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Cognitive Behaviour Therapy: Panic disorders

Panic attacks may result from catastrophic misinterpretation of certain bodily sensations or outside events that lead to bodily changes. How they monitor signals from within the body is vital but exaggerated. They have a fear that a vital body organ (heart or brain) is about to cease functioning. They are hypersensitive to any indication that the heart will stop beating, e.g. a rapid pulse or tightness in the chest could mean stop breathing.


Other signs that are monitored include early indications of loss of control over destructive impulses directed at themselves or others. Other fears monitored closely are signs that indicate (to them) that psychological or behavioural loss of control will lead to humiliation or hospitalisation.


Such pre-occupations with extreme responses lead to such people closely observing any minor bodily or mental symptom that is viewed as not being normal (to them). There is considerable pre-occupation with the belief that a minor symptom will progress to a major disaster, such as dying, loss of control or insanity. Indeed, there is a fixation on a sudden disaster soon to occur.


Once the panic attack commences, reasoning and problem solving are switched off and reality testing is lost. There may also be a deficiency in information processing.


The belief and pre-occupation with the approaching disaster becomes central in the person’s thinking and is augmented by vivid images of death or going insane and also by past experiences by themselves or others flashing into their awareness.


Their logic can be distorted in this way, the next panic attack will be different in that it will lead to death or loss control.


Indeed, this type of pre-occupation has been compared to an intense form of tunnel vision.


In summary, these are the important aspects:

  • There is a sensitivity to change from normal internal sensations
  • They are hypervigilant for the presents of such sensations and focus on them if they are seen as not normal or the beginning of the disaster.
  • The automatic fixation of attention on the sensation increases the idea of danger and leads to increasing the autonomic arousal.
  • An interaction between the interpretation that these sensations will lead to disaster and the magnification of the anxiety symptoms occurs, setting up a vicious cycle.
  • There is a loss of reasoning ability and problem solving is also reduced.


Cognitive Model of Anxiety, phobias and panic attacks



The cognitive model of panic: The suggested sequence of events in a panic attack (reprinted with permission from Clark 1986a, p.463)


The cognitive model of panic

The cognitive model of panic (Clark 1986a, 1988) states that individuals experience panic attacks because they have a relatively enduring tendency to interpret a range of bodily sensations in a catastrophic fashion. The sensations which are misinterpreted are mainly those which can be involved in normal anxiety responses (e.g. palpitations, breathlessness, dizziness) but also include some other sensations.


The catastrophic misinterpretation involves perceiving these sensations as indicative of an immediately impending physical or mental disaster.


For example, perceiving a slight feeling of breathlessness as evidence of impeding cessation of breathing and consequent death; perceiving the feeling of faintness which accompanies anxiety as evidence of imminent collapse; perceiving palpitations as evidence of a heart attack; or perceiving unusual and racing thoughts as evidence of impeding loss of control over thinking and consequent insanity.


The specific sequence of events which it is suggested occurs in a panic attack is shown in cognitive model of panic (above). A wide range of stimuli can provoke attacks. These stimuli can be external (such as a situation in which an individual has previously experienced a panic attack) but more often are internal (thoughts, images, or bodily sensations). If these stimuli are perceived as a threat, a state of apprehension results. This state is associated with a wide range of bodily sensations.


If these anxiety induced sensations are interpreted in a catastrophic fashion, a further increase in apprehension occurs. This produces a further increase in bodily sensations, and so on, in a vicious circle which culminates in an attack.


Once an individual has developed a tendency to catastrophically interpret bodily sensations, two further processes contribute to the maintenance of a panic disorder.


First, because they are frightened of certain sensations, patients become hyper-vigilant and repeatedly scan their body. This internal focus of attention allows them to notice sensations which many other people would not be aware of. Once noticed, these sensations are taken as further evidence of the presence of some serious physical or mental disorder.


Secondly, certain forms of avoidance tend to maintain patients’ negative interpretations (Salkovskis 1988b). For example, a patient who is preoccupied with the idea he may be suffering from cardiac disease avoided exercise (such as digging in the garden) or sex whenever he noticed palpitations. He believed that this avoidance helped to prevent him from having a heart attack. However, as he had no cardiac disease, the real effect of the avoidance was to prevent him from learning that the symptoms he was experiencing were innocuous. Instead his avoidance tended to reinforce his negative interpretation because he took the reduction in symptoms which followed avoidance as evidence that he really would have had a heart attack if he hadn’t stopped what he was doing.


As a further example, another anxious patient sat down or leaned against solid objects whenever she felt faint. She believed this behaviour prevented her from collapsing. Instead, it prevented her from learning that the feeling of faintness which she got when anxious would not lead to collapse.


Different types of panic

Some panic attacks are preceded by a period of heightened anxiety, others appear to come “out of the blue” when an individual is not anxious. In both cases it is assumes that the crucial event is a misinterpretation of bodily sensations.


In attacks preceded by heightened anxiety, these sensations are most commonly a consequence of the preceding anxiety, which in turn is either due to anticipation of an attack or to some anxiety-evoking event which is unrelated to panic, such as an argument with a spouse.


In the case of panic attacks which are not preceded by a period of heightened anxiety, the bodily sensations which are misinterpreted are initially caused by a different emotional state (excitement, anger) or by some innocuous event such as suddenly getting up from a sitting position (dizziness, palpitations), exercise (breathlessness, palpitations) or drinking coffee (palpitations). In such attacks, patients often fail to distinguish between the triggering bodily sensations and a subsequent panic attack and so perceive the attack as having no cause and coming “out of the blue”.


As patients often take the absence of any obvious triggers for these attacks as evidence that the attacks are due to some serious physical disorder, identifying antecedents of a spontaneous attack can be a helpful way of challenging patients’ catastrophic interpretations.





Credit: This resource was handed during my dr sessions. It has been transcribed with approval from psychiatrist but remains the intellectual property of him.