A Cognitive Behavioral Approach To Treating Panic Disorder

Anxiety disorders can be characterized with excessive nervousness, persistent worry, continuous stress or tension, frequently without any reason or cause, as well as with feelings of fear or discomfort, accompanied with panic or depressive thoughts. Specialists define several types of anxiety disorders, including panic disorders, obsessive-compulsive disorder, generalized anxiety disorder, social anxiety disorders and phobias and post-traumatic stress disorder (The National Institute of Mental Health).

General symptoms and signs of anxiety disorders include, first of all, extreme, persistent and long-lasting worry or excitement, muscular tension, emotional disturbances and discomfort, excessive irritability and being constantly suspicious of possible dangers. The symptoms of phobias are extreme emotional tension and desire to avoid the situations which seem to be scary to the patients. The symptoms of panic attacks are intense fears, inadequate behaviour and hysterical or sometimes irrational responses, etc.

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As a result, the patient can demonstrate such physical reactions as high blood pressure, pounding heart, nausea, dizziness, changes of body temperature or skin colour, and so on. Mental complications can include insomnia, nightmares, inability to concentrate, constant depression and pessimistic thoughts, sadness, continuous fatigue, de-realization and de-personalization, etc. Panic attacks can be accompanied with such reactions as sweating, shaking and trembling, pains in chest, problems with breathing, and others. Panic disorder clients will either also suffer with agoraphobia because of the fear or have no symptoms of agoraphobia.

Medical treatment (using sedatives or antidepressants, etc.) can be helpful for improving biological factors causing anxiety disorders. However, different methods and techniques of psychotherapy (such as attending support-groups meetings, meditation, stress management, etc.) are more effective types of treatment for anxiety. Treatment of different phobias includes behavioural and cognitive therapies. Specialists suggest physical exercise, healthy eating, home-care and active life-style is other effective ways to treat patients with anxiety disorders.

Anxiety disorders affect many clients across this world. This research will focus on panic

disorder without agoraphobia and treatment using a cognitive behavioral approach. Bottom of Form 0

Panic disorder, as defined by the American Psychiatric Association in the Third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980), is “the sudden onset of intense apprehension, fear, or terror, often associated with feelings of impending doom” (p.230). Panic disorder is generally characterized by cognitive or somatic symptoms and is often quite disabling for those affected by it. The etiology of panic disorder is unknown and considerations about its causes have been the subject of considerable research and debate. In seeking to understand anxiety disorders, psychologists have emphasized three familiar perspectives-psychoanalytic, learning, and biological.

Psychoanalytic theory assumes that, beginning in childhood, intolerable impulses, ideas, and feelings get repressed. This submerged mental energy nevertheless influences our actions and emotions, sometimes producing feelings of anxiety, depression, or other maladaptive symptoms that mystify even the sufferer. One of Freud’s classic cases concerned a 5-year-old boy known as “Littler Hans”, whose phobia of horses prevented (in those days before cars) his going outdoors. Freud’s controversial speculation was that Little Hans’ fear of horses expressed his underlying fear of his father, whom Hans viewed as a rival for his mother’s affections.

Alternatively, the forbidden impulses may break through as thinly disguised thoughts, which may provoke acts aimed at suppressing the associated anxiety. The result: obsessions and compulsions. Repetitive hand washing, for instance, may help suppress anxiety over one’s “dirty” urge.

Learning researchers link general anxiety with learned helplessness. In the laboratory, researchers can create chronically anxious, ulcer-prone rats by giving them unpredictable electric shocks (Schwartz, 2000). Like the rape victim who reported feeling anxious when entering her old neighbourhood, the animals are apprehensive in their lab environment. For many victims of post-traumatic stress disorder, anxiety swells with any reminder of their trauma.

When the shocks become predictable-when preceded by a particular conditioned stimulus- the animals’ fear focuses on that stimulus and they relax in its absence. So it can happen with human fears. The conditioned fears are similar to what Pavlov’s research into conditioned response. Once the client experiences anxiety they develop a fear that in the same given circumstances that the fear will arise again. Conditioned fears may remain long after we have forgotten the experiences that produced them (Jacobs & Nadel, 2004). Moreover, some fears arise from stimulus generalization. A person who fears heights after a fall may be afraid of airplanes without ever having flown. Someone might also learn such a fear through observational learning-by observing others’ fears.

