Cognitive Therapy of Anxiety Disorders · cognitive therapy for depressive disorders (Beck et al., 1979; Newman & Beck, 1990), cognitive therapy for anxiety disorders is a collaborative

CognitiveTherapyofAnxietyDisorders

CORYF.NEWMAN.PhD

e-Book2015InternationalPsychotherapyInstitute

FromAnxietyandRelatedDisorderseditedbyBenjaminWolman&GeorgeStricker

Copyright©1994BenjaminWolman&GeorgeStricker

Orig.Publisher:JohnWiley&Sons

AllRightsReserved

CreatedintheUnitedStatesofAmerica

TableofContents

COGNITIVETHERAPY:BASICELEMENTS

GENERALIZEDANXIETYDISORDER—COGNITIVECASEPROFILE

SIMPLEANDSOCIALPHOBIAS—COGNITIVECASEPROFILE

PANICDISORDERANDAGORAPHOBIA—COGNITIVECASEPROFILE

COGNITIVECONCEPTUALIZATIONANDTHERAPY:TECHNIQUESANDSTRATEGIESFORASSESSMENTANDTREATMENT

AssessmentandTreatmentofGAD:Roy

AssessmentandTreatmentofPhobias:Leslie

AssessmentandTreatmentofPanicDisorder:Penny

OUTCOMESTUDIES

Anxiety and Related Disorders 5

Author

CoryF.Newman,PhDClinical Director, Center for Cognitive Therapy Department of Psychiatry, andAssistantProfessorofPsychologyinPsychiatrySchoolofMedicine,UniversityofPennsylvaniaPhiladelphia,PA

http://www.freepsychotherapybooks.org 6

CognitiveTherapyofAnxietyDisorders

CORYF.NEWMAN.PhD

Thecognitivemodelofpsychopathologyandpsychotherapydeveloped

byBeck and his collaborators (e.g., Beck, Emery,&Greenberg, 1985; Beck,

Freeman,&Associates,1990;Beck,Rush,Shaw,&Emery,1979)posits that

anindividual’saffectivestateishighlyinfluencedbythemannerinwhichthe

individualperceivesandstructureshisorherexperiences.Accordingtothis

model, patients who suffer from anxiety disorders tend to misperceive

particular stimuli and/or life situations as being far more threatening or

dangerous than they actually are. Further, such patients compound their

problems by underestimating their abilities to copewith these stimuli and

situations,thuscausingareductioninself-esteem.

Thischapterwillfocusonthecognitivetherapyofthreemaintypesof

anxietydisorders: (1)generalizedanxietydisorder (GAD),which is typified

bynumerousexcessiveworriesineverydaylifecoupledwithawiderangeof

physicalsymptoms;(2)phobicdisorders(nonpanic),whicharecharacterized

byexaggeratedandintensefearsofdiscrete,innocuousstimuliorsituations;

and (3) panic disorder (with or without agoraphobia), in which patients


experienceasuddenescalationoffearthatseemstocome“outoftheblue,”

along with extreme changes in somatic sensations (e.g., rapid heart rate,

hyperventilation, dizziness) and a desire to avoid many activities that the

patientsassociatewiththeonsetofattacks.

Therearemarkedsimilaritiesbetweenthetypesofphysicalsymptoms

that accompany each of these three classes of anxiety disorders. Themost

basic similarity is that they all represent increased sympathetic nervous

systemactivity—the“fight,flight,orfreeze”reactionsthathumansevincein

response to theperceptionofdangerandrisk. In fact, there isconsiderable

overlap between both the symptomatology and treatment of each of these

threeclassesofanxietydisorders,andmanypatientsmeetdiagnosticcriteria

for more than one anxiety disorder. However, there are some important

distinctions between the aforementioned anxiety disorders that have

implications for case conceptualization and treatment (Clark, 1989), which

willbereflectedinthecasestudiesreviewedlaterinthischapter.

The treatment of anxiety disorders often is complicated by collateral

problems, such as depression (Barlow, 1988), personality disorders (e.g.,

avoidant personality disorder and dependent personality disorder)

(Sanderson&Beck,1991),abuseofdrugs,alcohol,orprescriptionanxiolytics

asaformofself-medication(Bibb&Chambless,1986),andstrainedmarital

and family relationships (Butler,1989).Thecase studieswill address these


additionalproblemsaswell.

