The cognitive model

The DSM-IV-TR definition of Panic Disorder presents individuals with panic disorder to experience reoccurring and unexpected panic attacks. After this, for at least one month, the individual progresses to continually worry about either, another panic attack occurring, worry about the possible detrimental effects that the panic attack may have incurred, or significantly change their behaviour due to the attacks. APA; American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders. 4th ed. APA. Washington, D.C. Clark (1986, p.462) details that to be diagnosed as an individual with panic disorder, the individual must have experienced “at least three panic attacks in the last three weeks”, furthermore, these attacks must not just arise in “phobic situations”. The panic attacks can occur unexpectedly, these are often referred to as ‘spontaneous’ attacks. Furthermore, Clark (1986, p.464) assumes that the “temporal stability” and severity of the panic attacks varies from patient to patient.

Clark (1986 p.461) presents a cognitive model of panic disorder, the model details the symptoms which accompany panic attacks, for example, “an intense feeling of apprehension or impending doom” this sensation is accompanied by “distressing physical sensations” such as “breathlessness”. The model explains that some attacks arise due to anxiety caused by “the anticipation of an attack”, others, are classed as “spontaneous” where the patient does not expect the attack to occur.

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The principle idea of Clark’s (1986) cognitive model stems from the research of Clark and Hemsley, 1982 and van den Hout and Griez, 1982 who carried out research into the effects of hyperventilation and CO2 inhalation respectively. Hyperventilation and the inhalation of CO2 were found to produce varying responses from their participants which was concluded to be dependent upon how the sensations produced were interpreted. Therefore, Clark (1986, p.462) seems to have based his model on the assumption that panic attacks occur due to “the catastrophic misinterpretation of certain bodily sensations” such as “palpitations [and] breathlessness”, thus, individuals who do not suffer from panic disorder would recognise these as being part of a normal, healthy anxiety response. Clark (1986, p.463) assumes that this misinterpretation often turns into a “vicious circle” of events, whereby the individual with panic disorder perceives the trigger stimulus as a threat and becomes apprehensive due to this, the apprehension is accompanied by anxiety induced body sensations, if these sensations are perceived to be dangerous then more apprehension results from this misinterpretation and thus, the cycle continues.

As an alternative to the aforementioned internal physical processes causing the attacks, Clark (1986, p.464) suggests that the sensations misinterpreted prior to the panic attack can be the sensations caused by “the perception of mental processes”. Or the anxiety responses can be produced by internal body sensations which are involved with other physical processes, but not with the anxiety response, by harmless occurrences, or by excitable moods.

Clark further hypothesizes that the length of time the individual with panic disorder experiences sensations and misinterprets them varies among individuals.

During a case study on a twenty-three year old male, Okada, F., Kinoshita, S., Ichikawa, K. (1995) found supporting evidence for Clarks (1986) model. The individual being studied was participating in an isolation experiment; however, he believed the experiment to have finished before it truly had. Therefore, he was left in isolation, this acted as his trigger stimulus as he believed he should have been released. Okada, F. et al (1995, p.268) detail how he experienced apprehension as he became “tense and had difficulty breathing” amongst other symptoms: “palpitations, sweating”. The individual misinterpreted these anxiety sensations catastrophically as he believed that if he did not “make a conscious effort to breathe”, he would be smothered. This case clearly supports Clark’s (1986) cognitive model because the individual with panic disorder behaved according to one of Clark’s main assumptions, by catastrophically misinterpreting his basic anxiety responses, he caused a panic attack to occur. Ottaviani and Beck (1987) also found supporting evidence in this area of Clark’s (1986) cognitive model. Detailing how one of their participants was fearful of eating in public. Ottaviani and Beck (1987, p.24) reveal that the trigger stimulus for this individual with panic disorder was simply the “thoughts of going out to eat”; he became apprehensive and suffered from “heart palpitations, a lump in his throat, and a pain in his chest”. Ottaviani and Beck (1987, p.24) describe how he interpreted these sensations catastrophically by imagining himself “having a heart attack in the restaurant”. This individual provides support for Clark’s (1986) model because he gives an example of one of Clark’s assumptions because he responded to a trigger; this caused the individual to become apprehensive, he then felt body sensations which he catastrophically misinterpreted. However, the personal story of ‘Nicola’ provides evidence that does not support Clark’s (1986) model, this individual with panic disorder seems to rationalise her anxiety sensations realistically. Nicola’s personal story. (2009, Dec 2). Retrieved from No More Panic website: http://www.nomorepanic.co.uk/articles/mystory/ describes that the individual was travelling by car when she recalls feeling “faint” and describes the journey as “a complete nightmare”, once she pulled over she recalls calming herself down. Therefore, because the individual had to make herself calm, it is clear that she had developed a feeling of apprehension due to the situation she found herself in. However, instead of catastrophically misinterpreting her symptoms, she interpreted it to be because she drank an excessive amount of alcohol the night before. However, the individual does describe this as being the beginning of her panic disorder, thus it could be possible that her early panic attacks were not as impactful as the attacks she experienced later in life, once her panic disorder had developed.