Biologically oriented researchers explain our anxiety-proneness in evolutionary, genetic, and physiological terms. Individuals seem biologically prepared to develop fears of heights, storms, snakes, and insects-dangers that our ancestors faced. Compulsive acts typically exaggerate behaviours that contributed to our species’ survival. Grooming gone wild becomes hair pulling. Washing up becomes ritual hand washing. Checking territorial boundaries becomes checking and rechecking a door known to be locked (Rapoport, 1999).

Some people more than others seem genetically predisposed to particular fears and high anxiety. Identical twins often develop similar phobias, in some cases even when raised separately (Carey, 2000). One pair of 35-year-old identical twins independently developed claustrophobia. They also become so fearful of water that each would gingerly wade backward into the ocean, only up to the knees.

The biology of general anxiety disorder, panic, even obsessions and compulsions is measurable as over-arousal (Baxter, 2000). PET scans of persons with obsessive-compulsive disorder reveal unusually high activity in an area of the frontal lobes just above the eyes and in a more primitive area deep in the brain. Some antidepressant drugs control obsessive-compulsive behaviour by muting this activity, though affecting the availability of the neurotransmitter serotonin, one of those messenger molecules that shuttles signals between nerve cells (Rapoport, 1999). Theorists have also studied genetic predisposition to anxiety disorders. Genetics play a role in the possibility of developing an anxiety disorder when experiencing stress.

Among the cognitive theorists, Clark (1993) suggests that individuals with panic disorder cognitively misinterpret certain bodily sensations. Somatic and psychological sensations are often perceived as more dangerous than they really are. Further, the tendency to misjudge physiological symptoms is said to stem from an enduring cognitive state. Patients who suffer from panic attacks are unable to distinguish between the triggering body sensation and the subsequent panic attack, thus leading the patient to believe that the attacks are spontaneous and without a specific cause. Cognitive misinterpretations are hypothesized to occur rapidly on both a conscious and sub-conscious level and according to Clark (1993), catastrophic misinterpretations need not be conscious to trigger a panic attack: “In patients who experience recurrent attacks, catastrophic misinterpretations may be so fast and automatic that patients may not always be aware of the interpretive process” (p.76). Thus, Clark’s cognitive model proposes that emotion results from the conscious labeling of unexplained physiological arousal. Clark’s model further gives credibility to nocturnal panic attacks. Patients with nocturnal panic disorder often wake up with a sense of intense anxiety. The anxiety is usually accompanied by confusion and intense autonomic activity that is unidentifiable to the person experiencing the attack. Since somatic and psychological sensations can be misinterpreted unconsciously, Clark maintains that people with nocturnal panic disorder will often unconsciously misinterpret their physiological sensations during sleep and subsequently experience a panic attack.

Cognitive theorists also examine locus of control in patients with panic disorder. Locus of control is generally felt to represent the extent to which an individual perceives personal control over events in one’s environment (Otto, Pollack, Penava & Zucker, 1999). A person who exhibits an internal, stable, global locus of control is theorized to have a more adaptive coping style; whereas an individual with an external, un-stable, unspecific locus of control is theorized to experience a sense of helplessness. Empirical studies have shown, using the Nowicki-Strickland Locus of Control scale [NSLOC]; 1973, that external control scores on the NSLOC have been found to correlate with manifest anxiety scores within a clinical sample (Ottto et al., 1999). This study was further supported by Nunn (1998). In an experiment involving 267 participants, Nunn also found that external control scores positively correlated with anxiety scores. Biglan, Minor, Dess, & Overmier, 1998, after extensive animal research, also contend that lack of control is one of the pathways to fear and anxiety.