COGNITIVETHERAPY:BASICELEMENTS

Cognitive therapy attempts to treat anxiety disorders by teaching

patientstoidentify,test,andmodifythethoughtsandbeliefsthataccompany

their excessive alarm reactions, as well as the avoidance behaviors that

perpetuate their faulty appraisals and responses. In similar fashion to

cognitive therapy for depressive disorders (Beck et al., 1979; Newman &

Beck,1990),cognitivetherapyforanxietydisordersisacollaborativeprocess

of investigation, reality testing, andproblemsolvingbetween therapist and

patient.Thetherapistsdonotforcefullyexhortpatientstochangetheirviews,

nor do they denigrate the patients’ thinking styles. Rather, the therapists

showrespectfortheirpatients,trytoaccuratelyunderstandhowthepatients

have come to develop their problems, and proceed to teach them a set of

durable skills that will help them to think more objectively, flexibly, and

constructively.

Cognitive therapy is a structuredandhighlyactive formof treatment.

Anxious patients who report that they often feel “scattered” or “out of

control” benefit from therapy sessions inwhich agendas are set, goals are

defined,prioritiesareestablished,andproblemsareconcretized.Therapists

andpatientssharetheresponsibilityfortheworkoftherapy,withtherapists


being willing to respond to direct questions with direct answers, but also

using Socratic questioning in order to help patients gradually learn to

recognizeandsolveproblemsforthemselves.Further,theimplementationof

between-sessionhomeworkassignmentshelpspatientstotranslatetheirnew

hypothesesandgoalsintoactualbehaviorsthatincreaseself-esteem,reduce

anxieties,fears,andavoidance,andimprovethepatients’qualityoflife.

GENERALIZEDANXIETYDISORDER—COGNITIVECASEPROFILE

ThecognitivemodelofGAD(Becketal.,1985)proposesthatindividuals

whoexperiencechronic,compelling,andpervasiveanxietiesmaintainbeliefs

thatmake themprone to interpret numerous situations as posing risk and

threat(Clark,1988).Thesebeliefs(alsocalledunderlyingassumptions)often

center around themes of personal acceptability, personal adequacy, and

control.Morespecifically,thegenerallyanxiouspatientmaybelievethatthe

failuretoperformagiventaskperfectlymeansthatheorsheisdefectiveand

incompetent. Similarly, such a patientmay assume that bymaking a slight

social error he or she will be humiliated, vilified, and cast aside by

acquaintances, friends, and loved ones. Further, these patients frequently

demonstrateafearof“whatmighthappen?"if theyneglecttotakerigorous

measurestoguaranteefavorableoutcomes.Byholdingsuchbeliefs,patients

place themselves under excessive and continual pressure to succeed and

wardofftrouble.Theseindividualsareidentifiableineverydaylifeaspeople


whoseemnevertorelax,whocontinuallyfeel"keyedup”or“onedge,”and

whoaredubbedas“worrywarts”byothersintheirlives.

For example, Roy is a successful, 47-year-old attorneywho seems to

have a rather secure and rewarding life. He earns a healthy salary, is well

respected by the local legal community as an expert litigator, serves as an

officer on the boards of a number of civic organizations, owns a beautiful

home, and has a loving wife and two daughters. Nevertheless, Roy sought

therapy,ashefeltthathewasgoingto“collapseunderthestrain.”Whenthe

therapisthelpedRoytoassessthebreadthanddepthofhisprofessionaland

personalactivities,itbecameclearthathewascarryingatremendousburden

of responsibilities, the likes of whichwould be stressful for anyone. These

factorsalonedidnotdistinguishRoyassufferingfromGAD.Instead,itwashis

beliefsaboutneedingtoprovehimselfateveryturnthatfueledhisanxieties

andhisquesttotakepartinmoreandmorechallengingactivities.

Tohighlight thispatient'sanxiogeniccognitivestyle,Royviewedeach

trailinwhichhelitigatedas“makeorbreak”forhiscareer.Althoughallthe

objective evidence suggested thathis glowing reputationwas secure in the

mindsofhiscolleaguesandfamily,Roybelievedthat“I’monlyasgoodasmy

lastcase."Suchanoutlookledtohisoverpreparingforhiscourtdatestothe

point of exhaustion. His anxiety steadily built as each trial drew near,

whereuponhewouldtypicallyutilizehis“nervousenergy”toputonatourde


force performance that would all but assure a favorable outcome for his

clients.Thus,hecametobelievethat“Ihavetogetmyselfworkedupintoa

frenzyinordertosucceed.IfI’mrelaxed,Iwillfail.IfIfail,mycareerwillbe

ruined.”Suchanabsolutisticchainofbeliefsdictatedthathemustnevertest

thiswayof thinking. InRoy’smind, if he somuchas attempted to takehis

wife’s advice to “relax a bit” he was certain that the result would be

professionaldisaster.Thus,hesilentlyavoidedallowinghimselftogetsome

restandrecreation,a tactic thatsupported themaintenanceofhisnegative

beliefs.

