attack. However, clients’
thoughts are more likely to be inaccurate and biased toward perceived
danger when they are anxious. Thus, the need to evaluate the veracity of
anxious thoughts by examining the evidence is emphasized. Evaluating
the evidence is essential because judgments based purely on emotional
reactivity are likely to be inaccurate.

As in the previous section, emphasize that avoidance and safety-seeking

behaviors, such as exiting a situation, seeking help from another person,
or distracting oneself, maintain and perpetuate negative thinking. Help-
ing clients to understand reasons why they continue to jump to conclu-
sions is part of the process for recognizing errors in logic and developing

102
 alternative points of view. For example, clients may believe that the only
reason why they did not die from a panic attack was because they always
escaped, avoided, or distracted themselves just in time. In other words,
they believe that danger really was imminent had it not been for the
safety behaviors.

Realistic Odds

Explain to the client that more realistic beliefs can be developed by con-
sidering all the evidence and obtaining additional information. This logi-
cal empiricism will override negative thinking. It incorporates looking at
the evidence and taking into account past mistaken reasons why actual
experience has not disconfirmed negative thinking.

The steps for developing more realistic thinking include the following.

■ Asking whether what one is most worried about has ever happened.

■ Acknowledging the mistaken reasons for continued worry.

■ Examining the evidence.

■ Rating the realistic odds, using a –-point scale.

■ Generating possibilities, recorded in a pie chart.

Ask the client to apply these steps to examples of jumping to conclusions

from the list of Negative Thoughts they generated in section . Have the
client complete a separate Changing Your Odds form for each example.
A blank form is included in the workbook, and multiple copies can be
downloaded from the TreatmentsThatWork™ website (http://www.oup
.com/us/ttw).

An example of a completed Changing Your Odds form is shown on

page .

103
Changing Your Odds

Negative thought: I might faint in the shopping mall.

How many times has it happened? Zero.
Reasons why I continue to worry about it:
. Avoidance behavior X
. Mistaken belief that past evidence does not apply X
. Mistaken belief that luck or my extra-cautious behaviors have prevented it from
happening X
. Mistaken belief that what I most worried about has come true
. Mistaken belief that dangers increase with intensity of anxiety or physical
symptoms X
What is the evidence? I have never fainted before, even though I have panicked many times;
panic attacks do not usually lead to fainting because physically, panic attacks are different
from fainting.
What are the real odds? (–) 5%
What are different thoughts? (Fill in the pie chart, including your anxious thoughts as the shaded
piece of the pie):

I’ve panicked
many times I am
before and unlikely to
never faint.
These fainted.
are symptoms
I will faint.
of adrenaline, but
not of fainting.

I can feel weak and

I have not fainted in
light-headed and not I the past.
faint. probably
The
would not
chances of
have fainted
fainting do not
if i’d stayed in
change from one
the mall instead
panic attack to
of escaping.
the next.

Figure 10.1.
Example of completed Changing Your Odds form

104
Case Vignettes

Case Vignette 1

C: You are asking me to rate my fears of fainting on a scale of probability.

What do you mean?

T: It means to judge the actual probability of fainting, given all the evi-
dence you can gather. Use a scale from zero (not at all probable) to 
(will definitely occur). What is the actual probability of fainting?

C: I don’t know, perhaps a score of .

T: So, that means that out of every  times you have panicked, you have
fainted once?

C: Well, no, I have never fainted.

T: So, what is the actual probability?

Case Vignette 2

C: Sure, I can tell myself that the chance of passing out when I panic is
very small. I tell myself that all the time. But what if I did pass out? It’s
that one-in-a-million chance that scares me.

T: By asking that type of “what if ” question, you might be dismissing the

evidence and emotionally reacting as if it is going to happen.

C: I guess I am, because it certainly feels like it could happen.

T: Remember, feelings are not a good basis for making probability judg-
ments. Let us check the evidence again. How many times have you
felt like you would pass out, and how many times have you actually
passed out?

105
Case Vignette 3

C: It’s easy to ask myself these questions now, but I have no chance of
thinking rationally when in the midst of a panic attack.

T: Yes, it is much harder to think rationally in the midst of intense fear.

But by rehearsing these thinking skills now, they will be more acces-
sible to you when you become very anxious. It is a bit like learning
anything—the more you practice, the more natural and automatic it
will become, and the easier it will be to use when under high stress.

Case Vignette 4

C: My biggest fear is that I’ll have to get up and leave. And that is exactly
what I do, so how can I say that what I am afraid of is not likely to
happen?

T: What do you think will happen if you stay in the situation?

C: If I don’t leave, who knows what will happen? That’s exactly why I do
leave.

T: Imagine yourself feeling panicky and trapped—you cannot leave.

What is going to happen to you?

C: That’s difficult. I don’t usually let myself think of that possibility. I

think I’m afraid that I’ll get so scared that I’ll just lose it and flip out.

T: What other pieces of evidence do you have to lead you to suspect that
you will “flip out” if you do not leave?

C: None, really.

T: Is it possible that you are jumping to conclusions about the chances of

“flipping out” if you stay and that your escape behavior has been
guided by the belief that “flipping out” is a very real possibility?

C: Yes.

106
Case Vignette 5

C: Last week, I was sick, but I was determined to interpret the symp-
toms as being anxiety related and not dangerous. It turns out that I
had the flu.

T: It sounds like you were going to the other extreme; you might have
been ignoring pieces of evidence which, under normal conditions,
would suggest the flu. But in the absence of objective evidence, I
would rather that you ignore the symptom than magnify its meaning.

Atypical and Problematic Responses

Three problems sometimes arise during discussion of jumping to con-

clusions. First, clients may report that although they know the chances
are slim, they are still afraid in the event that “it” did happen. By focus-
ing on a recognized, slim-chance event, clients are again engaging in
overestimation, because their emotional response (i.e., fear) is occurring
in association with an event that is actually unlikely to happen. The fact
that they are overestimating can be pointed out, and an evidence-based
analysis can again be used. Remind clients that the idea is not to guar-
antee that an event absolutely will not happen but, rather, that they are
reacting as if it is much more likely to happen than it really is. For ex-
ample, it is always a possibility that when we cross a street, we will get
hit by a car. However, most of us are willing to take that risk because the
likelihood of that event occurring is fairly slim; thus, we believe that the
trade-off of that small chance in exchange for normal activity is worth it.

Second, clients might report that they are fully aware of their safety when
not panicking, but in the midst of panic, they are convinced that they
are in danger. It can be pointed out that the state dependency of cogni-
tions is a very common feature of anxiety; that is, people often are able
to recognize that their fears are irrational when feeling calm. Further-
more, with practice and rehearsal of more realistic ways of thinking, it
will become easier to challenge their anxious thoughts, even in the midst
of distress. However, there may well be limited capacity for complex
cognitive processing during the height of intense distress; sometimes,

107
 the most effective thinking skill at the height of panic is a simple state-
ment, such as “This is a panic attack, it will pass.”

Finally, clients will occasionally say that their worst fear “came true”—
they have fainted or screamed. In these cases, the therapist may either
continue to point out that the chances of that event happening again are
small (e.g., of all the times you have panicked, how many times have you
fainted?) or use strategies of putting things back into perspective, as dis-
cussed in the next section.

Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic at-
tacks and daily average anxiety to the Progress Record.

✎ Instruct the client to complete a Changing Your Odds form for each
example of jumping to conclusions on the Negative Thoughts list, as
well as for any panic attacks that occur over the next week.

SECTION 3 Putting Things Into Perspective

Outline

■ Help the client learn ways of putting things back into perspective

Therapist Behaviors

As in the previous section, the therapist coaches the client to identify

times when things are blown out of proportion and ways of putting
things back into perspective. Alternative ways of interpreting a given sit-

108
 uation are offered. For example, if a client views an episode of embar-
rassment as disastrous, the therapist may point out that someone else
could view an episode of embarrassment as a relatively minor event. The
impact of different ways of viewing a situation can then be understood.
Asking clients to imagine the worst possible thing they believe could
happen is useful for identifying catastrophic thought processes. There is
neither an assumption that the person’s style of thinking is to blow things
out of proportion across all situations, nor that catastrophizing reflects
an underlying personality trait. Instead, blowing things out of propor-
tion is viewed as a learned cognitive style in response to specific stimuli,
which, in this case, are mainly somatic sensations.

Facing the worst head-on can be quite emotionally evocative. For clients
in distress, the therapist is to gently encourage continuation of facing
head-on what they are most worried about happening by visualizing the
scene as if it were actually happening (e.g., fainting, embarrassment,
others commenting on their anxiety, screaming in public). Then, clients
will learn to tolerate the distress caused by the image and also generate
ways of coping by visualizing what would happen at the moment of the
worst event and then how events would unfold the next day, and so
forth. By visualizing events unfolding over time, the client is being en-
couraged to recognize that the worst is time limited and that life con-
tinues. If the therapist were to discontinue the exercise of facing the
worst for clients who show acute distress, then the therapist is inadver-
tently reinforcing the client’s inability to tolerate distress.

Blowing Things Out of Proportion

In addition to jumping to conclusions, blowing things out of proportion

is a mistaken thought typical of anxiety and panic. This type of thinking
refers to viewing relatively benign events as if they were insufferable, in-
tolerable, or much worse than they really are.

The tendency to view events as insufferable, unbearable, or intolerable

only contributes to unnecessary anxiety. A key principle underlying de-
catastrophizing (i.e., putting things back in perspective) is that events
can be endured even though they may not be comfortable. Recognition

109
 of the time-limited nature of discomfort contributes to the development
of a sense of being able to cope.

The message is that there is a way of coping with feared outcomes, such
as fainting or being told that one appears extremely anxious. The criti-
cal distinction here is that although clients may prefer for these events
not to occur, if necessary, they can tolerate the discomfort of them. Fur-
thermore, if negative events are viewed as unbearable and unmanage-
able, they contribute to anxiety. By recognizing how one would cope, as
difficult as that may be, the client learns that anxiety eventually lessens.

The goal of thinking skills is to correct distortions in thinking. As with

the breathing skills, thinking skills are not intended to achieve immedi-
ate reductions in fear or in the physical symptoms, although this style of
evidence-based thinking is expected to lead to eventual reductions in
anxiety about the physical symptoms and, in turn, fewer symptoms.

Changing Your Perspective

Ask the client to use the Changing Your Perspective form for each example
of blowing things out of proportion from the list of Negative Thoughts
from section . A blank form is included in the workbook, and multiple
copies can be downloaded from the TreatmentsThatWork™ website
(http://www.oup.com/us/ttw).

An example of a completed Changing Your Perspective form is shown

on page .

Case Vignettes

Case Vignette 1

C: Is it best to say to myself that I don’t need to worry about feeling

anxious?

T: In a way, that is correct, but it is much more effective to be as specific

as you can. Rather than simply telling yourself to be less anxious, iden-

110
Changing Your Perspective

Negative thought: I might faint in the shopping mall.

Will this pass, and will I survive? I guess people have fainted before and managed to go on; my

life would go on; my embarrassment will not last forever.

Ways of coping: I would wake up and feel disoriented; I assume that someone walking by

would have come over to help me—maybe a bunch of people. They would probably want to help

me. I might ask them to help me get up and call my husband; I would sit there for a while

and just wait for my husband; then we would go home; I would probably call my doctor: I

would want to check if there is anything wrong that may have caused me to faint. I would

probably go back to work the next day, assuming I felt okay.

Figure 10.2.
Example of completed Changing Your Perspective form

tify specific predictions that you are making. What is the worst thing
you can imagine happening if you become anxious?

C: Maybe I’ll look really weird to other people. I can imagine being in a
crowd of people, with everyone staring at me as they walk by and
thinking I’m crazy.

T: Who are these people?

C: Just anyone shopping in a mall or people on the street.

T: So, if these strangers were walking past you thinking, “There is a crazy
woman,” what would happen?

C: I’d feel really embarrassed.

T: So, let us think about how bad it is to be embarrassed and of ways in

which to cope with that embarrassment.

111
Case Vignette 2

C: What if I fainted?

T: Well, let us think about that. Let us say that you are in the grocery
store, and as you are waiting in the checkout line, you faint.

C: That scares me to think about.

T: The fact that it scares you is a really good reason for us to continue to
face it head-on. What would happen? There you are, down on the
floor, and. . . ?

C: And I would regain consciousness.

T: And then what?

C: I guess someone would help me get up.

T: And then what?

C: I would find a place to sit and wait until I felt okay, and then I would
go home.

T: And what would happen the next day, and the next week, and the next
month?

C: I guess I would go back to doing the things that I normally do.

Case Vignette 3

C: Sometimes, it is difficult for me to know what I am thinking at the

time that I’m panicking. What should I do then?

T: Are you able to identify the feeling as a panic attack?

C: Yes.

T: So, at the very least, you can recognize what the feeling is. That is, you
could tell yourself that you are experiencing a panic attack. With that
in mind, what can you do with that information?

112
 C: Well, I suppose I can tell myself that this is a panic attack, and as with
all my previous panic attacks, it will pass quickly, and what is the worst
that can happen?

T: That is right.

Atypical and Problematic Responses

Occasionally, problems arise because clients view their escape behaviors

as out of control, dangerous, or both. For example, one client became
frightened when driving on a highway because she could no longer see
her friend in a car behind. Hence, she pulled over onto the median strip
in the middle of the highway and began to back up. Another client
would try to control panic attacks that occurred in the middle of the
night by jumping into her car and driving at very fast (e.g.,  mph)
speeds. A different client would hit his head to control the feeling of
panic.

In each case, the behavior is designed to escape from the feelings of panic
and is therefore motivated by physiological arousal, urges to escape, and
thoughts of danger. Furthermore, the escape behavior is a logical action
at the time because it is directed at achieving safety. In other words, the
escape behavior is logical and driven by perceptions of danger and safety.
Thus, it is not an out-of-control or irrational action, given the beliefs op-
erating at the time. The real problem is the misappraisal of danger which
led to the behavior. In these cases, one should use cognitive restructuring—
by examining the data or putting things back into perspective—to ad-
dress the negative thinking that motivated the escape behavior in the
first place. The real danger associated with these types of escape behav-
iors (e.g., high-speed driving), however, must be addressed, because they
do have the potential for causing harm.

Finally, the expectation that thinking skills will immediately decrease

physical symptoms is problematic and misdirected. It is also likely to
lead to more misappraisals and symptoms due to thoughts such as, “The
dizziness did not go away, so something must be wrong with me.”

113
Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic at-
tacks and daily average anxiety to the Progress Record.

✎ The client should use the Changing Your Perspective form for each ex-
ample of blowing things out of proportion from the Negative
Thoughts list.

✎ Instruct the client to complete either a Changing Your Odds or a

Changing Your Perspective form for any panic attacks that occur over
the next week.

SECTION 4 Review of Thinking Skills

Outline

■ Review thinking skills

■ Have clients recall and evaluate their worst panic attack by using a
step-by-step analysis

Therapist Behaviors

As in prior sections, therapists should avoid giving direct reassurance

and instead ask questions or pose juxtapositions that lead clients to rec-
ognize the distortions in their thinking.

Give corrective feedback on the Changing Your Odds and Changing

Your Perspective forms that the client completed over the last week, es-
pecially when the records lack specificity (e.g., clients who record that
what they are most worried about is panicking should be encouraged to

114
 detail what it is about panicking that worries them) or indicate a style of
blanket reassurance (e.g., clients who record that everything will be okay
as their evidence or ways of coping should be encouraged to list the evi-
dence or to generate actual coping steps).

Guide clients as they revisit their worst panic attack, and help clients
evaluate the sequence of events, with special emphasis on mistaken nega-
tive thoughts that lead to increased arousal or behaviors of escape that,
in turn, increase anxiety.

Recalling One’s Worst Panic Attack

By recalling their worst panic as a “lucky escape” or something that they

would never want to go through again, clients are maintaining the per-
ceived threat associated with panic. A successful, matter-of-fact analysis
of the components and processes involved in the worst panic is stressed.
Furthermore, an ability to understand previous worst panics in an ob-
jective fashion means less anticipation of future panic attacks.

