Panic disorder and agoraphobia can be overwhelming, leaving individuals feeling trapped by their fears. Cognitive interventions offer powerful tools to challenge and change the thoughts that fuel anxiety, helping people regain control and reduce panic. In this post, we will explore how these techniques work and how they can make a significant difference in managing these conditions.
Identifying Automatic Thoughts
During the initial assessment session, therapists note the automatic thoughts patients spontaneously report. However, this historical account isn't enough on its own. To better capture their thoughts in real-time, patients are asked to start keeping a thought record, such as the Patient’s Panic Record (e.g., Form 3.4). They log their thoughts whenever a panic attack occurs or when they feel one might be coming. Patients record their anxiety level (e.g., 90% on a 0–100% scale), the situation that triggered it (e.g., "I ran up the stairs"), their automatic thoughts (e.g., "My heart is pounding, so I must be having a panic attack"), and the actions they took to cope (e.g., "I lay down and called my doctor").
Identifying automatic thoughts can be challenging, especially for those with panic disorder, as they are often so focused on their physical discomfort and the urge to escape that they overlook their thoughts. Therapists use Socratic questioning to help patients uncover these thoughts. For example, by asking, "What do you think would have happened if you couldn't leave the subway?" patients may reveal fears like "I will collapse, faint, and die unless I get help," or "I won’t be able to cope."
Through guided discovery, therapists assist patients in understanding how panic attacks develop. They help link thoughts, emotions, and behaviours within the fight-or-flight response. For instance:
Situation: "I ran up the stairs."
Physical sensation: "My heart began pounding."
First-level thought: "My heart is pounding, so I must be having a panic attack."
Emotion and physical sensation: "I became anxious, and my heart began pounding even more."
Second-level thought: "I will collapse, faint, and die unless I get help."
Escalation of anxiety: "I became dizzy, got light-headed, and broke out into a sweat."
Third-level thought: "I won’t be able to cope with it."
Full-blown panic attack ensues.
Behaviour: "I lay down and called my doctor."
Patients learn to identify these automatic thoughts during sessions and are encouraged to continue filling out thought records between sessions.
Modifying Automatic Thoughts
To challenge automatic thoughts in individuals with panic disorder, therapists use various techniques, such as those outlined in Form 3.6, a checklist that helps identify the most common automatic thoughts. Through collaborative empiricism, therapists and patients work together to examine these thoughts and determine whether they involve misinterpretations, aiming to modify them and reduce anxiety and future panic episodes.
Here’s how a therapist might address the first-level automatic thought, "My heart is pounding, so I must be having a panic attack," and the second- and third-level thoughts, "I will collapse, faint, and die unless I get help," and "I won’t be able to cope with it":
Identify Thought Patterns: Patients might categorize their thoughts as "fortunetelling," "overestimating negative outcomes," "catastrophic thinking," or "underestimating their ability to cope."
Acknowledge Emotions: Patients often feel anxious or depressed when experiencing these thoughts.
Rate Confidence and Feelings: Patients might rate their belief in these thoughts and their emotional intensity (e.g., 90% confidence, 90% anxiety, 50% depression).
Challenge Misappraisals:
Evidence for and Against: Patients review evidence supporting and contradicting the thought. For example, while they may feel anxious and have had panic attacks before, they might realize that they often overestimate the likelihood of an attack.
Weigh the Evidence: Patients might allocate points to reflect the likelihood of a panic attack (e.g., 30 points in favour, 70 against).
Consider Alternatives: They might acknowledge that physical sensations like a pounding heart could be due to running up stairs, not necessarily a panic attack.
Reassess Misinterpretations:
Assess Probability: Patients might realize that the chance of fainting or dying during a panic attack is nearly zero.
Worst-Case Scenario: Even if the worst happens (e.g., fainting), they might accept that they can cope, as fainting is rare and not fatal.
Address the Fear: Patients explore the worst that could happen and consider if they can tolerate it. Often, they recognize that while panic attacks are distressing, they have always managed to cope.
Challenge Safety Reliance:
Evaluate Safety Behaviour: Patients who rely on safety people or objects (e.g., a water bottle) may be encouraged to test their assumptions. For example, riding the subway without a water bottle might show them that they can manage their anxiety without it.
Behavioural experiments can help patients test their fears in real-life situations. When their feared outcomes don’t occur, they can gradually reduce their reliance on safety behaviours, realizing that their anxiety is manageable without them. This process helps modify their thoughts and reduces the sense of danger that fuels panic attacks.
Identifying and Modifying Dysfunctional Schemas
Schemas are deep-rooted beliefs about oneself, others, and the world. For individuals with panic disorder, common schemas include the beliefs that the world is dangerous, they are vulnerable, and they are helpless in the face of danger. Other schemas may also play a role, such as the need to feel special, in control, or accepted by others. These beliefs can shape how a person experiences panic, with some feeling that panic undermines their sense of superiority or control.
While panic disorder can be treated without directly addressing these schemas, exploring and modifying them can lead to more lasting changes. By challenging automatic thoughts and assumptions, therapists help patients recognize how these deeper schemas contribute to their anxiety.
For instance, consider a 28-year-old male patient with panic disorder who previously abused alcohol to self-medicate. Throughout his treatment, his therapist helped him explore his schemas related to being "special" and "in control," as well as his fear of humiliation. These schemas were rooted in his upbringing, where his father, a perfectionist, demanded nothing less than excellence, often humiliating him for perceived failures. This led the patient to strive for perfection to avoid further humiliation, especially in his professional life.
During therapy, the patient examined the irrationality of his father's expectations and recognized that many of his colleagues faced even greater challenges. Role-playing exercises, where the therapist took on the role of the father and the patient asserted himself as an adolescent, helped him restructure his perfectionistic beliefs. As a result, the patient’s panic and anxiety decreased, and he became more productive and relaxed in his work.
By directly addressing these faulty beliefs, patients can better understand how their thoughts increase their anxiety, leading to more lasting and meaningful changes.
Conclusion
Cognitive interventions play a crucial role in managing panic disorder and agoraphobia by addressing the thoughts that drive anxiety. By challenging and reshaping these thoughts, individuals can break free from the cycle of fear and regain a sense of control. Implementing these techniques can lead to lasting improvements and a more empowered approach to dealing with anxiety.
References:
Leahy, R. L., & Holland, S. J. (2000). Treatment plans and interventions for depression and anxiety disorders (pp. 123-128). New York: The Guilford Press.
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