Roy’s anxiety-producingbeliefsdidn’t stophere, ashealso frequently

worriedaboutmaintaininghisfinancialstanding.Hereportedtohistherapist

thatheoftenlayawakeatnightwonderinghowhewouldcontinuetomake

payments on his very expensive home, cars, country club memberships,

daughters’collegetuitions,andtravelplansifhisearningsweretodecrease

from their current level. Such financial obligations might be daunting to

anyone,butRoy’sbeliefsystemcompoundedtheproblem.Specifically,hefelt

driven towin the love and approval of asmanypeople as possible, andhe

believed that only ahigh-profilemixtureof affluence andgenerositywould

assurethisoutcome.Therefore,heactuallysoughtoutnewfinancialburdens

thathethoughtwouldaccomplishhisgoalofsocialpopularity,includingthe

purchasingofaboatandmakinghugedonationstocharitableorganizations.

Hiserroneousassumptionthathewouldbevaluedlessasapersonifhecut


backonhisexpensesfedintohisconstantworriesaboutmoney.Bythetime

hesought treatment,Roywasconvinced thatheno longercouldcopewith

thedemandsofhislife.

SIMPLEANDSOCIALPHOBIAS—COGNITIVECASEPROFILE

Phobiasarechronic,exaggeratedfearsofparticularstimuliorsituations

that are in fact not dangerous (Butler, 1989). Patients who suffer from

phobias are so impaired by their fears that they experience disruptions in

importantaspectsoftheireverydaylives.Anexampleisapatientwhoisso

afraidofelevatorsthatsheturnsdownaveryattractivejoboffersolelyonthe

basis of the fact that her office would be on the 30th floor of a high-rise

building,thusnecessitatingthedailyuseofanelevator.

Asimplephobiainvolvesasingle,specificfearedobjectorsituation(e.g.,

bridges, snakes, sight of blood). Patients who are diagnosed with simple

phobiasgenerallydonotdemonstrate fearfulnessas longas theycanavoid

comingintocontactwith,orthinkingabout,theirphobicsituations.Asocial

phobiainvolvesabnormallystrongconcernsaboutinterpersonalinteractions

and evaluations. Patients with social phobias usually evidence more

pervasiveanxietyand fearfulness thansimplephobics, as it is considerably

moredifficulttoavoidpeoplethantoavoiddiscretesituationssuchasheights

orsnakes.


Socialphobicsmayfearparticularaspectsofsocialdiscoursemorethan

others,suchaspublicspeakingordating.Regardlessoftheovertelementsof

social interactions that the patients fear, the underlying concerns are

consistentacrossthisdiagnosticclassofpatients.Theseincludeexpectations

of being socially inept and/or experiencing derision and rejection from

others. Many social phobics, by virtue of their social avoidance, lock

themselves into self-defeating vicious cycles. They so fear botching their

chances towin the support, approval, acceptance, andpraiseofothers that

they either isolate themselves (thus perpetuating their loneliness and

depriving themof opportunities to gain experience in the social realm), or

revealtheiranxietiesbyactingawkwardly(thuscausingembarrassmentand

fulfilling their negative prophecies). Some social phobics demonstrate no

appreciably noticeable behaviors that would suggest ineptitude in dealing

with other people, yet such patients nevertheless assume that they are

comingacrosspoorlyandthatothersdonotenjoytheircompany.

“Leslie,” a 22-year-old college senior, demonstrated both simple and

socialphobias.Hersimplephobiaswerespecificfearsofgoingtodentaland

medicalappointments.Thesefearswereofsuchintensitythatshehadhadno

check-upsinoverfouryears.OneofthereasonsforLeslie’senteringtherapy

washerongoingembarrassmentinpostponingdentalappointments.