Occasionally, clients attribute their survival to external safety objects.

For example, “I survived only because my husband arrived just in time
to take me to the hospital.” Getting clients to appreciate that they would
have been safe even without the external safety object is an essential
component of understanding worst panic attacks.

Case Vignette

C: I can’t imagine ever going through another panic attack like that one
three years ago.

T: Let us think about that panic attack to get a better handle on why it
felt so bad and why you think you could not tolerate it happening
again. Using our step-by-step method, describe what happened.

C: I was rushing to an appointment with my mother’s surgeon (she was

about to have heart surgery), felt pain in my chest and numbness in

115
 my arm, and was convinced that I was having a heart attack. So, I pan-
icked and drove to the closest ER.

T: So, you have described the thoughts, feelings, and behaviors very well.
Obviously, you were very scared at the time because you thought that
you might die. What would you think now if you felt chest pain and
numbness in your arm?

C: Probably, I would realize that I was tense or maybe that my breathing

was off. I know I am healthy and not at risk for a heart attack, at least
not at my age.

T: That is a very good examination of the evidence. Now, what about the
idea of going through an intense panic attack? What is the evidence
that you could not survive it?

C: Well, actually, I suppose that I could survive it, because I have before.

Atypical and Problematic Responses

As before, it is not uncommon for clients to begin to use their thinking

skills as a safety signal, that is, as a way of immediately reducing symp-
toms or anxiety. In this case, the therapist can reiterate the purpose of
the thinking skills. In addition, therapists might consider shifting to a
paradoxical intention approach—at least for a short period of time—to
illustrate whether clients think about being unlikely to be harmed and
being able to cope with whatever happens (i.e., thinking skills), or whether
they think about the worst-case scenario to a ridiculous extreme (e.g.,
sweating so profusely that everyone around is laughing and actually slip-
ping in the sweat). In either situation, the outcome is the same.

Some clients may show high levels of distress when asked to think about
their worst panic. Alternatively, they may slip into rigid negative think-
ing patterns: for example, “That was horrible—I was really out of con-
trol.” In either case, continue with the practice in session and through
homework assignments so that the emotional reactivity eventually de-
creases over days of repeated practice and so that alternative narratives of
the experience are developed.

116
Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic at-
tacks and daily average anxiety to the Progress Record.

✎ The client should continue to complete either a Changing Your Odds

or a Changing Your Perspective form for any panic attacks that occur
over the next week.

✎ The client should practice a step-by-step analysis of a worst panic attack.

117
This page intentionally left blank
Chapter 11 Facing Agoraphobia Situations

(Corresponds to chapter  of the workbook)

This chapter is divided into three sections.

Materials Needed for All Sections

■ Facing Agoraphobia Situations form

■ Facing Symptoms and Agoraphobia Situations form

SECTION 1 Planning for Exposure

Therapist Behaviors

Note: If the client was not able to generate a Hierarchy of Agoraphobia

Situations (see chapter  in the workbook), and if the therapist is con-
vinced that there is neither agoraphobia nor reliance on safety behaviors or
safety signals in everyday functioning, then this chapter may be skipped.

Therapist guidance for in vivo exposure to agoraphobia situations is not

outlined in the workbook. However, it is conceivable that a therapist ac-
companies the client on some occasions to provide corrective feedback,
to provide participant modeling, and to facilitate the client’s toleration
of fear and anxiety in the agoraphobia situation. When such therapist-
directed exposure is conducted, it should immediately be followed by
self-directed exposure; for example, the therapist may accompany the client

119
 on a walk, and then the client should immediately repeat the walk on his
or her own to enhance self-directed practice over the following week.

Otherwise, the therapist’s role is to guide the client in setting goals, de-
signing practices, and giving corrective feedback, especially with man-
agement of escapes or avoidance.

Essential throughout all aspects of in vivo exposure is for the therapist to

be directive and confident and to encourage clients to continue despite
high levels of anxiety. To suggest to clients that a particular situation may
be too difficult or too distressing, or to overempathize with clients’ dis-
tress during in vivo exposure practices, will only reinforce their inability
to tolerate anxiety. On the other hand, therapists should not push clients
blindly into agoraphobia situations but, rather, should spend time pre-
paring clients for an exposure practice that will help them learn what
they need to learn (e.g., “I can drive four exits on the freeway feeling hot
and sweaty and not lose control of the car”; or, “I can shop in the crowded
shopping mall for one hour even though I feel weak in my legs”; or, “I
can walk around the park, and even though I am anxious the entire time,
I do not faint”), discussing ways of managing acute distress in the midst
of the practice with the client, dismantling reasons for premature es-
capes from an exposure practice, and providing encouragement to get
right back into it.

In Vivo Exposure

As mentioned in previous chapters, the goal of exposure therapy is not

immediate reduction in fear and anxiety; rather, the goal is for the client
to learn something new as a result of exposure. Exposure is best struc-
tured in a way that permits new learning. This means that clarification
of what it is that clients are most worried about as they face their feared
objects, situations, and physical sensations; clarification of the condi-
tions that will best help clients to learn that what they are most worried
about never or rarely happens; and clarification of the fact that they can
cope with the phobic stimulus and tolerate anxiety are essential for effec-
tive exposure. If what the client is most worried about is that fear and
anxiety will remain elevated for the entire duration of the practice, then
the corrective learning is about the client’s toleration of sustained anxiety.

120
There are right ways and wrong ways to conduct in vivo exposure. The
latter probably accounts for the lack of success that clients have had pre-
viously when they have attempted to expose themselves to fear-provoking
situations. The information in the workbook on “reasons why past at-
tempts may have failed” is intended to demystify in vivo exposure and
to elevate its credibility for those whose prior experiences have been nega-
tive. These reasons include failure to recognize the differences between
difficult or negative one-time experiences and repeated systematic expo-
sure practice; too much time between practices; insufficient duration of
practices, so that corrective learning (that anticipated negative conse-
quences rarely or never occur or that one can cope with the phobic stimu-
lus and tolerate the anxiety) is mitigated; and subtle avoidance, safety
signals, and distraction strategies used during practices.

The danger of facing a situation one time only is that the relief felt on
exiting the situation may overpower the learning that takes place. For ex-
ample, consider the woman who is afraid of walking around the block.
As she leaves her house to walk around the block, her anxiety rises until
she turns the last corner toward home when she feels better because her
safe place (her home) is visible, and therefore, the sense of danger
lessens. As she reaches the door of her home, she feels a great sense of re-
lief and goes inside to feel even more comfortable. What this practice has
done in essence is to reinforce the sense of safety of her home and to
magnify the sense of danger of being away from it. As she walks in the
door, her thoughts might be, “I just made it. I couldn’t do it again. I was
lucky.” In contrast, the goal of exposure therapy is to end a practice with
thoughts such as, “It wasn’t so bad after all. Nothing happened to me.
It’s really not that dangerous. I could do it again.” These latter types of
thoughts develop or grow in number through repeated experience. This
would mean that the client would benefit most by walking around the
block several times before returning to the house.

As stated previously, too much emphasis on fear reduction within an ex-

posure trial is at odds with the latest research, which indicates that fears
and anxiety disorders may be partly generated by overly rigid attempts
to avoid the emotional experience of fear and anxiety. Toleration of fear
and anxiety is a critical learning goal.

In general, the principle emphasized throughout the treatment is that

exposure and cognitive restructuring serve to develop a new set of non-

121
 fearful associations between stimulus (e.g., height), response (e.g., dizzi-
ness), and meaning (e.g., “I will fall”). The new set of associations (e.g.,
height, dizziness, “I will not fall”) gradually becomes more salient than
the old fearful associations, which, through disuse, are less and less likely
to guide emotions at any given time. Nonetheless, the old fearful associa-
tions are likely to remain intact, and although dormant immediately
after treatment, they are vulnerable to reactivation under certain condi-
tions, such as contexts that are salient reminders of when panic was first
acquired.

In the moment of fear, clients are encouraged to use their breathing and
thinking skills to encourage completion of the assigned task; the coping
skills are not intended as means for reducing fear and anxiety but, rather,
for tolerating fear and anxiety.

If escapes do happen, the goal is to learn from them rather than to re-
gard them as failures. Recognition of the precipitant to escape is very im-
portant, because the urge to escape is usually based on the prediction
that continued endurance will result in some kind of danger. For ex-
ample, clients may predict that the sensations will become intense and
lead to an out-of-control reaction. This prediction can be discussed in
terms of jumping to conclusions and blowing things out of proportion.
At the same time, escape itself need not be viewed catastrophically (i.e.,
embarrassment or a sign of failure).

Agoraphobia situations may not directly elicit physical sensations of panic,

but in some way, they have become associated with panic attacks. That
is, panic attacks are anticipated to occur in those situations. Usually,
these are situations from which escape is difficult or embarrassing, such
as driving on a highway where exits are few or being in the middle of a
crowd from which escape would be obvious to others. Nevertheless, sen-
sations play an important role in the level of anxiety or fear experienced
while in the situation. Also, the point at which clients want to escape
from the agoraphobia situation is likely to be related to the experience of
certain sensations. Eventually, the goal is to face both the situation and
the symptoms in the situation by deliberately inducing the sensations.
This is described in section .

In vivo exposure to situations can proceed in either a graduated or in-

tense form. The choice is left to the client. Evidence to date is largely based

122
 on a graduated approach to exposure, although some studies have indi-
cated success with flooding therapy, in which clients go directly to the
most intensely anxiety-provoking situations. The risk for the intense ap-
proach is that clients are not adequately prepared to tolerate intense dis-
tress, and therefore, they escape in the midst of intense distress and do
not return to the exposure task for some time. This escape behavior is
very likely to lead to sensitization and increased distress. Thus, a gradu-
ated approach is usually recommended.

Each practice is to be delineated as concretely as possible (e.g., driving

past two exits only rather than driving until too panicky to go on). Be-
fore attempting to face an agoraphobia situation, the client will clearly
understand exactly what the practice will entail (e.g., “I will walk around
inside of mall for  minutes by myself ”). In this way, there is no un-
certainty about whether the practice was conducted correctly. Without
such concrete details, clients may decide that they have failed. Also, the
practice should not be ended because of anxiety (e.g., “I will continue
driving on the freeway until I feel anxious”) because then the exposure
practice reinforces avoidance of anxiety.

Clients are encouraged to maintain a regular schedule of repeated in vivo

exposure practices and to conduct these practices regardless of internal
(e.g., having a bad day, feeling ill) or external (e.g., inclement weather,
busy schedules) factors that may prompt postponement of practices.

Practicing In Vivo Exposure

Instruct the client to choose one of the least anxiety-producing items

from the Hierarchy of Agoraphobia Situations with which to begin in
vivo exposure (starting with items rated as  or higher). The steps for in
vivo exposure to agoraphobia situations are as follows: identifying what
one is most worried about in the situation; establishing the most effec-
tive conditions for providing disconfirmatory experience for that worry;
establishing gradual or direct exposure to those conditions; envisioning
ways of managing moments of fear during the exposure; planning ways
of managing escapes from the exposure; and evaluating what was learned
following the exposure.

123
 The client should complete a Facing Agoraphobia Situations form for
each exposure completed. A blank form is included in the workbook, and
multiple copies can be downloaded from the TreatmentsThatWork™
website (http://www.oup.com/us/ttw).

An example of a completed Facing Agoraphobia Situations form is

shown on page .

Case Vignettes

Case Vignette 1

C: I really don’t want to face these situations because I know I’ll get very
anxious. I haven’t driven on my own for any distance for many, many
years, and now you’re asking me to do it.

T: Of course, you might expect to feel anxious or panicky the first time
that you attempt the situations you have been avoiding. On the other
hand, remember that through repetition, the exposures will get easier.
Also, you have a different set of skills than you had before, which will
most likely help you when you begin your driving. Would it help to
break down the task into a series of small steps and to perform each
one a number of times to feel more comfortable before proceeding to
the next step?

Case Vignette 2

C: I have so many situations that I need to practice that this is going to

take me forever. How long will it take?

T: The best procedure is to practice every situation you are currently

avoiding. It may take some time. However, with each task that you
accomplish or master, you will probably find that many of the other
tasks become a lot easier. Therefore, even though it seems overwhelm-
ing right now, it will get easier as you go on.

124
Facing Agoraphobia Situations

Date: 2/12/06

Situation: Driving from home to work on the freeway.

End Goals (excluding superstitious objects, safety signals, safety behaviors, and distractions):

Drive the entire distance without medication bottle, and in the middle lane.

Today’s Goals: Drive halfway, with medication bottle, and the in right lane.

Negative Thought (i.e., whatever it is you are most worried about happening): I will become

lost in feelings of unreality and lose control of the car.

How many times has it happened? Zero.

What is the evidence? I have had those feelings many, many times and yet have never lost

control of my actions.

What are the real odds? (–) 5

Ways of coping: When I feel those feelings, I will recognize that the chances of me losing

control are very slim; if I ever get to a point of not being able to physically control the car, I

will pull over.

Did what I most worried about occur? (Yes/No) No

Maximal anxiety (–): 8

----------------------------------------------------------------------
None Mild Moderate Strong Extreme

Figure 11.1.
Example of completed Facing Agoraphobia Situations form

125
Case Vignette 3

C: What I am most worried about in these situations is that I’ll panic, and
I do panic each time I go into them, so I really am being accurate in
thinking that.

T: What are you imagining will happen if you panic in these situations?

C: Mostly that I’ll pass out, and sometimes, that I’ll just really embarrass
myself because everyone will know that something is wrong with me.

T: Then those are the thoughts to examine. How many times have you
actually passed out from panic? How many times have people noticed
that you panic? What if they do notice?

Case Vignette 4

C: My fear is of losing control of the car when I feel dizzy. The risk is too
great, so I’ve always pulled off the road. I still think that I could lose
control of the car if I continue to drive.

T: At the moment, you do not have enough evidence to know. Once we

begin actually facing these situations, this is likely to change. Maybe in
planning for the exposures, we could come up with driving situations
that you consider safer, such as driving with someone or driving in an
empty parking lot. Once you have had some experience driving, you
will be in a better position to evaluate the accuracy of your thoughts.

Case Vignette 5

C: I’ve been avoiding malls for so long that I can’t even remember what
my original fear was—just how anxious it felt.

T: Can you imagine yourself in a mall now?

C: All I can imagine is running out of the mall.

T: What do you imagine happening if you do not run out of the mall?

126
 C: Oh, it’s all coming back to me now. I feel terrified that I’ll never find
an exit, and I’ll just keep panicking and go crazy.

Atypical and Problematic Responses

Because much of this section of the program is self-directed, compliance

with exposure assignments can become problematic. The therapist’s role
at this point is to emphasize the value of repeated exposure and the ne-
cessity of facing agoraphobia situations for further improvement. Occa-
sionally, as clients make changes in their typical daily patterns, family
members may be affected. Discussion of ways in which to incorporate,
or at least inform, significant others is useful under such conditions (see
chapter  in the workbook).

As reflected in the case vignettes, many clients doubt the value of re-
peated exposure. These doubts stem from their own history with expo-
sure, whether the exposure was a deliberate attempt to overcome fear or
was forced on them by circumstances. In most cases, these doubts are at
least partially quelled by reviewing the section on why in vivo exposure
has not worked in the past. Having clients describe a recent exposure at-
tempt, with emphasis on providing specific details, may reveal differ-
ences between their attempts and therapeutic exposure. If the client has
difficulty providing these details, prompting questions (e.g., “What was
going on right before you got in the car? Why did you choose to drive
this time? What was the very first symptom you noticed? What was the
first thought? How did you respond to these?”) usually manage to draw
out sufficient details. Because of the empirical support for exposure-based
treatment, ask clients who continue to have doubts to attempt the treat-
ment despite their doubts and to forestall judgments until they have
some experience with the treatment.

Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

127
 ✎ At the end of each week, the client should add the number of panic
attacks and daily average anxiety to the Progress Record.

✎ The client should continue to complete either a Changing Your Odds

or a Changing Your Perspective form for any panic attacks that occur
over the next week.

✎ The client should practice facing a situation from the Hierarchy of

Agoraphobia Situations at least three times over the next week.

SECTION 2 Review of In Vivo Exposure Practices

Outline

■ Review in vivo exposure practices conducted by the client over the

past week

■ Work with the client to design the next set of exposures

Therapist Behaviors

The therapist behaviors are the same as in section . Also, the therapist
will judge the number of sessions to spend on in vivo exposure to ago-
raphobia situations, with the aim of having the client repeatedly practice
most (if not all) items on their Hierarchy of Agoraphobia Situations.

Review of the Past Week

The main goal of this section is to reinforce corrective learning from the
in vivo practices conducted over the past week and to design the next set
of in vivo practices.

The objective evaluation of performance after each trial of exposure is

considered necessary to offset subjective and damaging self-evaluations.
As demonstrated in experimental literature on learning and condition-

128
ing, appraisals of aversive events after they have occurred can influence
anxiety about future encounters with the same types of aversive events.

Any practice that is terminated prematurely should be reviewed carefully

for contributing factors, which should then be incorporated into subse-
quent trials of facing situations. Escapes (i.e., leaving a situation before
the specific goals for the day had been accomplished) are likely to be mo-
tivated by specific sensations or misappraisals. Escapes can therefore be
useful learning experiences to the degree that fears of sensations or mis-
appraisals are identified and subjected to evidence-based analyses (i.e.,
thinking skills). Also, clients are encouraged to use their breathing and
thinking skills to remain in the situation until the specified duration or task
has been completed, despite uncomfortable sensations.

It is important for clients to recognize that the goal is to repeatedly face

situations despite anxiety, not to achieve a total absence of anxiety. Tol-
eration of fear rather than immediate fear reduction is the goal for each
exposure practice; this approach will lead to an eventual fear reduction.

Troubleshooting is part of the objective, matter-of-fact approach that

underlies the entire treatment: to identify obstacles to success and find
ways of problem-solving as opposed to resigning oneself to failure.

It is unrealistic to expect progress to be on a linear, upward trend. Clients

should not become discouraged by fluctuations in anxiety or avoidance
but, rather, should use these as cues to continue facing situations. As
noted earlier, reviewing practices that did not go well can lead clients to
a greater understanding of the factors contributing to their anxiety,
which can then be incorporated into future practices.

Anxiety that does not decline over repeated days of in vivo exposure may
result from too much emphasis being placed on fear and anxiety reduc-
tion; that is, trying too hard or wishing too much for anxiety to decline
typically maintains anxiety.

Discussion of the impact of context specificity on “return of fear” is in-

tended to encourage clients to practice in highly significant contexts,
such as those in which they experienced their first or their worst panic
attacks. If these salient contexts are not mastered, clients are at greater
risk for the return of fear.

129
Case Vignettes

Case Vignette 1

C: One of my situations is driving. I know you said to design driving

practices around distance, but it can vary so much. Sometimes, two
exits on the highway seem really easy, and other times, I’m terrified
with the idea of just one exit. Wouldn’t it make more sense to just keep
driving as long as I can?

T: Say you tried it that way, and, instead of stopping at two exits, you
drove until you panicked. What would you be teaching yourself then?

C: Well, I’d know that I could drive up to the point at which I panicked.

T: So, what you are actually doing in that kind of practice is teaching
yourself that at some point, you will still panic and have to stop driv-
ing. If you forced yourself to drive a certain distance, regardless of how
easy or hard it was, what do you think would happen?

C: I guess if it was really easy each time, I’d increase the distance for my
next practice. But if it was hard, and I did it anyway, I’d probably learn
that I could get through it, even if I did feel anxious. So, I shouldn’t
say I’ll practice till I panic, because I’ll always be setting myself up for
failure by stopping each time due to anxiety.

T: That is right.

Case Vignette 2

C: I haven’t even started yet, and I get anxious just planning my practices!

T: What happens when you plan to face agoraphobia situations?

C: I think of all the things that could go wrong, how awful I’ll feel if I
have to leave, and how I’ll never get over this problem.

T: So, you are really giving yourself a lot of negative information when
you think about these practices. So, it is no wonder that the prepara-

130
 tion upsets you. Using your skills, think over what you just said and
how you might think differently.

C: Well, for the things that I think could go wrong, those are my typical
panic fears: that I’ll pass out in the store or run out screaming, and
everyone will look at me and think that I’m crazy. And I already know
that won’t really happen, because it’s never happened before; I guess if
I really have to leave before the practice is over, it’s not the end of the
world. I’ll just have to try it again and, maybe, break that item down a
little to make it easier at first. And I really don’t have any evidence yet
that I’ll never get over this. I’ve made a lot of progress so far, but it was
a lot of work, and I suppose I felt at times that I’d never get this far.
So, I guess I’ll just keep trying.

Case Vignette 3

C: I stayed at the mall the entire time that I was supposed to, but I was
terrified the whole time!

T: That is great!

C: How is that great? I felt awful! I hate being that anxious.

T: Remember, the point of confronting these situations is not to be able

to do it without any fear. In fact, each situation you practice was cho-
sen specifically because it scares you, so it would be unrealistic not to
have any anxiety. The important point here is that despite your anxi-
ety, you stayed for your entire practice. And as we have discussed, it is
likely that by continuing to go to the mall, the fear will gradually begin
to decrease.

Atypical and Problematic Responses

Most problems that arise during in vivo exposure can be resolved

through perseverance. One of the most frequent complaints is that the
anxiety does not decrease quickly enough on a given occasion or that
even when it does decrease, it is still present on the next occasion. Re-

131
 member that what is most important is for fear levels to gradually decline
from one exposure practice to the next, but the amount of fear reduc-
tion within a session is not as important. Therapists play two important
roles here. First, by reviewing clients’ practices, they can provide correc-
tive feedback on aspects that may be contributing to the lack of anxiety
reduction over time, such as continued unhelpful coping styles. (A par-
ticularly important maladaptive coping style is to cling to safety signals.)
Second, therapists can be a source of great support and encouragement
as clients work through their hierarchies. For clients who have extensive
or long-standing avoidance patterns, overcoming agoraphobia can take
a considerable amount of time, and discouragement and frustration
are likely to arise. Reminding clients of their progress to date, even spe-
cifically pointing out strategies that they have successfully used in previ-
ous exposures and earlier periods of frustration, can serve as a needed
boost to help them continue facing their fears. As mentioned in the pre-
vious section, the therapist is to prepare clients for their exposure prac-
tice, so that the learning is optimal. Be confident and directive, so that
clients are encouraged to learn that they can tolerate anxiety and distress.

If fear and anxiety are not decreasing over days of exposure, consider
whether the client is holding on to safety behaviors or safety signals. Take
the example of the person who is facing a fear of heights by practicing
on balconies but who does so with one foot far back from the balcony
and his or her body weight away from the railing. The situation is being
faced but with a great deal of caution, as if the person still believes that
it is not safe to lean against the railing for fear of losing control and
falling over. This is self-defeating since the situation is being faced under
the assumption that danger is present.

Fighting anxiety—when clients do everything that they can to prevent

themselves from becoming anxious in the situation or are entering the
situation with the hope of not becoming anxious—is another reason
why the situation may remain anxiety provoking over many repetitions.
Remind clients that it is more beneficial to invite anxiety rather than to
fight it and that the more they try to resist internal events, the stronger
they will become. Give the example of attempting to suppress laughter
in a solemn setting (such as a religious ceremony) or of attempting to

132
 suppress an inappropriate fantasy; usually, such urges increase. Similarly,
by trying desperately not to be anxious, clients are likely to increase anxi-
ety. Examples of inviting anxiety would be statements such as, “Let us
see how anxious I can get”; “I want to feel the shakiest I have ever felt”;
or, “I want my heart to race faster than ever before.”

Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic
attacks and daily average anxiety to the Progress Record.

✎ The client should continue to complete either a Changing your Odds

or a Changing Your Perspective form for any panic attacks that occur
over the next week.

✎ The client should practice facing a situation from the Hierarchy of

Agoraphobia Situations at least three times over the next week.

SECTION 3 Facing Physical Symptoms in Agoraphobia Situations

Outline

■ Work with the client to deliberately induce feared physical sensa-

tions during exposure exercises

Therapist Behaviors

Therapist behaviors are the same as in section .

133
Facing Physical Symptoms in Agoraphobia Situations

The notion of deliberately inducing feared bodily symptoms within the

context of feared agoraphobia situations derives from evidence that
the compound relationships between external and internal cues can be
the most potent anxiogenic agent. That is, it is not just the situation, nor
is it just the bodily sensation that triggers distress; rather, it is the com-
bination of the bodily sensation in the situation which is most distressing.
Thus, effective exposure targets both types of cues. Otherwise, clients
run the risk of later return of fear. For example, repeatedly practicing
walking through a shopping mall without feeling dizzy does not ade-
quately prepare clients for occasions on which they feel dizzy walking
through a shopping mall, and without such preparation, clients may be
likely to panic and escape should they feel dizzy in this or similar situa-
tions in the future.

Have the client choose an item from the Hierarchy of Agoraphobia Situa-
tions, either one already completed or a new item, and choose which
symptom to induce and ways of inducing that symptom in that situa-
tion. The client will record this practice using the Facing Symptoms and
Agoraphobia Situations form in the workbook. This form differs from
the Facing Agoraphobia Situations form in that a section called Symp-
tom Exaggeration has been added. Clients use this section to record the
symptom that will be deliberately induced in the in vivo exposure prac-
tice and the way in which it will be induced. In addition, the negative
thoughts are tied to the situation and to the symptoms in the situation.

A blank form is included in the workbook, and multiple copies can be

downloaded from the TreatmentsThatWork™ website (http://www.oup
.com/us/ttw).

An example of a completed Facing Symptoms and Agoraphobia Situa-

tions form is shown on page .

134
Facing Symptoms and Agoraphobia Situations

Date: 3/24/06

Situation: Shopping in a crowded mall.

Symptom Exaggeration: Wearing a woolen sweater to increase body heat and sweating.

End Goals (excluding superstitious objects, safety signals, safety behaviors, and distractions):

To shop in a crowded mall for two hours, staying mainly in the center of the mall, away from

the exits.

Today’s Goals: To shop in a crowded mall for two hours, staying in the center of the mall for

one hour while wearing a heavy sweater.

Negative Thought (i.e., whatever it is you are most worried about happening, with the symptoms
in the situation):

I will pass out.

How many times has it happened? 0

What is the evidence? I have become hot and sweaty many, many times before and yet have

never fainted.

What are the real odds? (–) 2

Ways of coping: If I faint, I will wake up and get help.

Did what I most worried about occur? (Yes/No) No.

Maximal anxiety (–): 6

----------------------------------------------------------------------
None Mild Moderate Strong Extreme

Figure 11.2.
Example of completed Facing Symptoms and Agoraphobia Situations form

135
Case Vignettes

Case Vignette 1

C: I was doing really well for a while, facing each situation on my hierar-
chy. Then, the other day, I had a panic attack for the first time in ages.
Now I’m really afraid to go back to the same situations.

T: What did you do when you panicked?

C: At first, I was just so scared and so mad that it was happening again,
and then I remembered to look at my thinking. When I realized that I
was blowing things out of proportion, it got better.

T: So, it sounds like you actually did well. What would stop you from
continuing to face your situations?

C: When I panicked this time, I was in a mall, so it was still pretty safe.
But what if it happened again while I was driving?

T: What if it did? How would that be different?

C: It wouldn’t really, I guess. It would be harder to use my skills, but I had

to do that when I first started to face my fears, and it did get easier. It’s
more frustrating, because I thought I was really over that, but looking
back, I know I’ve handled worse panics before.

Case Vignette 2

C: I am so discouraged. I just want to feel normal again. I don’t want to

have to be on guard every time I leave my house.

T: What is it that you are on guard against?

C: The possibility of panicking.

T: Why do you feel the need to protect yourself against panicking? What
are your thoughts about what could happen if you panicked?

C: The same old things—that I will die.

136
 T: So, it sounds like we need to revisit the ways of looking at the evidence
and developing realistic probabilities.

Case Vignette 3

C: I haven’t taken any medication in ages, but I still like knowing that it’s
there if I need it.

T: What do you mean by “need it”?

C: You know, if I start to panic.

T: When we have reviewed your exposures, it seemed as if there were sev-

eral occasions when you panicked, but you still finished the task any-
way, even without the medication.

C: That’s true. But I’ve always known that I had it available.

T: It sounds like you have been using the availability of medication as a

safety signal. Maybe it is time to address this more directly by weaning
you from carrying medication with you in the same way by which you
weaned yourself from carrying a paper bag with you.

C: I guess that makes sense. It really is more superstitious than anything

else, because I never actually take the medication anymore.

Case Vignette 4

C: Do you really think I am ready to drink coffee and go to the movies?

T: What worries you about the combination of coffee and the movie
theater?

C: Well, I’ve practiced in movie theaters a lot, so that feels pretty good,
but the coffee is going to make me feel very anxious.

T: And if you feel very anxious in the movie theater, then what?

C: Then, I don’t know what. Maybe I will get those old feelings again,
like I have to get out.

137
 T: Based on everything that you have learned, how can you manage those
feelings?

C: Well, I guess my number-one rule is never to leave a situation because

I am feeling anxious. I will stick it out no matter what.

T: That sounds great. It means that you are accepting the anxiety and tak-
ing the opportunity to learn that you can tolerate it. What else?

C: I can ask myself what is the worst that can happen. I know that I am
not going to die or go insane. I will probably feel my heart rate going
pretty fast because of the coffee.

T: And if your heart rate goes fast, what does that mean?

C: I guess it just means that my heart rate will go fast.

T: This will be a really good way for you to learn that you can tolerate the
anxiety and the symptoms of a racing heart.

Atypical and Problematic Responses

The ups and downs of practicing can sometimes be discouraging to

clients. That is, they may feel as if they have conquered a particular situa-
tion and then experience an unexpected panic on the next occasion of
entering the same situation. In these cases, remind clients that learning
is rarely linear but, more importantly, that recurrences of panic and anxi-
ety provide excellent opportunities to learn the most critical thing for
them to learn—that is, to learn that they can tolerate anxiety and that
anxiety and the symptoms of panic are not harmful. In this way, recur-
rences of panic and anxiety are seen as excellent learning opportunities.
Again, the goal of this treatment is for clients to be less anxious about
panic and anxiety—the goal is not to prevent fear and anxiety.

Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

138
✎ At the end of each week, the client should add the number of panic
attacks and daily average anxiety to the Progress Record.

✎ Instruct the client to continue completing either a Changing Your

Odds or a Changing Your Perspective form for any panic attacks that
occur over the next week.

✎ The client should practice facing a situation from the Hierarchy of

Agoraphobia Situations at least three times over the next week until all
the items are completed.

139
This page intentionally left blank
Chapter 12 Involving Others

(Corresponds to chapter  of the workbook)

Materials Needed

There are no materials needed.

Outline

■ Discuss and plan ways for clients to involve significant others in their
treatment

Therapist Behaviors

Therapists can assist in this collaboration by role-playing the part of

coach and by reviewing practices in which one or both parties felt mis-
understood, pushed, or otherwise distressed.

Involving Significant Others

Significant others frequently have a big impact on agoraphobia and its

treatment, even when they are not directly involved in a treatment pro-
gram. For example, agoraphobia avoidance behavior generally leads to
increased dependence on significant others, which is likely to change the
dynamics of the interpersonal relationship. The behavior and attitudes
of significant others also can have strong effects, both positive and nega-
tive, on the client’s anxiety and avoidance. For these and other reasons,

141
 involving significant others in treatment can be quite beneficial, a sug-
gestion that has been supported by empirical research.