Similar to locus of control, attributional styles, as proposed by cognitive theorists, also play a role in the development of panic disorder. Abramson, Seligman, and Teasdale (1978) introduced the construct of attributional style, postulating that an individual’s attributions about the causes of positive and negative events play a critical role in the development of helplessness and anxiety. Further, early experiences with depression or negative events may contribute to the development of a cognitive style that lends itself to being susceptible to panic disorder.

Barlow (1998) also proposes a cognitive model of negative emotions as the etiology of panic disorder. He suggests that anxiety may play a central role in negative emotions. Further, his model assumes that the role of uncontrollability and unpredictability play a major part in the development of panic disorder, He furthers this by acknowledging the innate vulnerabilities that develop in early childhood.

Considered together, the aforementioned reviewed evidence suggests a number of important points. First, cognitive misinterpretations appear to play an important role in the onset and maintenance of panic attacks and, Clark’s research on cognitive misinterpretations has prompted the development of effective treatments such as cognitive behavioral therapy or Panic Control Treatment (PCT) (Clark, 1998). Second, the idea that experience with lack of control may play a substantial role in the development of anxiety appears to be substantiated by diverse areas of research. And finally, developmental vulnerabilities to panic disorder have been supported by a wide range of literature. These implications however do not shield the cognitive perspective from debate.

One of the debates stems from the fact that certain cognitive factors that are involved in panic disorders may be susceptible to modification by non-cognitive therapies (Millon, Blaney, & Davis, 1999). Another point of contention has to do with the theory’s focus on the way people misinterpret the environment versus the underlying trait that is itself responsible for the misinterpretation.

This type of therapy is much easier and faster than traditional Freudian methods. This type of therapy may be conducted in a variety of settings such as groups, families and individuals (“Cognitive Behavioral,” 2004). Problems like PD, depression, guilt, anger, and low self esteem, in addition to adjustment difficulties are treated with this type of therapy (2004). Issues that go to sleep disturbances and post-traumatic stress are things that may be addressed as well (2004). The goal of the treatment is to have the wherewithal to restructure perceptions, thoughts and beliefs (2004). An example might be that an individual has obsessive thoughts about a particular fear. The therapist might address the preconceived notions about the fear that may be false. For instance, someone is afraid that she will be mugged. The therapist may point out that only a small percentage of people are victims of crime. As a remedy, the individual may use affirmations or other techniques to break the thought pattern and instead think about other things. Several techniques used with this model include cognitive rehearsal, thought stopping, the channelling of irrational beliefs, self-monitoring, relaxation, and social skills training (2004).

Though the use of the CBT method can help panic disorder, clients are evaluated to make sure a history and background is discerned and then they are asked to complete a questionnaire (“Cognitive Behavioral,” 2004). Clients are asked to complete interviews or questionnaires and treatment generally occurs on a weekly basis; sessions usually examine current issues (2004). A Treatment Plan is suggested and goals are set in order to measure the progress of the therapy (History 2004). The amount of sessions one may require does vary with the type of difficulties that are being treated (2004). Yet, this therapy can be used on a short term basis. Clients are supposed to be active participants in respect to their own therapy (History 2004). They often choose when the treatment will end. Again, CBT is divided by different types of therapy so PD sufferers can be helped.

It seems that the first approach was developed by Albert Ellis and called Rational Emotive Therapy (RET) (“History,” 2004). Rational Emotive Therapy (RET), also called Rational Emotional Behavior Therapy (REBT) since 1993, is rooted in the 1950s, and maintains that all people are born with self defeating tendencies (McGinn, 1997). It is the brainchild of Albert Ellis and is quite well known amongst psychologists. According to R.E.B.T., when something goes wrong, people have a choice of feeling healthy emotions such as sorrow, disappointment or frustration or negative emotions such as terror, depression and self-pity (1997). The former are considered healthy because they entice the individual to try again (1997). For example, if a child loses at baseball and decides not to play the game again because of the emotional consequences, he is feeling sorry for himself. On the other hand, if he becomes angry because he was not paying attention or did not practice enough, he may go home and practice pitching or batting so that he might win the next time. While he is experiencing negative emotions in both instances, there is only a positive and rational component in the latter. Familiar techniques of cognitive therapy are supposed to be able to correct automatic thoughts as well as errors in perception (1998). One can see that Beck’s work is influential not only for the larger community but also for smaller, mentally ill populations.

