Empirically supported treatment for panic disorder: Research, theory, and application of cognitive behavioral therapy

In this article we review the DSM-IV criteria for Panic Disorder (PD), provide a brief overview of the cognitive model of PD, discuss empirically supported treatment components, and review pivotal experiments examining cognitive behavioral therapy for PD. A case example is also included to illustrate the application of treatment components. Panic Disorder (PD) (with and without agoraphobia) is a debilitating condition with an estimated lifetime prevalence of 1.5% (American Psychiatric Association, 1994). Approximately twice as many women as men suffer from PD. Although PD typically first appears between late adolescence and early adulthood, it can also begin in childhood and in later life. While data on the course of PD are lacking, retrospective patient accounts indicate that PD appears to be a chronic condition that waxes and wanes in severity. Unfortunately, the chronicity of the disorder may be due, in part, to the lack of appropriate treatment. As defined in the DSM-IV (American Psychiatric Association, 1994), the essential feature of PD is the experience of recurrent, unexpected panic attacks. A panic attack is defined as a discrete period of intense fear or discomfort that develops abruptly and reaches a peak within 10 minutes and is accompanied by at least 4 of the following 13 somatic and cognitive symptoms: shortness of breath, dizziness, palpitations, trembling, sweating, feeling of choking, nausea/abdominal distress, depersonalization, paresthesias (numbness/tingling), flushes/chills, chest pain, fear of dying, fear of going crazy or doing something uncontrolled. To warrant the diagnosis of PD in accordance with the DSM-IV, the individual must experience at least two unexpected panic attacks followed by at least one month of concern about having another panic attack. The frequency of attacks varies widely and ranges from several attacks each day to only a handful attacks per year. Although community estimates suggest that approximately one-half of individuals who experience PD also develop agoraphobia, the prevalence of agoraphobia is much higher in clinical samples. In fact, the vast majority of PD patients seeking treatment present with agoraphobia. The DSM-IV defines agoraphobia as the experience of anxiety in situations in which escape might be difficult or where help may not be immediately available in the event of the occurrence of a panic attack. Common agoraphobic situations include airplanes, buses, trains, elevators, being alone, being in a crowd of people, and so forth. As a result of the anxiety experienced in these situations, individuals often develop phobic avoidance resulting in a constricted lifestyle. The severity of agoraphobia may range from relatively mild (e.g., travels unaccompanied when necessary but typically avoids traveling alone) to quite severe (e.g., unable to leave home alone). THE COGNITIVE MODEL OF PANIC DISORDER The cognitive model of PD proposes that panic attacks occur when individuals perceive certain somatic sensations as considerably more dangerous than they truly are, and interpret them to mean that they are about to experience sudden, imminent disaster (Clark, 1986). For example, individuals may develop a panic attack if they misinterpret heart palpitations as signaling an impending heart attack or jittery, shaky feelings as indicating that they will lose control or go crazy. Clark (1986) believes that these "catastrophic misinterpretations" may arise not only from fear but also from a variety of other emotions, such as anger or from other stimuli (e.g., caffeine, exercise). The vicious cycle culminating in a panic attack develops when a stimulus perceived as threatening creates feelings of apprehension. If the somatic sensations that accompany this state of apprehension are catastrophically misinterpreted, the individual experiences a further increase in apprehension, elevated somatic sensations, and so on, until a full-blown panic attack occurs. …