Clark’s (1986) model assumes that the anxiety sensations that fuel panic attacks are viewed as normal responses by individuals who do not suffer from panic disorder, and thus, they do not misinterpret them. This assumption is supported in ‘Cathy’s Story’ as the individual was experiencing a panic attack and she was “convinced there was something horribly wrong with” her, whereas her husband knew it was “just anxiety” (Pravel. S, 2009). This highlights how individuals with panic disorder misinterpret their normal anxiety responses. Raffa, S., White, K., Barlow, D. (2004) studied 207 out-patients, this study found some of the consequential effects that individuals with panic disorder feared would happen after they experienced a panic attack. Raffa, S., et al (2004, p.203) categorized these into five subsections: “Loss of behavioural control”, “Social evaluation concerns”, “Specific physical catastrophe”, “Alter quality of life/ability to maintain role functioning”, “Discomfort (physical or mental) perceived as intolerable”. This research supports Clark’s (1986) cognitive model because it highlights what are possibly the main fears that individuals with panic disorder have about panic attacks. Thus, these fears are likely to contribute to the development of apprehension and them catastrophically misinterpreting their body sensations; whereas individuals without panic disorder do not have these concerns therefore they do not misinterpret sensations. An example of an individual with panic disorder losing control is seen in Ottaviani and Beck (1987, p.26) where an individual with panic disorder experienced “light-headedness and unsteadiness” the individual linked this to losing control and imagined herself driving off a bridge, she was so fearful about this occurring that it consequently happened. This supports Clark’s (1986) cognitive model because the individual felt body sensations, became apprehensive and fearful, and misinterpreted the sensations resulting in her experiencing a panic attack and losing control.

The sensations mentioned in the accounts detailed above were all caused due to internal physical sensations of anxiety, however, Clark’s (1986) model also assumes that the sensations that start a panic attack can also be induced by a happy mood, this assumption is supported by Ottaviani and Beck (1987, p.26), as one of their patients “got excited and had an increased heart rate” because she “received good news”. She misinterpreted the body sensations by believing “she was having a heart attack”, instead of accepting that because her physiological arousal increased, her internal sensations had changed too. This supports Clark’s (1986) model because the onset of this individual’s panic attack was caused by the individual being in a happy mood.

Clark (1986) assumes that the sensations can arise due to how mental events are interpreted, an individual with panic disorder in Ottaviani and Beck’s (1987, p.26) study “experienced mental clouding”, the sensations he felt were a “rapid heart rate and shortness of breath”, he misinterpreted these, believing “his heart would explode”. This individual supports this aspect of Clark’s (1986) model as he catastrophically misinterpreted his mental processes resulting in a panic attack.

Clark (1986, p.463) differentiates the two types of onset of panic attacks as occurring “out of the blue” or caused by anxiety induced by anticipating the attack. An individual with panic disorder named Arthur details how he mainly suffered from spontaneous panic attacks which were caused by “non-triggered events”. He experienced fast increasing “somatic” symptoms and “psychological symptoms” such as being fearful of death (Shipko, S.M.D., Wesley, J., Lifschitz, S., Lifschitz, M., Herman, R., Eisenberg, S., et al, 2003). The fact that these panic attacks did not seem to have an obvious trigger supports Clark’s assumption that sometimes panic attacks occur unexpectedly. An example of a triggered panic attack arises in Nicola’s personal story whereby this individual recalls experiencing feelings of panic whenever she sat in a car to travel somewhere. Here, the individual’s panic episodes are triggered by her being anxious of having a panic attack. Nicola’s personal story. (2009, Dec 2). This supports Clark (1986) because it shows that his assumption was correct in that some individual’s panic attacks have a clear, notable trigger.