During the 1960s, Maxie C. Maultsby, Jr., M.D., who was a student of Ellis’, would go on to develop Rational Behavior Therapy (“History,” 2004). Maultsby would contribute several ideas including an emphasis on “client rational self-counselling skills and therapeutic homework” (History 2004). Maultsby’s did contribute the concept of “thought shorthand “and calls these “attitudes” (History 2004). Those types of thoughts Beck would later refer to as “automatic thoughts” (2004). Other disciplines that fall under this therapeutic umbrella include Rational Emotive Imagery, the Five Criteria for Rational Behavior, and Rational Self-Analysis (History 2004). Additional therapists who made contributions in this area are Michael Mahoney, Ph.D., Donald Meichenbaum, Ph.D. and David Burns, M.D (History 2004). David Burns would once again made CBT popular with his best seller entitled Feeling Good, a book that came out in the 1980s (History 2004).

Cognitive behavioral therapy (CBT) has in fact become a respected and empirically established mode of psychotherapy and in particular in treating panic disorder and a review of the literature demonstrates the effectiveness of CBT for adults (Dia, 2001). In the review, CBT had been efficacious for depression and generalized anxiety disorder as well as social phobia and obsessive compulsive disorder (2001). It has also been recommended for substance abuse and dependence, agoraphobia, and panic disorder (DeRubeis & Crits-Christoph, 1998 as cited in Dia, 2001).

Women are twice as likely as men to be diagnosed with panic disorder (Millon, et al., 1999). The diagnosis bias does not provide evidence that women suffer more from panic disorder; rather it lends evidence to the fact that women are probably more likely to clinically present with the disorder. Panic disorder symptoms are similar in men and women and the clinical features are almost synonymous. The reason for the possible bias in diagnosis may be due to societal factors. It is plausible that a panic disorder diagnosis would be more acceptable for a woman than for a man. Gender-role expectations about anxiety and panic disorder need further examination.

With regards to cultural differences, overt panic can manifest itself in a variety of ways. It is imperative that the practicing clinician remember the client’s cultural reference group when making diagnosis and planning therapeutic treatment. For example, in some cultures, symptoms of panic attacks may be evident when people have a cultural fear of witchcraft or evil spirits. The DSM-IV distinguishes these symptoms from true panic disorder because there is typically not an underlying fear about the event and the specific trigger can readily be identified. Once again, further research is warranted on the presentation and experience of anxiety and panic in minority cultures.

CBT obviously involves the use of both behavioral and cognitive techniques so that the patient, when confronted with a situation, can use self talk methods as well as specific behaviour modifications. Key concepts of the approach will again depend upon the disorder being treated but it’s clear that this line of therapy can help patients of panic disorder. However, it becomes clear that CBT and its various forms are appropriate to treat a variety of patients.

Clark (1993) hypothesizes that people with panic disorder misinterpret somatic and psychological sensations, both consciously and unconsciously. He furthers his stance by suggesting an underlying enduring cognitive trait in individuals with PD. Cognitive theorists also point to locus of control and misatributional styles as the causes of panic disorder. On the other hand, biological theories postulate a problem with the neurotransmitter regulation process and the neocortical development in children. Biological theorists also maintain that cortisol excess is experienced in individuals with panic disorder. Simultaneously, conditioning theorists believe that panic disorder stems from the associated pairing of panic eliciting unconditioned stimulus with conditioned stimulus. Treatment implications, with regards to the aforementioned theories, involve treatments such as cognitive-behavioral therapy, medication, and counter-conditioning.

In the future, it will be necessary to continue research, in all theoretical areas, so that diagnostic techniques and subsequent treatment options for people with panic disorder can be somewhat universal. One unifying theory of the etiology of panic disorder will possibly enable clinicians to come to a consensus on the therapeutic treatments that need to be utilized, and the diagnostic criteria that need to be met, for people suffering from panic disorder. It is also important that future research be done on the presentation and experience of panic disorder within multicultural populations.

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