Significant others can play both positive and negative roles in the devel-
opment and maintenance of agoraphobia and also in its treatment. It is
important that this information is conveyed both to clients and to sig-
nificant others in such a way that blame and recrimination are mini-
mized and that all parties approach treatment with as collaborative an
attitude as possible. A large part of this chapter consists of ways in which
this communication might be facilitated, primarily through increasing
others’ understanding of the anxiety difficulties and the methods of
treatment.

A major step in involving significant others in treatment is to help them

to understand panic and agoraphobia, as well as the treatment program.
In this way, the reasons for seemingly irrational fear and avoidance will
be made clearer, and the difficulty of the treatment program will be
more greatly appreciated.

Communication with significant others is crucial. First, discussion with

significant others is critical in helping them to learn more about how the
client’s agoraphobia has been maintained by inadvertent reinforcement
and how agoraphobic behavior has affected the relationship. Second, be-
fore others begin assisting with in vivo exposure, everyone involved must
have the same clear understanding of what each person’s roles and re-
sponsibilities are and how various concepts and feelings are to be com-
municated during the height of anxiety, so that the practices do not end
in misunderstandings or animosity.

Involving Significant Others in Exposure Exercises

Significant others take on several roles in assisting with exposure prac-

tices. Providing support is one key role, because overcoming agorapho-
bia can be very stressful. Acting as a coach before, during, and after prac-
tices is also important.

Involving significant others as coaches encourages a supportive team ap-

proach. However, in order to avoid a dependency on the significant other,

142
 clients are informed that exposures with significant others must be fol-
lowed by exposure practices without the aid of significant others.

Case Vignettes

Case Vignette 1

C: My boyfriend and I have gotten into so many fights about my cancel-

ing plans to go out that I’m afraid to ask him to practice with me. It’ll
just make things worse.

T: That is one possibility. Are there other ways in which he might react?

C: Well, he might be so relieved that I’m finally getting over this that he’d
want to help me so we could go out more. Or he could do it because
it’s important to me.

T: Do you have any evidence that any of these possibilities are more likely
than the others?

C: I guess I do. He’s been pretty supportive of my treatment so far. He

drives me here, even though he gets annoyed about it sometimes. And
I know he’s proud of me for working so hard. Maybe when he learns
more about it, it’ll be even easier.

Case Vignette 2

C: Our practices together have been going pretty well, and I’m really
starting to feel confident. But sometimes, I almost wish that I wasn’t
doing as well, because it’s not as okay anymore to tell my wife I don’t
feel like going out.

T: So, in some ways, the avoidance served some useful purposes for you.

C: Sort of; I mean, I never planned for it, but sometimes, it’s just nice to
know my wife will help me when things feel difficult or will under-
stand if I want to stay home.

143
 T: It sounds like this might be a good time for the two of you to discuss
how your becoming more independent might affect your relationship,
both good and bad, and maybe to come up with other ways to com-
municate the desire for wanting to be taken care of that we all feel
sometimes.

Case Vignette 3

(Note: “P” stands for “Partner” in the following vignette.)

P: Most of the time, we work really well together, but sometimes, I get
really frustrated when she hesitates because I know she’s been able to
do this before. She’ll get mad at me for pushing too hard, and we end
up in a fight.

T: Have the two of you come up with a way of communicating when you
are out doing the exposures?

C: We did at the beginning, but, as I worked more and more on my own,

we didn’t really need to use them as much, so we kind of stopped.

T: So, one solution would certainly be to get back in that habit, if it

worked well for you before. It sounds like there have also been some
disagreements about the responsibilities each of you have here. How
does each one of you see your roles in this?

P: Mine is to try to be supportive and to help Sally when she doesn’t re-
member to use all of her skills. Isn’t it?

C: Yes, but not to push me all the time. It’s my responsibility, ultimately,
and if I don’t want to practice, or if I want to end early, I need you to
understand that also. Sometimes, I feel too anxious, and you’re really
helpful then, but other times, I’m just too worn out, and it would be
worse to keep going.

T: So, it sounds almost like you need Tom to read your mind to know
when to push and when to stop.

C: When you put it that way, it sounds like I’ve been pretty unfair. But it
seems so obvious to me at the time.

144
 T: Maybe the two of you can come up with some ways by which to let
each other know how you are feeling during the practices, so each of
you can know very clearly what you are looking for from the other.
Let’s role play them here.

Atypical and Problematic Responses

For clients who are not involved in intimate relationships or whose part-
ners are unable or unwilling to become involved in treatment, close friends
can be equally useful. This is especially true if the friend lives with or has
very frequent contact with the client, because some of the reinforce-
ments discussed earlier are likely occur within that relationship, too. Some
clients might even prefer to involve a friend rather than a partner.

Clients who have been especially secretive about their anxiety are some-
times uncomfortable with the level of communication needed to fully
use another person as a coach. Role-playing in the therapist’s office can
be helpful here, as can a guided discussion regarding everyone’s expecta-
tions for treatment and for specific in vivo exposures.

In some cases, the client’s agoraphobia avoidance was instrumental in

maintaining the relationship, and increasing independence can seriously
disrupt the relationship. For some, discussion of these issues during
treatment may suffice. In other cases, however, these issues may reflect
much greater relationship problems that have perhaps been masked by
the anxiety and avoidance. Such issues would be better dealt with through
couples’ therapy that focuses on issues separate from agoraphobia. How-
ever, it is noteworthy that most studies report increased marital satisfac-
tion from the effective treatment of agoraphobia.

Homework

✎ Instruct the client to return to chapter  of the workbook and to con-

tinue planning and practicing exposures to agoraphobia situations, ei-
ther with or without the help of a significant other.

145
This page intentionally left blank
Chapter 13 Facing Physical Symptoms

(Corresponds to chapter  of the workbook)

This chapter is divided into four sections.

Materials Needed for All Sections

■ Symptom Assessment form

■ Facing Symptoms form

■ Activities Hierarchy

■ Facing Activities form

SECTION 1 Facing Physical Symptoms

Outline

■ Work with the client in order to conduct symptom exercises

Therapist Behaviors

Participant modeling procedures are used to arrive at a hierarchy of anxiety-

producing symptom exercises (i.e., the therapist models each exercise, and
then the client copies the therapist), followed by therapist-guided, re-
peated exposures. Self-directed exposure is assigned for practice between
sessions. For the in-session practice, therapists are to encourage clients to
induce the sensations, to tolerate them for specified periods of time, and

147
 to focus on the sensations in an objective (rather than an affective or sub-
jective) manner. Following completion of the exercise, clients are en-
couraged to use their breathing and thinking skills. The therapist then
provides corrective feedback.

As with exposures to feared situations, therapists are to be directive, con-

fident, and encouraging of clients to continue the exercises despite anxi-
ety, fear, or symptoms. To be overly hesitant with clients will only reinforce
their sense of inability to handle the anxiety and the symptoms. Also,
while cognitive preparation is very helpful (i.e., helping clients to recog-
nize that they are unlikely to be harmed by the symptoms, etc.), be wary
of spending too much time on the cognitive preparation, as it may ac-
tually become a form of avoidance of the exercises. It is essential to allo-
cate a good portion of the session just to the symptom exercises (e.g., 
minutes).

Fear of Physical Symptoms

Facing fear of symptoms means to be deliberately exposed to the feared

sensations that trigger panic attacks. Typically, these types of sensations
are avoided. Subtle avoidance includes distracting oneself from thoughts
about physical sensations. Obvious avoidance includes avoiding activi-
ties, such as arguments or sexual relations, which elicit strong sensations.
Avoidance precludes relearning and instead maintains the vigilance for
and acute sensitivity to such sensations. Hence, an essential component
of treatment is to confront repeatedly the feared sensations, so that clients
learn they can tolerate the sensations and associated anxiety and that the
sensations are not harmful. After a number of such practices, anxiety
over the symptoms eventually declines. This process begins by inducing
sensations by using a set of standardized and artificial exercises, such as
spinning and hyperventilating. The client’s response to these exercises is
first assessed so that they can be ranked in order from least- to most-anxi-
ety producing using the Symptom Assessment form shown on page .

Clients’ own repeated experiences of physical sensations are very differ-

ent from systematically facing feared sensations. Their own exposures to
the sensations have been associated with fear and avoidance. In contrast,
the exposure exercises prevent avoidance. Through repeated exposures,

148
Symptom Assessment

----------------------------------------------------------------------
None Mild Moderate Strong Extreme

Anxiety Level Similarity

Exercise Symptoms 1–10 1–10

Run in place

Spinning

Overbreathing

Drinking-straw breathing

Stare at self in mirror

Lift head quickly

Tense body

Other

Other

Figure 13.1.
Blank Symptom Assessment form

149
 clients learn that they are not harmed by the sensations and thus achieve
increased confidence in their ability to tolerate symptoms. Hence, the sen-
sations become less salient or meaningful. Consequently, vigilance for
these sensations decreases, as does general anxiety about the sensations
and panic attacks.

Symptom Exercises

The symptom-induction exercises are designed to elicit the sensations

most relevant to the client. The exercises are to be performed in a way
that elicits sensations as strongly as possible. Although clients may be able
to persist for only a short time initially, the length of exposure gradually
can be extended. However, even with the first exposure trial, it is impor-
tant to induce the sensations fully and to continue the exercise beyond the
point at which the sensations are first noticed. To terminate the exercise
on first noticing distressing symptoms will reinforce fear of the symp-
toms. Also, instruct clients to focus on the sensations during the exer-
cises, not to distract from them. Also, breathing and thinking skills are
to be implemented only after finishing the symptom-induction exercise.

All obvious and subtle forms of avoidance (e.g., distraction, minimal

symptom induction) should be prevented in order to obtain the most
benefit from these exposures. Similarly, all safety behaviors and safety
signals (e.g., holding on for support, remaining in close proximity to an
exit, etc.) should be eliminated.

After clients perform each exercise, they will rate the intensity of the
symptoms, fear of the symptoms, and similarity of the symptoms to those
that occur during panic attacks using the Symptom Assessment Form in
the workbook. From these ratings, a hierarchy is developed, from least- to
most-feared exercise (of the exercises that elicit sensations that are at least
mildly similar to those experienced during panic attacks).

Repeated Exposures

Clients proceed up their own hierarchy of anxiety-provoking symptom

exercises in order of increasing intensity. In addition, within each exer-

150
 cise, the duration of exposure to sensations gradually can be lengthened.
Through repeated exposure, the intensity of sensations should either
remain the same or increase. The sensations rarely decrease markedly, al-
though the level of fear eventually decreases, and the ability to endure
sensations increases.

Facing Symptoms

Date: 3/26/06

Symptom exercise: Hyperventilation

Negative thought (i.e., whatever it is you are most worried about happening):

I will not be able to function—I will not be able to talk or walk.

First Exercise

Did what I most worried about occur? (Yes/No) No.

Maximal anxiety (–): 8

Second Exercise

Did what I most worried about occur? (Yes/No) No.

Maximal anxiety (–): 8

Third Exercise

Did what I most worried about occur? (Yes/No) No.

Maximal anxiety (–): 6

----------------------------------------------------------------------
None Mild Moderate Strong Extreme

Figure 13.2.
Example of completed Facing Symptoms form

151
 At the end of each repetition, the client will complete a Facing Symp-
toms form. A blank form is included in the workbook, and multiple copies
can be downloaded from the TreatmentsThatWork™ website (http://www
.oup.com/us/ttw).

An example of a completed Facing Symptoms form is shown on page .

Case Vignettes

Case Vignette 1

C: You said it was important not to distract when I feel the sensations.
Should I concentrate on how awful I feel?

T: The point is not to concentrate on feeling awful but to allow yourself

to experience fully the sensations. By giving yourself permission to feel
these sensations, you are giving yourself the chance to appreciate fully the
fact that you can handle the sensations and that they are not harmful.

Case Vignette 2

C: So this means that for the week before my menstrual period, I should
always expect to panic more because of the hormonal changes going
on, and it’s the hormones that cause my panic attacks?

T: When did you begin to experience panic attacks?

C: Two years ago.

T: When did you begin to menstruate?

C: Twenty years ago.

T: Why do you think that you did not panic in the first  years of your
menstrual cycle?

C: I don’t know. I never even thought about panicking up until 

years ago.

152
 T: This highlights the fact that panic is not the direct result of certain
physical sensations becoming apparent, whether due to hormonal fluc-
tuations or other reasons. Rather, panic occurs as the result of a com-
plex interaction between physical sensations and fear of those sensa-
tions. The panics that you experience just prior to menstruating may
indeed be triggered by physiological sensations arising from hormonal
fluctuations, but the panic attack only occurs if you are afraid of the
sensations.

C: I see what you mean. So as long as I can learn not to be scared of the
feelings, I shouldn’t panic.

T: That is right. In turn, by being less afraid of these physical sensations,

you will be less attentive to them, less anxious overall, and less vulnera-
ble to experiencing the symptoms in the first place. Nevertheless, you
might always notice some physical symptoms before menstruating.

Case Vignette 3

C: Why do I think this way? Is it part of my personality to be afraid of

physical symptoms?

T: It seems that the way in which we interpret different events in our lives
is strongly influenced by our whole history of learning experiences.
So, if through a series of experiences, you have learned to associate
physical symptoms with danger, then it would make sense for you to
respond to benign physical symptoms with a sense of potential danger.
For example, being very sickly as a child, or seeing someone else go
through a serious illness, may lead you to be more likely than someone
who has not had such experiences to view bodily sensations as poten-
tially risky. The good news is that we can structure learning experiences
to change the ways in which we think. In fact, that is what this treat-
ment is about: using experience to develop new ways of thinking
about physical symptoms.

153
Atypical and Problematic Responses

Occasionally, clients continue to be perplexed by the experience of so-

matic sensations that occur for no apparent reason. It is useful to reiter-
ate several main points as follows: “First, if you are generally anxious or
worried (e.g., about experiencing panic), your level of physical arousal
will be ‘up a notch.’ Therefore, you will be more susceptible to experi-
encing physical symptoms that are by-products of heightened arousal,
such as sweating or shaking. Second, if you worry a lot about panicking,
you will be very attentive to signals of impending panic—the physical
symptoms.”

An occasional problem with the interoceptive exposure procedure is the

failure to experience anxiety due to perceived safety, predictability, and
controllability. That is, in the context of the exercises conducted in ses-
sion with a therapist, the level of anxiety about the symptoms is miti-
gated by knowing where the symptoms come from, that they will end,
and that they are safe. In contrast, the same symptoms elicit much more
anxiety if they occur for no apparent reason in the client’s daily life. Dis-
cussion of the thinking that leads to more or less fear of sensations under
different conditions is very helpful. This discussion highlights the signifi-
cance of anxious thoughts—the symptoms are the same, but the thoughts
are different. Also, even though the symptoms are thought about differ-
ently in different circumstances, the actual risk associated with the symp-
toms has not changed.

Occasionally, clients report difficulty performing the symptom exercises

at home. This difficulty is most often associated with the sense of dan-
ger in the event that they panic or that “something happens.” In addi-
tion to putting things back into perspective (i.e., “What is the worst that
can happen?”), a graduated approach can be employed. Initially, clients
may practice in the presence of a friend or family member, or even in the
therapist’s office with the therapist out of the room. The next step is to
practice when alone.

In a similar vein, clients may perform the exercises but with limited
symptom exposure. That is, clients may terminate the exercise as soon as
sensations are felt or may not perform the exercise with the intensity
needed to experience the sensations fully. Full benefit is unlikely to be
achieved under these conditions. Therapists should address such avoid-

154
 ance behavior and help clients to modify their anxious beliefs about
what would happen if they were to experience the symptoms.

Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic
attacks and daily average anxiety to the Progress Record.

✎ The client should continue to complete either a Changing Your Odds

or Changing Your Perspective form for any panic attacks that occur
over the next week.