The patient's social phobia was especially pronounced in the area of


publicspeaking.Althoughshewasquitesecureandadeptinhavingone-on-

oneconversationswithclose friends,shegenerallyremainedquietwhen in

thepresenceofagroupofpeople.Herworstfearsconcernedhavingtospeak

in class. Leslie, as a senior, was taking two advanced level seminars that

stronglyemphasizedtheimportanceofclassparticipation,thusputtingherin

“peril”ofhavingtoanswerquestionsbeforeherprofessorandclassmateson

a moment’s notice. She had attempted to circumvent this problem by

privatelyaskingherprofessorsnottocallonherinclass,butbothinstructors

agreed to thisarrangementonlyona temporarybasis.Thus,Leslieentered

therapyasa“lastresortbeforeIhavetodroptheclasses.”

Although Leslie’s simple and social phobias seemed unrelated on the

surface,thepatientmaintainedtwounderlyingbeliefsthattiedtogetherthe

two types of fears. Specifically, Leslie believed that, “I cannot tolerate

discomfortwithoutbecominganervouswreck,”and“If Ibecomeanervous

wreck in front of others theywill think I’m crazy and theywill rejectme.”

AlthoughthekindofdiscomfortthatLesliepresumedshewouldexperience

as amedical or dental patientwas physical, while her expected classroom

discomfortwaspsychological, Leslie anticipated thatbothof these typesof

experienceswouldcauseherto“becomeanervouswreck”infrontofothers.

Sheenvisionedbecoming tongue-tied inclass, resulting inherscreaming in

frustrationandhavingtofleefromtheclass.Similarly,sheimaginedthatshe

woulddissolve intotears ifherphysicianrecommendedabloodtestorher


dentistsuggestedthatshewouldhavetodrillatooth.Lesliewascertainthat

shewould“createascene,” the likesofwhichwouldpreventher fromever

showingherfacetothesepeopleagain.

PANICDISORDERANDAGORAPHOBIA—COGNITIVECASEPROFILE

Thecognitivemodelofpanicdisorder(Beck&Greenberg,1988;Clark,

1988; Ehlers, 1991; Greenberg, 1989; Salkovskis& Clark, 1991) holds that

individuals produce the onset of attacks by tending to make catastrophic

interpretationsaboutawiderangeofphysicalsensationsandmentalstates

that they may experience. Exacerbating this habit is the panic patient’s

hypervigilanceto(anddreadof)normalchangesthattakeplaceinthebody

and mind. The most common misinterpretations that panic patients make

includethefollowing:

1.Believingthatarapidheartrateandchesttightnessareindicativeofanimpendingcoronaryandsuddendeath

2.Viewingdifficultyinbreathingasleadingtoasphyxiation

3. Interpretingmentalphenomenasuchasmemory flashbacks,dejavu,sensesofunrealityanddepersonalization,anddisruptionofattentionspanasprecursorstoinsanity

4. Expecting that the discomfort associated with a number ofsymptoms (e.g., dizziness, cardiopulmonary distress,


abdominalpain, feelingdetached fromone’s surroundings)will become so intolerable as to cause the patient to “losecontrol,” resulting in a number of dreaded consequences,such as social humiliation (e.g., screaming, fainting, losingcontrolofone’sbowels)orcommittingterribleacts(hurtingoneselforlovedones).

Twokey factorsseemtoperpetuatethepanicpatients’extremefears:

(1)apatienthavingapanicattackis insuchastateofalarmthatheorshe

unwittingly activates the sympathetic nervous system even further. The

resultant rush of adrenaline in the bloodstream exacerbates the very

symptomsthatthepatientfearsinthefirstplace,thus“confirming”thatthe

symptomsareoutofcontrol.(2)Panicpatientsoftenavoidsituationsthatthe

associatewith the attacks (e.g., staying away from places that are deemed

“unsafe,” such as cars, shoppingmalls, theaters, and any place fromwhich

escapewill be difficult in the event of emergency), and/or engage in fear-

drivenrituals(e.g.,goingtotheemergencyroomofanearbyhospital)atthe

onset of attacks, thus depriving such patients of ever realizing that their

symptomsarenotdangerous(Salkovskis,1988).

Forexample,anindividualmayhavehadahundredpanicattacksinhis

lifetime,each time fearing thathewashavingaheartattack. Inspiteof the

fact that no heart attack ever actually occurred, the patient’s fear does not

extinguishbecausehebelievesthathisritualisticactions inresponsetothe

attacks(e.g.,callinghiswife,takingapill,goingtothehospital,escapingfrom


the room) save his life each time. In this way, the patient’s thinking style

maintainsthefear,evenintherepeatedabsenceofthefearedoutcome.