However, Clark (1986) fails to outline that sometimes panic attacks can occur due to the individual causing it themselves, for example, by recreational drug use. Roszell, D., K, and Struger, J (1984, p.306) report the case of ‘Mr. A’ who “‘snorted’ heroin” this caused the individual to feel apprehensive and feeling as though he was going to choke. This led to the individual to experience a panic attack. A possible explanation for the individual feeling as though he needed to choke is that when taking heroin, a short-term consequence is “a dry mouth” (National Institute on Drug Abuse (NIDA); Drug Enforcement Administration (DEA)) (as cited in The Partnership for a Drug Free America, 2009). However, this is a secondary source of data and thus the validity needs to be questioned. Also, the information I used for this symptom is from a non-academic website, again, this threatens the validity.

Finally, Clark’s (1986) model outlines that the length of time an individual experiences the sensations and misinterprets them varies amongst individuals. For example, ‘Nicola’ had panic disorder for twelve years, whereas the individual in Ottaviani and Beck’s (1987) study experienced irregular panic attacks after his first major attack.

To conclude, Clark’s (1986) cognitive model of panic disorder boasts supporting evidence from various types of sources. The fact that the evidence used in this essay was extracted from journals and from personal online accounts increases the validity of the essay because there is a plentiful supply of data originating from different backgrounds and authors. However, this does lead to a problem, this being that some evidence used has more validity and reliability than others. The personal accounts of Cathy, Nicola, and Arthur are unreliable because they are not formal, published journals and the author is not verified. However, they do provide a vast amount of rich, qualitative data concerning panic disorder. Therefore, clearly, the journals boast more reliability and validity. However, Roszell, D., K, and Struger, J’s (1984) study only concerns a man participating in war, therefore this study may lack population validity as these findings are cannot be generalised to the rest of the population as verifiably as others.

References:
APA; American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders. 4th ed. APA. Washington, D.C
Clark, D., M (1986). A Cognitive Approach to Panic. Pergamon Journals Ltd, 24 (4), 462.
Clark and Hemsley, 1982 and van den Hout and Griez, 1982 (as cited in Clark, D., M (1986). A Cognitive Approach to Panic. Pergamon Journals Ltd, 24 (4), 462.)
Hamer, H.P., McCallin, A.M. & Garrett, N. (2009). Searching the self: The layers and labels of panic disorder: A New Zealand study. Nursing and Health Sciences, 11, 51-57
(National Institute on Drug Abuse (NIDA); Drug Enforcement Administration (DEA)) (as cited in The Partnership for a Drug Free America, 2009). http://www.drugfree.org/portal/drug_guide/heroin
Nicola’s personal story. (2009, Dec 2). Retrieved from No More Panic website: http://www.nomorepanic.co.uk/articles/mystory/
Okada, F., Kinoshita, S., Ichikawa, K. (1995). A case of panic disorder induced by complete isolation experiment. Eur Psychiatry, 11, 268-269
Ottaviani, R., & Beck, A. T. (1987). Cognitive Aspects of Panic Disorders. Journal of Anxiety Disorders, I. 15-28.
Pravel.S (n.d) Cathy’s Story. Retrieved 2nd December 2009 www.paniccare.org/id34.html
Roszell, K., D & Struger, J. (1984). Single Case Study: Panic Disorder associated with Opioid Dependency and Methadone Maintenance Treatment. Drug and Alcohol Dependence, 13 (1984) 305-309
Shipko, S.M.D., Wesley, J., Lifschitz, S., Lifschitz, M., Herman, R., Eisenberg, S., et

al. (2003). A Comparison of Physiological Panic Disorder with Psychological Trauma. Retrieved 6 September 2003 from http://anxiety-panic.com/arthur/arp-comp.htm

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