✎ The client should practice symptom exercises three times each day.

SECTION 2 Review of Symptom Exercises

Outline

■ Review the client’s symptom exercises from the past week

■ Encourage the client to continue symptom exercises

Therapist Behaviors

Therapist behaviors are the same as in section .

Review

The main goal of this section is to review what was learned as a result of
the between-session practices; to continue therapist-directed, in-session,
symptom-induction practices; and to encourage continued between-
session practices.

155
Case Vignettes

Case Vignette 1

C: Spinning in the chair makes me dizzy and nauseous no matter how

many times I do it. Should I keep spinning?

T: Do you feel anxious or afraid when you become dizzy or nauseous?

C: Not anymore. I did the first couple of times, but now it’s just an un-
comfortable feeling of dizziness and nausea.

T: If you are no longer afraid of the sensations, there is no need to con-

tinue with the exercise. The exercises are not designed to eliminate the
sensations but to lessen the fear and avoidance of those sensations.

Case Vignette 2

C: I’m only afraid of the sensations produced by these exercises when I’m
in certain situations, like being in a crowded shopping mall or on a bus.

T: Later, we will work on confronting the symptoms in these types of

situations. For now, let us examine what kind of thoughts make the
symptoms more anxious in those situations because, in reality, the
symptoms are no more harmful in a crowded shopping mall than they
are here.

Case Vignette 3

C: After all of my aerobic exercise over the last few weeks, I’ve certainly
learned not to be afraid of my heart racing. But in the last week, I’ve
noticed a weakness in my arms, and now, that symptom scares me. Does
this mean that I’ll always be anxious about one or another symptom?

T: The fact that you have become frightened of a new symptom may in-
dicate a continuing tendency to misinterpret bodily sensations as dan-
gerous in some way. You can apply the same procedures as you did for

156
 the racing heart. With time, the general tendency to view symptoms in
a threatening way will decrease.

Case Vignette 4

C: Every time I breathe through the drinking straw, it feels as if I’m suffo-
cating, and I have to stop. It never gets any easier.

T: Since you know that this practice will not really suffocate you, it is best
to continue with the repeated exposures. If it is difficult to continue for
 seconds beyond the point at which you begin to feel like you can-
not breathe, cut it back to five seconds, and do that enough times until
you feel comfortable. Then, gradually go up to  seconds, and so on.

Case Vignette 5

C: I tried hyperventilating on my own. However, I wasn’t very successful

because I felt too scared, and I stopped it as soon as I noticed the
strange feelings.

T: What did you think would happen if the sensations became more
intense?

C: I thought the feelings would get worse and worse and worse and just
overwhelm me. I didn’t want to have that feeling of panic again.

T: If you did become overwhelmed, what would happen to you then?

C: Then I’d feel really terrible.

T: And if you felt really terrible?

C: Well, nothing. I’d just feel terrible.

T: The word “terrible” carries a lot of meaning. Let us see if we can pin
down your anxious thoughts, which make the feelings so terrible.

C: I just can’t tolerate the feeling.

T: What tells you that you cannot tolerate it? How do you know that you
cannot tolerate it?

157
Atypical and Problematic Responses

As with exposures to agoraphobia situations, fear and anxiety about the

symptoms may fail to decline over repeated days of exposure practice. In
this case, look for examples of safety behaviors or safety signals that may
be inadvertently contributing to the anxiety. In addition, assist clients in
looking at the realistic odds or changing their perspective (i.e., thinking
skills) for whatever it is that they are most worried about happening, and
help them to appreciate the value of learning to tolerate anxiety and its
symptoms.

Occasionally, clients report that they ended the exercises because they
were producing long-lasting symptoms. For example, practicing spin-
ning in a chair was reported by one of our clients to induce dizziness for
one entire week. Assuming that there are not true medical explanations
(e.g., vertigo), this protracted symptomatology is likely due to misap-
praisals of the symptoms as being harmful or indicative of something
wrong; attempts or desires to get rid of the symptoms; or safety behav-
iors. In these cases, help clients to conduct a step-by-step analysis of the
week’s worth of symptoms, and practice the exercise in session with the
instruction to make the symptoms as intense as possible. It is also pos-
sible to arrange for clients to engage in normal daily routines and tasks
immediately after the exercises or after they leave the office so as to rein-
force their abilities to tolerate the symptoms. For example, a client can
be encouraged to go to the store, make a phone call, or ask someone for
directions despite the presence of dizziness or lightheadedness immedi-
ately following the treatment session. In other words, encourage contin-
ued approach behavior and minimize safety behaviors following each
session involving interoceptive exposure.

Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic
attacks and daily average anxiety to the Progress Record.

158
 ✎ The client should continue to complete either a Changing Your Odds
or Changing Your Perspective form for any panic attacks that occur
over the next week.

✎ The client should continue to practice symptom exercises three times

a day.

SECTION 3 Facing Symptoms in Activities

Outline

■ Extend symptom exercises to activities that are common in day-to-

day life

■ Have the client choose items to practice from the Activities Hier-
archy in the workbook

Therapist Behaviors

Exposure to certain activities can be conducted in session, with therapist

feedback and participant modeling. For example, drinking coffee or eat-
ing chocolate is very suitable for in-session exposure. Between sessions,
self-directed exposure is essential in order to facilitate generalization and
to lessen the reliance on safety signals (i.e., presence of others). Thera-
pists are to review clients’ practices over the prior week, brainstorm com-
plications such as procrastination or escape, and help clients design their
next between-session practices. As with exposure to feared situations, the
therapist is to be directive and confident and to encourage clients to per-
sist despite anxiety.

Facing Activities Exercises

Naturalistic activities are now used in the same way that symptom exer-
cises were used to induce relevant feared sensations. Examples of these
activities include aerobic activity, sexual arousal, high excitement, watch-

159
 ing suspenseful movies, anger, being in hot or stuffy conditions, and so
forth.

Although the activities may result in sensations that are not easily
stopped (e.g., as in the case of drinking coffee), the sensations should
not be viewed as more dangerous.

Like the symptom exercises, the activity exercises are designed to be sys-
tematically graduated and repetitive. Clients may apply the breathing
and thinking skills while the activity is ongoing. This is in contrast to the
symptom-induction exercises, where coping skills are used only after
completion of the symptom exercises. This is because the activities often
are considerably longer than the symptom-induction exercises. Never-
theless, clients are encouraged to focus on the sensations and to experi-
ence them fully throughout the activity, while not using the coping skills
to prevent the onset of sensations.

A multitude of behaviors are designed to avoid certain physical sensa-

tions. Very subtle avoidance can occur without full awareness. For example,
being unwilling to place oneself in stressful situations or confrontational
encounters with other people could reflect anxiety about experiencing
panic-like sensations. Similarly, hesitation about walking in the open (in
contrast to staying close to a structure or another person) may reflect an-
ticipation of intense sensations. Best results come from combining inte-
roceptive exposure (to the symptom exercises or to activities like drink-
ing coffee) with elimination of the excessive safety behaviors.

The activities that elicit panic-like sensations are different from typical
agoraphobia situations. Agoraphobia situations are those in which panic
is expected because of previous experiences of panic in similar situations.
For example, highway driving may be avoided because of a history of
panic in that situation. On the other hand, the activities described in this
section directly elicit sensations (e.g., drinking coffee induces sensations
in everyone, not just those fearful of panicking), although the intensity
of the sensations is likely to be stronger when the sensations are feared.

For practice, the client should choose activities from the Activities Hier-
archy included in the workbook. At the end of each practice, the client

160
 will complete a Facing Activities form. A blank form is included in the
workbook, and multiple copies can be downloaded from the Treatments
ThatWork™ website (http://www.oup.com/us/ttw).

An example of a completed Facing Activities form is shown below.

Facing Activities

Date:

Activity: Jogging

End Goals (excluding superstitious objects, safety signals, safety behaviors, and distractions):

Jog for 20 mins, alone.

Today’s Goals: Jog for five minutes, with running group.

Negative Thought (i.e., whatever it is you are most worried about happening):

I will become breathless and stop breathing.

How many times has it happened? None.

What is the evidence? Even though I feel breathless, I am healthy and unlikely to stop breathing.

What are the real odds? (–) Zero.

Ways of coping: I will go slowly and remind myself that breathlessness is not dangerous.

Did what I most worried about occur? (Yes/No) No.

Maximal anxiety (–): 5

----------------------------------------------------------------------
None Mild Moderate Strong Extreme

Figure 13.3.
Example of completed Facing Activities form

161
Case Vignettes

Case Vignette 1

C: What if I go to an aerobics class, get really anxious, and have to leave?

T: Remember, you can do this in graduated steps. For example, you ini-
tially could decide to attend an aerobics class for  minutes; and then,
the next time, you could go for  minutes, and so on. Also, if you feel
like you have to leave in the midst of an aerobics class, think about
what it is that you are most worried about happening, and then con-
sider the realistic odds or ways of coping. If that is not possible in the
class, step outside to give yourself time to think things through, and
then return to the class.

Case Vignette 2

C: One of the things that I’m going to do is to walk at a vigorous pace

while carrying weights. But I haven’t done exercise for so long that I
wonder if it might be too much.

T: Indeed, you need to consider what is reasonable. For anyone who has
not exercised for a long time, it is unwise to jump immediately into
very vigorous exercise. Let us start slowly and then build up to more
strenuous workouts.

Atypical and Problematic Responses

Occasionally, clients report that their level of fear does not reduce across
repeated exposure trials. Sometimes, this occurs because clients continue
to hope that the sensations do not become intense, and they try to elim-
inate the sensations as soon as possible after the exercise or activity is ter-
minated. In such cases, the breathing skills in particular tend to become
safety crutches rather than adaptive strategies. In addition to putting
things back into perspective (e.g., “So what if my heart races?”), it is
helpful to practice the symptom exercises and activities without subse-
quent use of breathing. Instead, instruct the client to make the sensa-

162
 tions last as long as possible. A paradoxical intentional approach can be
used also (i.e., make the sensations as intense as possible).

Sometimes, a client’s reluctance is expressed in the view that “I never

drink coffee, so why should I start now? Even if I wasn’t scared, I would
not drink coffee”; or, “Who wants to feel sick from a fairground ride?”
Here, you need to help clients to realize that, sometimes, exposure hier-
archies go beyond what is “normally done” or what is preferred in order
to instill a strong sense of mastery and control. Therefore, even though
they would not typically engage in certain activities, there is value in car-
rying them out. Failing to complete the top hierarchy items could leave
the client susceptible to a return of fear at some later time.

Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic
attacks and daily average anxiety to the Progress Record.

✎ The client should continue to complete either a Changing Your Odds

or Changing Your Perspective form for any panic attacks that occur
over the next week.

✎ The client should practice activity exercises at least three times a week,
until the client’s anxiety reading on a given day is no more than a score
of two.

SECTION 4 Review of Activity Exercises

Outline

■ Review the client’s activity exercises from the past week

■ Discuss with the client what has been learned and ways of manag-
ing escape behaviors

163
Therapist Behaviors

Therapist behaviors are the same as in section .

Review

The exposure principles are the same as in the previous sections, al-
though now, more attention is given to reinforcement of progress, brain-
storming of problems with exposure, and creativity in generating exposures.

Case Vignettes

Case Vignette 1

C: I’m going to eat certain foods that I’ve avoided in the past because
they made my stomach feel very heavy, which always signals to me the
possibility of choking. However, I never like to eat alone, not because
I’m scared, but because I just prefer to eat with other people. Will that
be okay?

T: For the purposes of the exposure, it will be more useful for you to eat
alone despite your preference for eating with other people. Eating
alone would allow the fullest exposure in which you will learn to be
less afraid of the sensation of fullness in your stomach. That is, you
will learn that you do not need the safety of the presence of others.

Case Vignette 2

C: If I drink a cup of coffee, I know it’s going to make me feel really agi-
tated and jumpy. Then I won’t be able to concentrate or function at
work. Do you really want me to drink a cup of coffee?

T: Again, you can use a graduated approach. For example, you could
drink a small amount first. Alternatively, you could drink coffee on the

164
 weekends so as to allow yourself to become more comfortable with the
sensations and then drink on days that you go to work. Also, remem-
ber that poor concentration is probably due to being too attentive to
the sensations that will also interfere with your concentration on other
tasks. Learning to be less anxious about the symptoms will cause you
to be less attentive to them and, thus, better able to concentrate on
other things around you.

Case Vignette 3

C: One of my practices is to drive my car with the heater on and the win-
dows closed. That is complicated by the fact that I don’t like to drive
long distances away from home. How should I design my practice?

T: You could choose from among a number of different options. You

could practice driving longer distances with the heater off, and then
you could do so with the heater on. Or, you could practice driving the
same distance with the heater on, then drive a longer distance with the
heater off; and finally, you could drive the longer distance with the
heater on. Which way makes most sense to you?

Atypical and Problematic Responses

The activities often are more difficult than the symptom exercises. For
example, they sometimes are conducted in public places; the duration of
the sensations is difficult to control; and they take more time overall. For
this reason, clients sometimes find these exercises to be more anxiety
provoking and may be less compliant with them.

In other cases, reluctance to face these activities stems from the increased
fear associated with the unpredictability and uncontrollability of these
exposures. Unlike the symptom exercises, in which the sensations usu-
ally end shortly after stopping the exercise, clients often have no control
over the onset or offset of symptoms resulting from naturalistic activi-
ties. For example, once the coffee has been ingested, the client can nei-
ther stop the exposure nor predict exactly when the effects of the caffeine
will end. Clients should be reminded of any errors in thinking which

165
 may lead them to view these symptoms as being more dangerous rather
than as merely more unpredictable and uncontrollable.

Homework

✎ The client should continue to record anxiety and panic using the Panic
Attack Record and the Daily Mood Record.

✎ At the end of each week, the client should add the number of panic
attacks and daily average anxiety to the Progress Record.

✎ The client should continue to complete either a Changing Your Odds

or Changing Your Perspective form for any panic attacks that occur
over the next week.

✎ The client should practice activity exercises at least three times a week,
until the client’s anxiety reading on a given day is no more than a score
of two.

166
Chapter 14 Medications

(Corresponds to chapter  of the workbook)

Materials Needed

There are no materials needed.

Outline

■ To teach clients about medications for anxiety and panic

■ To teach clients about ways of weaning themselves off medications

■ To show clients how medication can be combined with this treatment

program

Therapist Behaviors

This chapter is primarily didactic in orientation, and it places medica-

tions, side effects, and withdrawal symptoms within the psychobiologi-
cal conceptual model of the treatment. The therapist’s role is to be in-
formed, to able to answer questions, and to provide clarifications, where
necessary.

Medications for Anxiety and Panic

Medication is not described as a more or less effective form of treat-

ment in comparison to cognitive behavioral therapy (CBT ) but as a
more or less appropriate treatment dependent on different beliefs and
life circumstances.

167
 Medications are described, so that clients may understand their effec-
tiveness, side effects, and withdrawal problems.

Weaning Off Medications

A program to help wean clients from medication is described in the

workbook. In this program, withdrawal effects from medication, particu-
larly benzodiazepines, are managed using the skills taught in the work-
book. The withdrawal effects are conceptualized as an opportunity to
face fears of symptoms.

Combining Medications With This Treatment Program

The issue of combining medications with CBT of the sort outlined in

this guide and the corresponding workbook is complicated, and it has
been alluded to in previous chapters with reference to the use of anxi-
olytics when facing fears of symptoms and fears of agoraphobia situa-
tions. Data concerning medications in combination with CBT for panic
and agoraphobia are presented in the first few chapters of this therapist
guide. There is some evidence that benzodiazepines combine least well
with CBT, and there is some evidence that, overall, the combination of
medications with CBT is less efficacious in the long term than is CBT
alone. However, long-term data are sparse. Furthermore, it is believed
that the detrimental impact of adding medications to CBT can be over-
come in part by encouraging continued exposure to feared stimuli as
medications are withdrawn, by removing the reliance on medications as
safety signals, and by encouraging an attribution of therapeutic im-
provement to oneself as opposed solely to medications. These issues are
outlined in more detail in the workbook.