The avoidance that is described above is a prime factor in the

development of the agoraphobic component of the disorder (Chambless &

Goldstein,1982).Patientsoftenbegintosteerclearofanyandallsituations

that theyassociatewith the likelihoodofexperiencingapanicattack.Some

patients accomplish this goal subtly, such as by making advance plans to

obtaintheaterticketsthatwillbeonanaisleordeliberatelysittinginthelast

pewatchurch,sothataneasyexitcanbemadeifanattackseemsimminent.

Inmoreseverecases,however,thepatientmayrefusetoventureoutsideofa

veryrestricted“safezone”(thedefinitionofwhichisentirelyaproductofthe

patient's beliefs), which sometimes entails remaining completely

housebound.Commonbeliefsthatagoraphobicpatientsmaintaininclude:

1. If I ventureoutsideofmy safe zone, Iwill bebereftofnecessaryassistanceshouldIhaveanattack.

2.Icannotcopewithanythingnewandunfamiliar.

3. I need to plan easy escape routes lest I become trapped in asituationinwhicheveryonewilldiscovermymentalillness.

4.IfIgointoasituationinwhichIpreviouslyhadapanicattack,Iwillsurelyhaveanotherattack.


5.Avoidingsituationsthatcausemypanicattacksisthebestwaytoeliminatemypanicattacks.

6.IfIcan’tavoidsituationsthatcausemypanicattacks,Icanrelyona“safeperson”totakecareofme.

7.IfIcan’trelyona“safeperson”totakecareofme,Ihavenochoicebuttorelyonmymedicationsoralcohol.

“Penny” is a 35-year-old single woman who suffers from both panic

disorderandagoraphobia.Althoughshe successfullymeets thedemandsof

herhigh-level,white-collarjobwithoutsufferingappreciableanxiety,shehas

great difficulty in coping with traveling moderate distances or staying at

home alone. Thus,whenher roommate gotmarried andmovedout. Penny

feltcompelledtoaskherboyfriendtomoveinwithherinordertomakeher

feelsafefrompanicattacks,eventhoughshehadnointentionofmakingthe

relationshipmoreserious.Unfortunately,theboyfriendtooktheinvitationto

moveinasasignthatPennywaslookingtogetmarried,andhebegantotalk

aboutplansfortheirfuture.Pennyfelttrapped;ontheonehandshebelieved

thatsheneededherboyfriendinordertohelphertocopewithheranxiety,

buttokeephimclosebymeantthatshewouldhavetoabandonherdreamsof

becominginvolvedwithanothermanwithwhomshehadfalleninlove.

Further complicating Penny’s dilemmawas the fact that she felt very

guiltyfor“using”herboyfriendinthisway.Thisfeelinginandofitselfoften


triggered panic attacks, characterized by heart palpitations and breathing

difficulties thatweresosevere thatshe thoughtshewasgoing tosuffocate.

Ironically,theboyfriendwaswell-schooledincomingtoPenny'saidwhenshe

wouldexperiencethesesymptoms,thusbecomingbothhersourceofcomfort

andguiltatthesametime.

“Tim,” themanwithwhomPennywas in love, livedapproximately30

miles from her home. Interestingly, Penny claimed that she was unable to

travelmorethan25milesfromherhomewithoutsufferingtheonsetofhigh

anxiety and panic attacks. After two months of therapy, she was able to

identify for the first timeavery tellingautomatic thought thatwould cross

hermindwhenever she drove close to her limit of 25miles—namely, “If I

driveanyfurther,ImightbetemptedtogotoTim’shouse.”Thisthoughtwas

accompanied bymomentary images ofmaking love to Tim, and shewould

begin to feel sexually aroused. Both the feelings of guilt and physiological

arousal that Penny experienced as a result of these thoughts and images

broughtonpanicattacks,thuseffectivelydissuadingherfromconsideringthe

possibilitythatshecoulddrivelongdistances.Inessence.Pennywascaught

between a figurative sense of suffocation in her relationship with her

boyfriend, and actual breathing difficulties brought on by thoughts of

becoming involved with Tim. Although Penny could plainly see the

interpersonalfactorsthatwerefeedingheranxiety,panic,andagoraphobia,

shecontinuedtobelievethatanygivenpanicattackcouldleadtoherdeath


byasphyxiation.Asaresult,shecontinuedtobehypervigilanttochangesin

herbreathing,andavoidedallsituationsinwhichshebelievedshemighthave

a panic attack. She remained with her boyfriend and grew increasingly

frustratedandanxious.

COGNITIVECONCEPTUALIZATIONANDTHERAPY:TECHNIQUESANDSTRATEGIESFORASSESSMENTANDTREATMENT

As noted, the assessment and treatment of GAD, simple and social

phobias. and panic (with or without agoraphobia) entail some basic

similarities.Ineachofthesetypesofanxietydisorders,thecognitivetherapist

strivestodothefollowing:

1.Assessthepatients’thoughtsthatprecede,accompany,andfollowtypical situations where anxieties, fears, panic, andavoidanceoccur.

2. Assess the patients’ core beliefs that underlie their automaticthoughtsaboutthemselves(andtheirdisorders),theirlives,andtheirfutures.

3. Review the patients’ life experiences that fostered suchmaladaptivecorebeliefs.

4.Elucidatethecurrentlifefactorsthatseemtomaintainthepatients’problematicthoughts,emotions,andbehaviors.

Note:Takentogether,thesefourpointscompriseacaseconceptualization(cf.


Persons,1989).

5.Establishawarm,collaborative,trustingtherapeuticrelationshipasanimportantpartoftheprocessofchange.

6.Teachpatientstobecomemoreobjectiveevaluatorsofthemselvesand their life situations. For example, describe to patientsthe common cognitive distortions of all-or-none thinking,overgeneralizing, fortune-telling, mind-reading,catastrophizing,andotherbiasedprocessesoutlinedinBecket al. (1979) and Burns (1980); then, train patients torespondwithalternative,moreadaptiveresponses.

7.Instructpatientsintheskillsofactiveproblem-solving(Nezu,Nezu,&Perri,1989)inordertobuildhope, increaseself-efficacy,foster independence,andmakemeaningful, lastingchangesinpatients’lives.

8. Help patients to become aware of their most salient areas ofvulnerability, so as to prepare for scenarios that mightotherwiseprecipitaterelapse.

This section of the chapter will focus first on the treatment of GAD,

reviewingmanyof thestrategiesand techniques thatarepertinent toallof

the anxietydisorders.Then, as attention turns to the treatmentofphobias,

moreemphasiswillbeplacedonthebehavioralaspectsoftreatmentthatare

so important when patients habitually avoid feared situations. Finally, the

case description of panic disorderwith agoraphobiawill review the highly


specific techniques of interoceptive exposure (panic induction), breathing

control, and recognition of emotions that are so important with this

population(Barlow,1988;Salkovskis&Clark,1991).Takenasawhole, the

three case studies will explicate many of the key ingredients of cognitive

assessmentandcognitivetherapyforthefullrangeofanxietydisorders.

AssessmentandTreatmentofGAD:Roy

Roypresentedhimselfasanassertive,gregarious,“takecharge”person.

Hewasarticulate,speakingwithgreatanimationaboutarecenthigh-profile

case that he won for his firm, and about an upcoming amateur golf

tournament that he aspired to win. The therapist began the process of

facilitating a positive therapeutic relationship with Roy by giving him

appropriatepositive feedback forhis storiesof success,whilealso showing

somesympathyfor“allthepressuresthatyoumusthavetofaceonaregular

basis.”

Roystatedthat,“IamwhereIamtoday[asuccessfulperson]becauseI

always go to the limit of my endurance. People have always been able to

dependonme,knowingthatIcangetthejobdone.Ican’tgobackwardsnow.

I’veworkedtoohardtoreachthispointtostartslackingoff.”

Over the course of a number of sessions, the therapist was able to

demonstratetoRoythathisbeliefs(e.g.,thosenotedabove)playedatleastas


bigaroleinhisanxietyashisactuallifedemands.Roy’sstatementsrevealed

thatheascribedallhissuccessinlifetohisfreneticpace.Hegavelittlecredit

tohisnaturalabilities,andsawanylet-upasaninvitationtodisaster.Further,

itwasclearthathehighlyvaluedothers’beingabletodependonhim(ashe

believedthatthismadehimalikableperson),andheviewedanydiminution

inhisdailydemandsastantamountto“slackingoff.”Roy’soverdevotionto

work at the expense of his health and personal life, along with his

stubbornness,overattentiontodetails,certaintythathispointsofviewwere

correct, and need to be in control indicated an obsessive-compulsive

personalitydisorder(OCPD)inadditiontohisGADdiagnosis.Byrecognizing

thisaspectofRoy’spersonality,thetherapistwasabletoformulatemethods

thatwouldhelpthepatienttochange,yetstillallowRoytomaintainamuch-

valuedfeelingofindependenceandcontrol.