168
Case Vignettes

Case Vignette 1

C: What if I panic when I come off the medication?

T: Why do you think you would panic?

C: Because all those old feelings would come back again.

T: What feelings are you talking about?

C: I’m sure I’d get scared, because my heart would be racing, and I’d feel
sweaty and shaky, just like before—just like it was before I started the
medication.

T: Based on what you have learned from this treatment program, how
could you react differently to those feelings?

C: I would think about the fact that the feelings are not harmful, I would
think of the worst that could possibly happen, and I would put things
into perspective. Even if the symptoms didn’t go away, I’d realize that
they’re just physical symptoms.

Case Vignette 2

C: I always thought that the medication was controlling a chemical im-

balance.

T: To date, there is no clear evidence for a specific chemical imbalance

that causes panic attacks. However, medications seem to work on the
chemical neurotransmission in a way that lessens distress.

Case Vignette 3

C: I don’t think I can drive, or be alone, without my medications. It

makes me really anxious to think of not having any more medication.

T: What do you think will happen if the medication is not available?

169
 C: That I will panic and not be able to control the panic.

T: How do you think that the medication is stopping you from panicking?

C: It gives me reassurance that I can stop the feelings.

T: And what would happen if you were not able to stop the feelings?

C: I guess that they would get so intense and out of control that I would
lose it completely.

T: So, it sounds as if you see the medication as preventing a catastrophic

outcome. Let us evaluate that catastrophic outcome by examining the
evidence, and we will see if it is at all likely. How do you know that
you will “lose it” completely?

Atypical and Problematic Responses

Letting go of the safety of medication is sometimes very difficult in

terms of both physical and psychological dependency. In addition to a
process of gradual weaning away from higher dosages (under the super-
vision of the prescribing physician), weaning a client from psychologi-
cal dependence can be facilitated by the client’s gaining further and fur-
ther autonomy over the medication bottle. For example, clients may
practice by giving their medication to a companion, leaving it in the
glove box of their car, or leaving it at home. In addition, correction of
misinterpretations about what the medication is supposedly doing is
helpful. Many times, clients mistakenly think that the medication is
preventing catastrophic occurrences, and they feel vulnerable to dying,
losing control, or going insane without the help of their medication.
This kind of reasoning, of course, is very suitable for cognitive restruc-
turing. The fact is that while medication may be effective in blocking
panic attacks, it is not preventing the catastrophic consequences from
happening, because those catastrophic consequences are unlikely to
happen in the first place, with or without medication. A common mis-
assumption related to this issue is that intense panic and anxiety increase
the risk of catastrophic outcomes, and thus, the medication is valuable
because it blocks intense anxiety and panic. In this case, use thinking

170
 skills to address the mistaken notion that catastrophic outcomes are
more likely with more intense panic.

It is likely that clients who have relied on medication to control their

anxiety will be apprehensive about stopping their use of medication,
even if they have stated a desire to do so. This anxiety may translate into
doubts regarding their progress in the workbook programs and doubts
about their ability to maintain or continue making gains if they cease
medication use. In these cases, it is important to emphasize to clients, as
in the first case vignette, that their own efforts have been effective be-
yond simple medication use. Incorporating medication use into an ex-
posure hierarchy also can be helpful. Doing so brings medication use in
line with other factors that make situations easier or harder to cope with,
in a way that the client has become familiar with. This approach also ad-
dresses the very likely possibility that as clients decrease their medica-
tion, some anxiety will recur. Preparing for this recurrence in advance
can forestall unnecessary anxiety while reaffirming to the client that they
do in fact have control over even heightened levels of anxiety.

Homework

✎ Have the client speak with the prescribing physician if the client is
currently taking medication and wishes to stop.

✎ The client should develop a step-by-step plan for dealing with any
withdrawal symptoms by using the skills learned throughout this
program.

171
This page intentionally left blank
Chapter 15 Accomplishments, Maintenance,
and Relapse Prevention

(Corresponds to chapter  of the workbook)

Materials Needed

■ Progress Evaluation form

■ Practice Plan

■ Long-Term Goals form

Outline

■ Review the client’s progress up to this point

■ Encourage the client to continue to face fear and anxiety

■ Discuss ways of maintaining progress

Therapist Behaviors

The therapist’s role is to assist clients in making objective statements re-

garding their progress to this point; perhaps reminding clients of im-
provements that they have not themselves noted. In addition, the thera-
pist should assist clients in designating areas in need of further work for
the Practice Plan.

173
Evaluating Progress

Instead of focusing on feelings in general, which is likely to be biased,

progress is best evaluated by examination of objective data. Progress is
indexed by improvement—not by reaching an absolute end goal of no
panic, anxiety, or agoraphobia—and by skill development.

Change or improvement is a continuing process, as is the case when

learning any new set of responses or skills. Improvement can continue
after the client completes the workbook because of the learning that has
occurred, and results indicate that continued improvement is very typical.

Reasons for lack of progress, such as insufficient practice, lack of under-

standing of the principles, the need for more time to implement the
therapeutic strategies, and an initial error in diagnosis, all imply what
type of action can be taken next in order for the client to progress. In
other words, lack of progress is not presented as a hopeless outcome.

Client can evaluate their own progress by completing the Progress Eval-
uation form in the workbook.

If hesitations about approaching situations or physical symptoms occur

in the future, these are not signs of the underlying problems resurfacing
to uncontrollable levels or signs that the underlying problems were never
treated effectively in the first place. Instead, it means that this is the tem-
porary reappearance of old habits that can be treated in the same ways
as learned through this workbook. The temporary resurgence of old
habits is not a sign that treatment did not work.

Stressful events are described as leading to increased emotional vulnera-

bility and increased physiological arousal, which, in combination or alone,
may increase susceptibility to old ways of reacting for a brief period of time.

Practice Plans

If necessary, work with the client to identify areas for further practice.
The client will use the Practice Plan in the workbook to list all of the
things to be practiced over the next few weeks. A blank form is included

174
Practice Plan

Things to Practice Description

Breathing Skills More practice of returning fast, shallow breathing back to a

slow and abdominal pattern; go back to practice of 10

minutes, twice per day, in relaxing places.

Thinking Skills I am doing well with jumping to conclusions, but I need to do

more with my habit of blowing things out of proportion.

Imagine scenarios of panicking in public, and think through

facing the worst and putting things back into perspective

Facing Agoraphobia Situations I am ready to drive out to visit my brother.

Facing Symptoms Push myself harder in exercise class since I am holding back

too much.

Figure 15.1.
Example of completed Practice Plan

in the workbook, and multiple copies can be downloaded from the

TreatmentsThatWork™ website (http://www.oup.com/us/ttw).

An example of a completed Practice Plan is shown above.

Long-Term Goals

Now that treatment is ending, the client may begin planning for things
that he or she was previously unable to do because of panic and anxiety.
Clients can use the Long-Term Goals form in the workbook to list their
goals and the steps needed to reach those goals. A blank form is included

175
Long-Term Goals

Long-Term Goal Steps to Achieve Long-Term Goal

Career move into managerial position Talk to personnel staff.

Look at courses being offered.

Enroll in a course.

Develop new friendships Join singles group at my church.

Talk to others at my gym.

Join associations and organizations.

Going back to school Call admissions office.

Get schedule of classes.

Talk to others who have returned to school.

Figure 15.2.
Example of completed Long-Term Goals form

in the workbook, and multiple copies can be downloaded from the

TreatmentsThatWork™ website (http://www.oup.com/us/ttw).

An example of a completed Long-Term Goals form is shown above.

Ending Treatment

Clients frequently express concerns about ending the program. It is there-

fore important to emphasize again that the treatment was designed to
provide clients with the necessary skills for managing anxiety and that
they now can take these skills to continue their progress.

176
Case Vignettes

Case Vignette 1

C: Even though I’m doing most of the things I used to avoid, just the
thought of driving on my own makes me anxious. Driving was always
my biggest problem, and it looks like I’ll never get over it now.

T: It sounds like you are separating driving from all the other items in
your hierarchy because it is the hardest thing for you to face. How
might you make the idea of driving less frightening?

C: When the other situations seemed overwhelming at first, I broke them

down into smaller steps. So I suppose that I could start with driving a
tiny bit with someone in the car with me and then work up to longer
distances gradually. It’s really not that different from the other situa-
tions, then.

Case Vignette 2

C: I really feel like I’m not ready to finish; I still have a lot of situations
which I’m avoiding.

T: How would you approach each of these situations? What procedures

would you use to deal with them?

C: Well, I would decide which one I’m going to do first, think about
what I am most worried about, look at the odds and ways of coping,
and practice facing each situation enough times, until I feel more
comfortable.

T: So, you know what principles to apply and how to approach the task
of learning to be less afraid.

C: Yes.

T: Then you have successfully learned the principles of this workbook.

Now it is up to you to apply them to whatever situations may cause
you difficulty.

177
Case Vignette 3

C: I thought I’d be “cured” by the end of treatment, but now it’s the last
session, and I’m still not all better. How long will it take until I am?

T: If by “cured” you mean never feeling anxious, remember that anxiety is

an adaptive response and that the goal is not to eliminate it completely.
Rather, treatment has focused on learning skills to control excessive
anxiety and panic. Like any new set of skills, these must be practiced
regularly, and this takes time. But the more that you practice, the more
natural that these skills and these ways of thinking and behaving will
become. How long it takes until these new responses feel natural varies
from person to person, but it depends mostly on the amount of effort
that you put into it.

Case Vignette 4

C: I’m afraid that once I stop coming here, I won’t get any better because
I’ll have no one to review my progress with me or to give me feedback
on how to do things differently.

T: Do you mean you are not sure how to structure appropriate assign-
ments on your own?

C: Well, that’s part of it. I know what to do in general—to break down

harder tasks into little steps until I feel comfortable with them and to
face the sensations fully instead of distracting myself like I used to. So,
while I’d like the security of hearing from you that I’m doing it right,
it’s more that I’m not sure I have the discipline to make myself practice.

T: In that case, it is more a question of coming up with ways to stay mo-

tivated. You might try asking a friend or family member to help at
first, if you feel you must report back to someone. You could also
schedule a time each week when you consider your progress and report
back to yourself. Some people find that giving themselves little rewards
for completing their practices works well, and after a while, the bene-
fits from practicing become motivation enough.

178
Case Vignette 5

C: I’ve finished my hierarchy, but I still feel nervous sometimes when I

face a new situation. Are you sure I’m ready to end treatment?

T: Do you mean that you should stay in treatment until you never feel
anxious ever again?

C: Well no, I know that’s unrealistic. But how do I know for sure that I
can really cope with new situations on my own?

T: I guess you can never know anything for sure until you try it. But how
have you handled these new situations so far?

C: The same way in which I did the ones on my hierarchy, by breaking

them down into manageable steps, preparing to confront them, and
using my skills to face them. I suppose that’s what I’ll keep doing.

Atypical and Problematic Responses

Clients sometimes feel discouraged at this point because they still expe-
rience panic attacks or avoid situations on occasion. Frequently, these
clients minimize the improvements they have made while magnifying
the problems still experienced. It is helpful to review records kept from
the beginning of treatment so that clients may accurately evaluate their
levels of change. Point out instances of discounting positive changes in
favor of dwelling on the negative (e.g., “Sure, I’ve gone to shopping
malls and movies a lot, but I still get anxious driving long distances by
myself, so I’m really no better”; or, “Even though I’m not panicking
every day anymore, I’ve still had some panics recently”). Emphasize that
even though there is still room for improvement, they have made great
strides so far, have worked very hard to get to this point, and should
allow themselves to feel proud of their accomplishments.

When major life crises occur toward the end of treatment, a client may
actually regress a bit and feel back at “square one.” In such cases, ac-
knowledge the setback, but explain that a setback does not mean that all
progress is lost. Reviewing records kept throughout treatment can be en-
couraging: The client made progress before and can certainly do so again.

179
 In addition, relearning skills is generally easier than learning them the
first time.

As in termination of any therapy program, many clients will feel uncer-

tain of their ability to continue to progress or to maintain their progress
once the treatment ends. Acknowledging that this uncertainty can feel
frightening will assure clients that it is an expected and normal reaction.
For clients who are more worried, explicitly pointing out the work that
they have done on their own, such as practicing without the therapist
present, can alleviate some of their fears. Planning together ways of con-
fronting difficult situations that may arise in the future can also increase
a client’s sense of readiness.

Sometimes, scheduling one or two monthly “booster” sessions allows

clients to experience the sense of being on their own while continuing
to have the safety net of a scheduled therapy session. It is important to
use these sessions to review the client’s independent progress, however,
rather than to reassure or to work on new goals; otherwise, the therapist
risks strengthening the belief that continuing in therapy is crucial for
continued success.

180
Chapter 16 Modification for Primary Care Settings

Panic disorder is prevalent and costly in primary care settings, making

the need for effective interventions paramount. Community prevalence
studies (Eaton, Romanoski, Anthony, & Nestadt, ; Kessler et al., )
indicate a current (in the last  months) prevalence rate for panic dis-
order of –% of the population, whereas estimates from primary care
settings range from . to %, with a median of –% (e.g., Leon, Por-
tera, & Weissman, ; Shear & Schulberg, ; Tiemans, Ormel, &
Simon, ).

Elevated prevalence in primary care settings may be due in part to the

high comorbidity between Panic Disorder (PD) and unexplained physi-
cal symptoms and the tendency for patients to interpret panic-related
symptoms as evidence of medical illness (e.g., Katerndahl & Realini,
; Katon & Roy-Byrne, ). Consequently, PD patients use pri-
mary care services at three times the rate of other patients (U.S. Depart-
ment of Health and Human Services, ), exceeding that of depressed
patients (Simon, ) and patients with other psychiatric disorders (Kler-
man, McGonagle, Zhao, Nelson, Hughes, Eschleman, et al., ).

Unfortunately, PD is poorly recognized in primary care (e.g., see Fleet,

Dupuis, Marchand, Burelle, Arsenault, & Beitman, ; Perez-Stable,
Miranda, Munoz, & Ying, ; Spitzer, Williams, & Kroenke, ).
Moreover, even when recognized by primary care physicians, PD and
anxiety disorder appear to be inadequately treated (Katon et al., ;
Meredith, Delaney, Horgan, Fisher, & Fraser, ; Young, Klap, Sher-
bourne, & Wells, ). According to one investigation (Roy-Byrne et
al., ), of  primary care PD patients followed for – months,
% did not receive any form of therapy, only % received liberally de-
fined cognitive-behavioral therapy (CBT ), less than % received medi-
cations, and only % received an efficacious medication regimen.

181
 Thus, we modified panic control treatment (PCT ) for PD which is tai-
lored to a primary care setting.

Length and Schedule of Treatment

We shortened treatment relative to usual PCT, which typically lasts from

 to  or more visits, so that the treatment would be more acceptable
for primary care patients. Thus, we modified PCT to be delivered in six
visits with a behavioral health specialist in the primary care clinic.

Treatment Setting

We conducted the treatment sessions in the clinics because patients are

more likely to accept mental health treatment when offered in the primary
care setting. Also, it decreased the burden on patients, presented a more
collaborative care model to patients, and facilitated communication with
physicians. In some overcrowded clinics, space was at a premium, and be-
havioral health specialists met with patients at nonpeak periods or after-
hours (e.g., early evening) clinic times.