InordertoappealtoRoy’ssenseofautonomyandinordertominimize

resistance(e.g.,tothetherapists’attemptstogetRoytorelaxandenjoylifeat

a slightly slower pace), the therapist taught Roy a number of standard

cognitivetherapyskillsthathecouldapplyonhisown.Forexample,Roywas

given the “challenge” (Roy could not resist a challenge!) to take mental

inventoryofhisthoughtsattimesofhighstress.Thiskindofcognitiveself-

monitoringisakeyingredientofcognitivetherapy,as itteachespatientsto

recognize how their internal dialogues contribute to their emotional and

behavioralreactions.


Roy also was given the task of charting his activities, in order to

evaluatewherehewas“pushingthelimit”toofar,evenbyhisstandards.The

therapistwas able tomotivateRoy to engage in this taskbyusing Socratic

questioninginthefollowingmanner:

T:Roy,you’vetoldmethatyoubelievethatyoumustmaintainyourcurrentlevelofactivitiesinordertosucceed.Isthatright?

R:Basically.

T:Doesyourcurrentlevelofdemandsfatigueyouandplaceagreatstrainonyou?

R:Yes,ofcourse.That’swhatwe’vebeentalkingabout.

T:OKthen.Howefficientareyou,asanattorney,asagolfer,asafamilyman,andasanactiveleaderinthecommunitywhenyou’refatiguedandwrungoutfromworrying?

R:NotasefficientasI’dlike,butIstillgetthejobdone.

T: Roy, believe me, I know that you are capable of accomplishing someextraordinarythings.Ihavealotofrespectandadmirationforyou,but,doyourememberwhatyousaidwhenyouenteredtherapy?Somethingabouta“collapse”beingimminent?

R:(Nods.)Ifeltlikeanengineabouttooverheatandbreakdown.

T:That’sagreatanalogy.You’vebeenasuper-charged,high-performanceenginefora longtime.Whatkindofenginecarehaveyoubeendoinginordertokeepitfrombreakingdown?

R:Notmuch.MydoctorthinksI’macandidateforacoronary.

T:Andthenhowefficientwillyoube?


R:IguessI’vegottolettheenginerecouponceinawhile.

T:Yousaidit.

Following this, Roy was willing to keep tabs on, and then eliminate,

someofhislowerpriorityactivities.

Another important facet of his treatmentwas Roy’s learning how his

beliefs fed into his need to over achieve. By taking a close look at Roy’s

personal history as well as his current thoughts, the therapist and patient

were able to ascertain howRoy actually perceived threat and danger if he

didn’toverextendhimselfineverythinghewasdoing.Earlierinlife,hisfather

haddemandedperfectionfromRoy,andfosteredanall-or-nothingmentality

byignoringhimwhenRoywouldbea“disappointment,”andpraisinghimto

theskywhenhewouldmakehim“proudtobeyourfather.”Themessagewas

clear—“You’ll be loved if you are thebest.Anything less than that andyou

willbeinadequateandadisappointment.”Inthepresent,Roylivedoutthis

credo by going to great lengths to be the best—not just out of a need to

succeed—but as a way to avoid deprivation of love and nurturance. This

realization opened the therapeutic door for Roy to attempt new ways of

thinking(e.g.,“Icanturnthiscaseovertomycolleaguesandstillbeheldin

highesteembythefirm.MeanwhileI’llhavealittlemoretimetorelax!”and“I

can performmy job at 95% efficiency and still win the lion’s share of my

cases.100%isn’talwaysnecessary,andit'sbestthatIpacemyselfattimes.")


andacting(e.g.,clearinganentiremorningoffofhisWednesdayschedulein

ordertoswimorplayaleisurelygameofgolfwithhiswife).Roy'stherapeutic

improvementshoweditselfnotonlyinhissubjectivesenseofwell-being,but

alsoinhisdecreasedbloodpressure.

AssessmentandTreatmentofPhobias:Leslie

Leslieenteredtherapyhopingthatshecouldridherselfofherfearsof

publicspeaking,aswellashertrepidationofseeingherphysiciananddentist.

Unfortunately, it had not occurred to her that part of her treatmentmight

entail directly confronting her fears. The therapist explained to the patient

thatexposuretothefearedsituationswasanimportantpartofthetreatment

package (cf.Butler,1985),andassuredher thathewoulddoeverythinghe

could to teach her a set of skills that would help her to get through the

“ordeals" in such a way that she would find the feared situations

progressively more tolerable. In the end, a critical achievement would be

Leslie’sincreasedself-confidenceasaresultofherinvivopractice.