Patient Eligibility

Patient eligibility involved two stages. First, patients responded to a brief

screening, beginning with two gating questions regarding the occurrence
of anxiety attacks or unexplained paroxysms of physical symptoms (e.g.,
tachycardia). Those who responded affirmatively completed a subsequent
three questions about the occurrence of attacks outside dangerous or
performance situations, their frequency (in the last month), and the ex-
tent of worry about the recurrence of panic attacks. This simple screen-
ing is highly sensitive, although lacking in specificity (Stein, Roy-Byrne,
McQuaid, Laffaye, Russo, McCahill, et al., ). Positive responses to
the screening questions were followed by a lay-administered, structured
composite diagnostic interview (World Health Organization, ;
Wittchen, Zhao, Abelson, & Kessler, ) with follow-up questions
asked of the patient by a psychiatrist in the event of diagnostic uncer-

182
 tainty. Patients were excluded if they had conditions that threatened life
or participation in the study, including major medical illnesses, active
suicidality, pregnancy, dementia, mental retardation, psychosis, and cur-
rent substance abuse/dependence. Methods of screening and diagnosing
are described in detail elsewhere (Roy-Byrne, Sherbourne, Miranda,
Stein, Craske, Golinelli, et al., ).

Treatment Structure

This treatment entails the same components as PCT, including psy-

choeducation and cognitive restructuring aimed at educating patients
about the nature of anxiety and panic and correcting misconceptions
about the physical symptoms of panic attacks and about medication and
its side effects. A second component, breathing retraining, aims to edu-
cate patients about respiratory physiology and to teach respiratory regu-
lation. The interoceptive exposure component aims to extinguish fears
of bodily sensations by repeatedly inducing sensations and applying
panic control strategies until fear is diminished. The in vivo exposure
component aims to extinguish fears of agoraphobia situations by re-
peated and systematic confrontation with those situations until fear is
diminished. Each component is tailored to the individual’s specific pres-
entation and needs. For reasons of treatment acceptability and patient
burden, we did not include the usual ongoing record-keeping of panic
and anxiety, and we decreased the usual number of homework assign-
ments (e.g., practice of interoceptive exposure).

In addition, the primary care PCT included more discussion of medica-

tions, since this treatment was evaluated in a study in which PCT was com-
bined with medications (Roy-Byrne, Craske, Stein, et al., ). The in-
clinic visits ended with the development of a relapse prevention plan
that covered medication adherence and implementation of cognitive-
behavioral strategies and the coordination of continued care with the
primary care physician and other community resources. There were six
phone contacts following the in-clinic visits which reinforced the relapse
prevention plan, allowed ongoing symptom monitoring, and facilitated
consultation in the event that panic worsened or was treatment resistant.
Use of the telephone has been shown to be effective for delivering both
primary medical care for various chronic illnesses (Wasson, Gaudette,

183
 Whaley, Sauvigne, Baribeau, & Welch, ) and psychological inter-
ventions in medically ill patients (Mermelstein & Holland, ). In fact,
we found that improvement was correlated with the number of treatment
sessions and the number of telephone contacts (Roy-Byrne, Sherbourne,
et al., ).

The specific structure of the workbook for primary care is as follows.

Session : Education about panic and anxiety and medications.

Session : Correction of myths about panic and medications; cogni-

tive restructuring (labeling of jumping to conclusions and put-
ting things into perspective); and breathing skills (slowed and
diaphragmatic breathing).

Session : Cognitive restructuring (changing your own odds and

changing your perspective) and breathing skills (in distracting
environments).

Session : Breathing and thinking skills to cope with anxiety; intero-

ceptive exposure to feared physical sensations.

Session : Interoceptive exposure to feared physical sensations; exten-

sion of interoceptive exposure to naturalistic activities that produce
feared physical sensations; and in vivo exposure to feared agorapho-
bia situations.

Session : Instructions to continue to face feared sensations and situa-

tions; relapse prevention.

Obviously, the six-session structure did not permit extensive practice

with interoceptive exposure or in vivo exposure to feared situations, and
so, in some ways, the primary care modification represents an introduc-
tion of PCT skills and principles which would then be continued by
clients on their own. In our study, this approach to treatment was highly
effective in comparison to treatment as usual within primary care set-
tings (Roy-Byrne, Craske, et al., ), and the results were due prima-
rily to the CBT rather than the medication (Craske & Mystkowski, ).

184
References

American Psychiatric Association. (). Diagnostic and statistical manual

of mental disorders (rd ed., rev.). Washington, DC: Author.
American Psychiatric Association. (). Diagnostic and statistical manual
of mental disorders (th ed.). Washington, DC: Author.
Antony, M., Craske, M., & Barlow, D. (). Mastering your fears and pho-
bias: Workbook, second edition. New York: Oxford University Press.
Arntz, A., Hildebrand, M., & van den Hout, M. (). Overprediction of
anxiety and disconfirmatory processes in anxiety disorders. Behaviour
Research & Therapy, , –.
Arntz, A., & van den Hout, M. (). Psychological treatments of panic
disorder without agoraphobia: Cognitive therapy versus applied relaxa-
tion. Behaviour Research and Therapy, , –.
Bakker, A., van Balkom, A. J. L. M., & Spinhoven, P. (). SSRIs vs.
TCAs in the treatment of panic disorder: A meta-analysis. Acta Psychi-
atrica Scandinavica, , –.
Ballenger, J. C., Burrows, G. D., DuPont, R. L., Lesser, I. M., Noyes, R.,
Pecknold, J. C., et al. (). Alprazolam in panic disorder and agora-
phobia: Results from a multi center trial: I. Efficacy in short-term treat-
ment. Archives of General Psychiatry, , –.
Bandura, A. (). Self-efficacy: Toward a unifying theory of behavioral
change. Psychological Review, , –.
Barlow, D. H. (). Anxiety and its disorders: The nature and treatment of
anxiety and panic. New York: Guilford.
Barlow, D. H. (). Psychological treatments. American Psychologist, ,
–.
Barlow, D. H., Brown, T. A., & Craske, M. G. (in press). Definitions of
panic attacks and panic disorder in DSM–IV: Implications for research.
Journal of Abnormal Psychology.
Barlow, D. H., Craske, M. G., Cerny, J. A., & Klosko, J. S. (). Behav-
ioral treatment of panic disorder. Behavior Therapy, , –.

185
 Barlow, D. H., O’Brien, G. T., & Last, C. G. (). Couples’ treatment of
agoraphobia. Behavior Therapy, , –.
Beck, A. T. (). Cognitive approaches to panic disorder: Theory and
therapy. In S. Rachman & J. D. Maser (Eds.), Panic: Psychological per-
spectives (pp. –). Hillsdale, NJ: Erlbaum.
Beck, N. G., Stanley, M. A., Baldwin, L. E., Deagle, E. A., & Averill, P. M.
(). Comparison of cognitive therapy relaxation and training for
panic disorder. Journal of Consulting Clinical Psychology, , –.
Bouton, M. E. (). Context, time, and memory retrieval in the interference
paradigms of Pavlovian learning. Psychological Bulletin, , –.
Bouton, M. E., Mineka, S., & Barlow, D. H. (). A modern learning
theory perspective on the etiology of panic disorder. Psychological Re-
view, , –.
Bowlby, J. (). Attachment and loss: Vol. . Separation: Anxiety and anger.
New York: Basic Books. (Reissued )
Brown, T. A., Antony, M. M., & Barlow, D. H. (). Diagnostic comor-
bidity in panic disorder: Effect on treatment outcome and course of co-
morbid diagnoses following treatment. Journal of Consulting & Clini-
cal Psychology, , –.
Brown, T. A., & Barlow, D. H. (). Long-term outcome in cognitive-
behavioral treatment of panic disorder: Clinical predictors and alterna-
tive strategies for assessment. Journal of Consulting & Clinical Psychol-
ogy, , –.
Brown, T. A., DiNardo, P. A., & Barlow, D. H. (). Anxiety disorders inter-
view schedule for DSM–IV: Clinician’s manual. Albany, NY: Graywind.
Carlbring, P., Ekselius, L., & Andersson, G. (). Treatment of panic dis-
order via the Internet: A randomized trial of CBT vs. applied relaxa-
tion. Journal of Behavior Therapy & Experimental Psychiatry, , –.
Carter, M. M., Turovsky, J., & Barlow, D. H. (). Interpersonal rela-
tionships in panic disorder with agoraphobia: A review of empirical
evidence. Clinical Psychology: Science & Practice, , –.
Cerny, J. A., Barlow, D. H., Craske, M. G., & Himadi, W. G. ().
Couples’ treatment of agoraphobia: A two-year follow-up. Behavior
Therapy, , –.
Chambless, D. L., Caputo, G. C., Bright, P., & Gallagher, R. (). As-
sessment of fear in agoraphobics: The Body Sensations Questionnaire
and the Agoraphobic Cognitions Questionnaire. Journal of Consulting
& Clinical Psychology, , –.
Chambless, D. L., Sanderson, W. C., Shoham, V., Bennett Johnson, S.,
Pope, K. S., Crits-Christoph, P., et al. (). An update on empirically
validated therapies. Clinical Psychologist, , –.

186
Clark, D., Salkovskis, P. M., & Chalkley, A. J. (). Respiratory control as
a treatment for panic attacks. Journal of Behavior Therapy & Experi-
mental Psychiatry, , –.
Clark, D. M., Salkovskis, P. M., Hackmann, A., Middleton, H., Anastasi-
ades, P., & Gelder, M. (). Comparison of cognitive therapy, ap-
plied relaxation and imipramine in the treatment of panic disorder.
British Journal of Psychiatry, , –.
Clark, D. M., Salkovskis, P. M., Hackmann, A., Wells, A., Ludgate, J., &
Gelder, M. (). Brief cognitive therapy for panic disorder: A ran-
domized controlled trial. Journal of Consulting & Clinical Psychology,
, –.
Craske, M. G. (). Anxiety disorders: Psychological approaches to theory
and treatment. Boulder, CO: Westview.
Craske, M. G. (). The origins of phobias and anxiety disorders: Why more
women than men? Oxford, England: Elsevier.
Craske, M. G., Brown, T. A., & Barlow, D. H. (). Behavioral treatment
of panic disorder: A two-year follow-up. Behavior Therapy, , –.
Craske, M.G., Lang, A. J., Aikins, D., & Mystkowski, J. L. (). Cogni-
tive behavioral therapy for nocturnal panic. Behavior Therapy, , –.
Craske, M. G., Maidenberg, E., & Bystritsky, A. (). Brief cognitive-
behavioral versus nondirective therapy for panic disorder. Journal of
Behavior Therapy & Experimental Psychiatry, , –.
Craske, M. G., Rowe, M., Lewin, M., & Noriego-Dimitri, R. ().
Interoceptive exposure versus breathing retraining within cognitive-
behavioural therapy for panic disorder with agoraphobia. British Jour-
nal of Clinical Psychology, , –.
de Beurs, E., Lange, A., van Dyck, R., & Koele, P. (). Respiratory train-
ing prior to exposure in vivo in the treatment of panic disorder with
agoraphobia: Efficacy and predictors of outcome. Australian & New
Zealand Journal of Psychiatry, , –.
Deacon, B. J., & Abramowitz, J. S. (in press). A pilot study of two-day
cognitive-behavioral therapy for panic disorder. Behaviour Research &
Therapy.
Eaton, W. W., Romanoski, A., Anthony, J. C., & Nestadt, G. (). Screen-
ing for psychosis in the general population with a self-report interview.
Journal of Nervous & Mental Disease, , –.
Eifert, G. H., & Forsyth, J. P. (). Acceptance and commitment therapy
for anxiety disorders: A practitioner’s treatment guide to using mindfulness,
acceptance, and values-based behavior change strategies. Oakland, CA:
New Harbinger.

187
 Evans, L., Holt, C., & Oei, T. P. (). Long-term follow-up of agorapho-
bics treated by brief intensive group cognitive behavioural therapy. Aus-
tralian & New Zealand Journal of Psychiatry, , –.
Fava, G. A., Zielezny, M., Savron, G., & Grandi, S. (). Long-term
effects of behavioral treatment for panic disorder with agoraphobia.
British Journal of Psychiatry, , –.
Fleet, R. P., Dupuis, G., Marchand, A., Burelle, D., Arsenault, A., & Beit-
man, B. D. (). Panic disorder in emergency department chest pain
patients: Prevalence, comorbidity, suicidal ideation, and physician recog-
nition. American Journal of Medicine, , –.
Foa, E. B., & Kozak, M. J. (). Emotional processing of fear: Exposure
to corrective information. Psychological Bulletin, , –.
Ghosh, A., & Marks, I. (). Self-treatment of agoraphobia by exposure.
Behavior Therapy, , –.
Gould, R. A., & Clum, G. A. (). Self-help plus minimal therapist con-
tact in the treatment of panic disorder: A replication and extension. Be-
havior Therapy, , –.
Gould, R. A., Clum, G. A., & Shapiro, D. (). The use of bibliotherapy
in the treatment of panic: A preliminary investigation. Behavior Ther-
apy, , –.
Gould, R. A., Otto, M. W., & Pollack, M. H. (). A meta-analysis of
treatment outcome for panic disorder. Clinical Psychology Review, ,
–.
Huppert, J. D., Bufka, L. F., Barlow, D. H., Gorman, J. M., Shear, M. K.,
& Woods, S.W. (). Therapists, therapist variables, and cognitive-
behavioral therapy outcome in a multicenter trial for panic disorder.
Journal of Consulting and Clinical Psychology, 69, –.
Institute of Medicine, Committee on Quality of Health Care in America.
(). Crossing the quality chasm: A new health system for the st cen-
tury. Washington, DC: National Academy of Sciences.
Katerndahl, D. A., & Realini, J. P. (). Where do panic attack sufferers
seek care? Journal of Family Practice, , –.
Katon, W., & Roy-Byrne, P. P. (). Panic disorder in the medically ill.
Journal of Clinical Psychiatry, , –.
Katon, W., Von Korff, M., Lin, E., Lipscomb, P., Russo, J., Wagner, E., et
al. (). Distressed high utilizers of medical care: DSM-III-R diag-
noses and treatment needs. General Hospital Psychiatry, , –.
Keijsers, G., Schaap, C., Hoogduin, C., & Lammers, M. W. (). Patient-
therapist interaction as a predictor of outcome in the behavioural treat-
ment of panic disorder. Behavior Modification, , –.

188
Kessler, R. C., Berglund, P., Demler, O., Jin, R., & Walters, E. E. ().
Lifetime prevalence and age-of-onset distributions of DSM-IV disorders
in the National Comorbidity Survey Replication. Archives of General
Psychiatry, , –.
Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E.
(). Prevalence, severity, and comorbidity of -month DSM-IV
disorders in the National Comorbidity Survey Replication. Archives of
General Psychiatry, , –.
Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M.,
Eshleman, S., et al. (). Lifetime and -month prevalence of DSM-
III-R psychiatric disorders in the United States. Archives of General Psy-
chiatry, , –.
Klerman, G. L., Weissman, M. M., Ouellette, R., Johnson, J., Greenwald, S.
(). Panic attacks in the community: Social morbidity and health care
utilization. Journal of the American Medical Association, , –.
Klosko, J. S., Barlow, D. H., Tassinari, R. B., & Cerny, J. A. (). A com-
parison of alprazolam and behavior therapy in treatment of panic dis-
order. Journal of Consulting & Clinical Psychology, , –.
Leon, A. C., Portera, L., & Weissman, M. M. (). The social costs of
anxiety disorders. British Journal of Psychiatry, , –.
Lidren, D. M., Watkins, P. L., Gould, R. A., Clum, G. A., Asterino, M., &
Tulloch, H. L. (). A comparison of bibliotherapy and group ther-
apy in the treatment of panic disorder. Journal of Consulting & Clini-
cal Psychology, , –.
Margraf, J., Barlow, D. H., Clark, D. M., & Telch, M. J. (). Psychologi-
cal treatment of panic: Work in progress on outcome, active ingredi-
ents, and follow-up. Behaviour Research & Therapy, , –.
Marks, I. M., Swinson, R. P., Basoglu, M., Kuch, K., Noshirvani, H.,
O’Sullivan, G., et al. (). Alprazolam and exposure alone and com-
bined in panic disorder with agoraphobia: A controlled study in Lon-
don and Toronto. British Journal of Psychiatry, , –.
McLean, P. D., Woody, S., Taylor, S., & Koch, W. J. (). Comorbid panic
disorder and major depression: Implications for cognitive-behavioral
therapy. Journal of Consulting & Clinical Psychology, , –.
Meredith, K., Delaney, J., Horgan, M., Fisher, E. Jr., & Fraser, V. (). A
survey of women with HIV about their expectations for care. AIDS
Care, , –.
Mermelstein, H. T., & Holland, J. C. (). Psychotherapy by telephone:
A therapeutic tool for cancer patients. Psychosomatics: Journal of Con-
sultation Liaison Psychiatry, , –.

189
 Mitte, K. (). A meta-analysis of the efficacy of psycho- and pharma-
cotherapy in panic disorder with and without agoraphobia. Journal of
Affective Disorders, , –.
Morissette, S. B., Spiegel, D. A., & Heinrichs, N. (). Sensation-focused
intensive treatment for panic disorder with moderate to severe agora-
phobia. Cognitive & Behavioral Practice, , –.
Neron, S., Lacroix, D., & Chaput, Y. (). Group vs. individual cognitive
behaviour therapy in panic disorder: An open clinical trial with a six-
month follow-up. Canadian Journal of Behavioural Sciences, , –.
Newman, M. G., Kenardy, J., Herman, S., & Taylor, C. B. (). Com-
parison of palmtop-computer-assisted brief cognitive-behavioral treat-
ment to cognitive-behavioral treatment for panic disorder. Journal of
Consulting & Clinical Psychology, , –.
Ost, L. G. (). Applied relaxation, description of a coping technique and
review of controlled studies. Behaviour Research & Therapy, , –.
Otto, M. W., Jones, J. C., Craske, M. G., & Barlow, D. H. (). Stopping
anxiety medication: Panic control therapy for benzodiazepine discontinu-
ation, therapist guide. San Antonio, TX: Psychological Corporation.
Otto, M. W., Pollack, M. H., & Barlow, D. H. (). Stopping anxiety med-
ication: Panic control therapy for benzodiazepine discontinuation, patient
workbook. Boulder, CO: Graywind Publications.
Otto, M. W., Pollack, M. H., & Sabatino, S. A. (). Maintenance of re-
mission following cognitive-behavior therapy for panic disorder: Pos-
sible deleterious effects of concurrent medication treatment. Behavior
Therapy, , –.
Otto, M. W., Pollack, M. H., Sachs, G. S., Reiter, S. R., & Rosenbaum, J.
F. (). Discontinuation of benzodiazepine treatment: Efficacy of
cognitive-behavior therapy for clients with panic disorder. American
Journal of Psychiatry, , –.
Perez-Stable, E. J., Miranda, J., Munoz, R., & Ying, Y. (). Depression
in medical outpatients: Underrecognition and misdiagnosis. Archives of
Internal Medicine, , –.
Persons, J. B. (). Disputing irrational thoughts can be avoidance behav-
ior: A case report. Behavior Therapist, , –.
Rachman, S. J. (). Unwanted intrusive cognitions. Advances in Behavior
Research and Therapy, , –.
Rego, S. A. (). An examination of the impact of massed-intensive ver-
sus traditionally administered cognitive restructuring for panic disorder.
Dissertation Abstracts International: Section B. The Physical Sciences and
Engineering, , .

190
Reiss, S., Peterson, R. A., Gursky, D. M., & McNally, R. J. (). Anxiety
sensitivity, anxiety frequency and the prediction of fearfulness. Behav-
iour Research & Therapy, , –.
Richards, J. C., Klein, B., & Carlbring, P. (). Internet-based treatment
for panic disorder. Cognitive Behaviour Therapy, , –.
Rijken, H., Kraaimaat, F., De Ruiter, C., & Garssen, B. (). A follow-up
study on short-term treatment of agoraphobia. Behaviour Research &
Therapy, , –.
Roy-Byrne, P. P., & Cowley, D. S. (). Pharmacological treatments for
panic disorder, generalized anxiety disorder, specific phobia, and social
anxiety disorder. In P. E. Nathan & J. M. Gorman (Eds.), A guide to
treatments that work (nd ed., pp. –). New York: Oxford Univer-
sity Press.
Roy-Byrne, P. P., Craske, M. G., Stein, M. B., Sullivan, G., Bystritsky, A.,
Katon, W. J., et al. (). A randomized effectiveness trial of cognitive
behavior therapy and medication for primary care panic disorder.
Archives of General Psychiatry, , –.
Roy-Byrne, P., Sherbourne, C., Miranda, J., Stein, M., Craske, M., Golinelli, D.,
et al. (). Poverty and response to treatment among panic disorder pa-
tients in primary care. American Journal of Psychiatry, , –.
Roy-Byrne, P. P., Stein, M. B., Russo, J., Mercier, E., Thomas, R., Mc-
Quaid, J., et al. (). Panic disorder in the primary care setting. Jour-
nal of Clinical Psychiatry, , –.
Schmidt, N. B., Staab, J. P., Trakowski, J. H., & Sammons, M. (). Effi-
cacy of a brief psychosocial treatment for panic disorder in an active
duty sample: Implications for military readiness. Military Medicine,
, –.
Shear, M. K., & Schulberg, H. C. (). Anxiety disorders in primary care.
Bulletin of the Menninger Clinic, , A–A.
Simon, G. E. (). Psychiatric disorder and functional somatic symptoms
as predictors of health care use. Psychiatric Medicine, , –.
Spiegel, D. A., Brace, T. J., Gregg, S. F., & Nuzzarello, A. (). Does cog-
nitive behavior therapy assist slow-taper alprazolam discontinuation in
panic disorder? American Journal of Psychiatry, , –.
Spitzer, R. L., Williams, J. B., Kroenke, K., et al. (). Utility of a new pro-
cedure for diagnosing mental disorders in primary care: The PRIME-MD
 study. Journal of the American Medical Association, , –.
Stein, M. B., Norton, G. R., Walker, J. R., Chartier, M. J., & Graham, R.
(). Do selective serotonin re-uptake inhibitors enhance the effi-
cacy of very brief cognitive behavioral therapy for panic disorder? A
pilot study. Psychiatry Research, , –.

191
 Stein, M. B., Roy-Byrne, P. P., McQuaid, J. R., Laffaye, C., Russo, J.,
McCahill, M. E., et al. (). Development of a brief diagnostic
screen for panic disorder in primary care. Psychosomatic Medicine,
(), –.
Street, L., Craske, M. G., & Barlow, D. H. (). Sensations, cognitions,
and the perception of cues associated with expected and unexpected
panic attacks. Behaviour Research & Therapy, , –.
Tiemens, B. G., Ormel, J., & Simon, G. E. (). Occurrence, recogni-
tion, and outcome of psychological disorders in primary care. Ameri-
can Journal of Psychiatry, , –.
Tsao, J. C., Lewin, M. R., & Craske, M. G. (). The effects of cognitive-
behavioral therapy for panic disorder on comorbid conditions. Journal
of Anxiety Disorders, , –.
Tsao, J. C., Mystkowski, J., Zucker, B., & Craske, M. (). Effects of
cognitive-behavior therapy for panic disorder on comorbid conditions:
Replication and extension. Behavior Therapy, , –.
Tsao, J. C. L., Mystkowski, J. L., Zucker, B. G., & Craske, M. G. ().
Impact of cognitive behavioral therapy for panic disorder on comor-
bidity: A controlled investigation. Behaviour Research and Therapy,  (),
–.
van Balkom, A. J., de Beurs, E., Koele, P., Lange, A., & van Dyck, R. ().
Long-term benzodiazepine use is associated with smaller treatment
gain in panic disorder with agoraphobia. Journal of Nervous & Mental
Disease, , –.
van den Hout, M., Arntz, A., & Hoekstra, R. (). Exposure reduced ago-
raphobia but not panic, and cognitive therapy reduced panic but not
agoraphobia. Behaviour Research & Therapy, , –.
Wardle, J., Hayward, P., Higgitt, A., Stabl, M., Blizard, R., & Gray, J.
(). Effects of concurrent diazepam treatment on the outcome of
exposure therapy in agoraphobia. Behaviour Research & Therapy, ,
–.
Wasson, J., Gaudette, C., Whaley, F., Sauvigne, A., Baribeau, P., & Welch,
H. G. (). Telephone care as a substitute for routine clinical follow-
up. Journal of the American Medical Association, , –.
Westin, D., & Morrison, K. (). A multidimensional meta-analysis of
treatments for depression, panic, and generalized anxiety disorder: An
empirical examination of the status of empirically supported therapies.
Journal of Consulting & Clinical Psychology, , –.
Williams, K. E., & Chambless, D. L. (). The relationship between ther-
apist characteristics and outcome of in vivo exposure treatment for ago-
raphobia. Behavior Therapy, , –.

192
Williams, S. L. (). Perceived self-efficacy and phobic disability. In
R. Schwarzer (Ed.), Self-efficacy: Thought control of action (pp. –
). Washington, DC: Hemisphere.
Williams, S. L., & Falbo, J. (). Cognitive and performance-based treat-
ments for panic attacks in people with varying degrees of agoraphobic
disability. Behaviour Research & Therapy, , –.
Wittchen, H. U., Reed, V., & Kessler, R. C. (). The relationship of ago-
raphobia and panic in a community sample of adolescents and young
adults. Archives of General Psychiatry, , –.
Wittchen, H. U., Zhao, S., Abelson, J. M., Abelson, J. L., & Kessler, R. C.
(). Reliability and procedural validity of UM-CIDIDSM-III-R
phobic disorders. Psychology in Medicine, , –.
Wolpe, J. (). Psychotherapy by reciprocal inhibition. Stanford, CA: Stan-
ford University Press.
Wolpe, J. (). The practice of behavior therapy (th ed.) (Pergamon Gen-
eral Psychology Series, ). Elmsford, NY: Pergamon.
World Health Organization (). Composite International Diagnostic
Interview. Geneva: WHO, Division of Mental Health.
Young, A. S., Klap, R., Sherbourne, C. D., & Wells, K. B. (). The qual-
ity of care for depressive and anxiety disorders in the United States.
Archives of General Psychiatry, , –.

Additional Readings

Background reading that provides more extensive coverage of the theoreti-

cal basis of the program described in this guide, as well as empirical data
supporting the efficacy of the treatment, can be obtained from the following.

Barlow, D. H. (). Anxiety and its disorders: The nature and treatment of
anxiety and panic (nd ed.). New York: Guilford.
Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (). Cog-
nitive behavioral therapy, imipramine, or their combination for panic
disorder: A randomized controlled trial. JAMA: Journal of the American
Medical Association, , –.
Craske, M. G. (). Anxiety disorders: Psychological approaches to theory and
treatment. Boulder, CO: Basic/Westview.
Craske, M. G., & Barlow, D. H. (in press). Panic disorder and agorapho-
bia. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders
(th ed.). New York: Guilford.

193
 Craske, M. G., Lang, A. J., Aikins, D., & Mystkowski, J. (). Cognitive
behavioral therapy for nocturnal panic. Behavior Therapy, , –.
Craske, M. G., & Mystkowski, J. (). Exposure therapy and extinction:
Clinical studies. In M. G. Craske, D. Hermans, & D. Vanstweegen
(Eds.), Fear and learning: Basic science to clinical application. Washing-
ton, DC: American Psychological Association Books.
Craske, M. G., Roy-Byrne, P., Stein, M. G., Donald-Sherbourne, C.,
Bystritsky, A., Katon, W., et al. (). Treating panic disorder in pri-
mary care: A collaborative care intervention. General Hospital Psychia-
try, , –.
Craske, M. G., & Tsao, J. C. I. (). Assessment and treatment of noc-
turnal panic attacks. Sleep Medicine Review, ,–.
Roy-Byrne, P. P., Craske, M. G., Stein, M. B., Sherbourne, C., Bystritsky,
A., Golinelli, D., et al. (). Cognitive behavior therapy and med-
ication for primary care panic disorder: Sustained superiority for usual
care. Archives of General Psychiatry, , –.

194
About the Authors

David H. Barlow received his PhD from the University of Vermont in

 and has published over  articles and chapters and almost 
books and clinical workbooks, mostly in the areas of emotional disor-
ders and clinical research methodology. The books and workbooks have
been translated into over  languages, including Arabic, Mandarin, and
Russian.

He was formerly Professor of Psychiatry at the University of Mississippi

Medical Center and Professor of Psychiatry and Psychology at Brown
University and founded clinical psychology internships in both settings.
He was also Distinguished Professor in the Department of Psychology
at the University at Albany, State University of New York. Currently, he
is Professor of Psychology, Research Professor of Psychiatry, and Director
of the Center for Anxiety and Related Disorders at Boston University.

Barlow is the recipient of the  American Psychological Association

(APA) Distinguished Scientific Award for the Applications of Psychol-
ogy. He is also the recipient of the First Annual Science Dissemination
Award from the Society for a Science of Clinical Psychology of the APA
and recipient of the  Distinguished Scientific Contribution Award
from the Society of Clinical Psychology of the APA. He also received an
award in appreciation of outstanding achievements from the General
Hospital of the Chinese People’s Liberation Army, Beijing, China, with an
appointment as Honorary Visiting Professor of Clinical Psychology. Dur-
ing the – academic year, he was Fritz Redlich Fellow at the Cen-
ter for Advanced Study in Behavioral Sciences in Palo Alto, California.

Other awards include Career Contribution Awards from the Massachu-

setts, California, and Connecticut Psychological Associations; the 

195
 C. Charles Burlingame Award from the Institute of Living in Hartford,
Connecticut; the First Graduate Alumni Scholar Award from the Grad-
uate College of the University of Vermont; the Masters and Johnson
Award from the Society for Sex Therapy and Research; the G. Stanley
Hall Lectureship, American Psychological Association; a certificate of
appreciation for contributions to women in clinical psychology from
Section IV of Division  of the APA, the Clinical Psychology of Women;
and a MERIT award from the National Institute of Mental Health
(NIMH) for long-term contributions to clinical research efforts. He is
Past President of the Society of Clinical Psychology of the APA and the
Association for the Advancement of Behavior Therapy, Past Editor of
the journals Behavior Therapy, Journal of Applied Behavior Analysis, and
Clinical Psychology: Science & Practice, and currently Editor-in-Chief of
the TreatmentsThatWork™ series for Oxford University Press.

He was Chair of the APA Task Force of Psychological Intervention

Guidelines, was a member of the DSM-IV Task Force of the APA, and
was a co-chair of the work group for revising the anxiety disorder cate-
gories. He is also a Diplomate in Clinical Psychology of the American
Board of Professional Psychology and maintains a private practice.

Michelle G. Craske received her PhD from the University of British Co-
lumbia in  and has published more than  articles and chapters in
the area of anxiety disorders. She has written books on the topics of the
etiology and treatment of anxiety disorders, gender differences in anxi-
ety, and translation from the basic science of fear learning to the clinical
application of understanding and treating phobias, in addition to several
self-help books. In addition, she has been the recipient of continuous
NIMH funding since  for research projects pertaining to risk factors
for anxiety disorders and depression among children and adolescents,
the cognitive and physiological aspects of anxiety and panic attacks, and
the development and dissemination of treatments for anxiety and re-
lated disorders. She is Associate Editor for the Journal of Abnormal Psy-
chology and Behaviour Research & Therapy, and she is a Scientific Board
Member for the Anxiety Disorders Association of America. She was a
member of the DSM-IV Anxiety Disorders Work Group Subcommittee
for revision of the diagnostic criteria surrounding panic disorder and
specific phobia. Craske has given invited keynote addresses at many
international conferences and frequently is invited to present training

196
workshops on the most recent advances in the cognitive behavioral treat-
ment for anxiety disorders. She is currently a Professor in the Depart-
ment of Psychology and Department of Psychiatry and Biobehavioral
Sciences at the University of California, Los Angeles, and Director of
the UCLA Anxiety Disorders Behavioral Research Program.

197