Thetherapist'ssimplydiscussingthisaspectoftreatmentbroughtforth

afloodoftearsfromthepatient.HeaskedLesliewhatwasgoingthroughher

mindthatmadehersoupset,whereuponLesliereplied, “Ican’tdo it. I just

can’tdoit.’’ThetherapistaskedLesliewhyshebelievedsostronglythatshe

wasincapableofdealingdirectlywithfearedsituations.Thepatientexplained


that she had been a fearful person all her life. She added thatmost of her

mother’ssideofthefamilysufferedfromanxietiesandphobiasaswell.She

concluded thather “cowardicewas inborn,” therefore itwas inevitable that

she would always feel incapacitated by fears. She said, “I’m just like my

mother, my grandmother and my uncle . . . we can’t tolerate anything

uncomfortable. We’re all pathetic. I'm ashamed of my family, and I’m

ashamedofmyself.”

The therapist acknowledged that there seemed to be a hereditary

component to her disorder. He also silently realized that Leslie’s phobias

probablywerepartofanavoidantpersonalitydisorder,acommondiagnosis

inpeoplewhohavesuch longhistoriesof fearsandavoidance (indeed, she

met diagnostic criteria for the disorder, as per the DSM-III-R, APA, 1987).

However,hebegantoquestionLeslie'sconclusionsinanattempttohaveher

rethink some of her suppositions. Some of the questions that the therapist

askedLeslietoponderwere:

•Doyouhaveall yourmother's genes?What roledoesyour fatherplayinyourgeneticmake-up?Howfearfulishe?

•Howmuchofyourfearfulnessandlackofself-worthwaslearned?

•Whataresomememorableexperiencesthatyou’vehadinyourlifewhereyoulearnedtofearthings?

•Whataresomedifferencesbetweenyouandyourmother?Didshe


gotocollegelikeyou?Didshegetalongwellwithfriendsonaone-to-onebasisthewaythatyoudo?

Lesliewas intrigued by these questions. She admitted that her father

seemed“normal”inthathewasn’tfazedbyverymuch.Also,shenotedthat,

unlikeherself,hermotherneverwenttocollege,asthemotherwasafraidof

dealingwithallthesocialandscholasticdemands.ThetherapistaskedLeslie

whatshecouldconclude fromthis,andthepatientsaid, “Iguess I’mnotas

hopeless asmymother after all. It just seems thatway sometimesbecause

certainthingsfrightenme.”

With this incremental increase in hope, Leslie was willing to start

working on her self-image, as well as her exaggerated senses of risk and

dangerinspeakinginclass.Animportanttooltobeusedinthisprocesswas

theDaily Thought Record (DTR) (Figure 18.1). The standard format of the

DTRpresentspatientswithfivecolumnsinwhichtheywriteabout:

1.Problematicsituations,

2.Concomitantemotions,

3.Dysfunctionalautomaticthoughts,

4.Adaptivealternativethoughts,and

5.Theoutcomeof theDTRexercise (in termsof resultantemotionsandresidualbeliefinthedysfunctionalautomaticthoughts).


TheDTRisapowerfulpartoftherapyifpatientspersevereinpracticing

itsuseonaregularbasis.ThemostcriticalsectionsoftheDTRarethethird

and fourth columns—“automatic thoughts,” and “adaptive responses.” In

column three, patients ask themselveswhat they are thinking during their

times of emotional distress. This helps to concretize the problem, to

demystify theemotions that seem toariseoutofnowhere, and to start the

processof thepatients’beginningtoopentheirmindstomoreconstructive

waysofviewingtheirsituations.Suchadaptive(or“rational”)thinking,which

is recorded in column four, often leads to decreased anxiety and improved

problem-solvingskillsandself-esteem.

Figure18.1.Leslie’sDailyThoughtRecord(DTR)regardingspeakinginclass.

Inordertofacilitatetheprocessofdiscoveringadaptiveresponses,the

therapist instructed Leslie to ask herself the following four questions in

responsetoherautomaticthoughts:

1. What is the evidence that supports or refutes my automaticthoughtsandbeliefs?

Forexample,whenLesliepredictedthathermindwouldgoblankifshe tried toansweraquestion inclass, shewasasked toreviewher scholastic history in order to judgehowwellshehaddoneinsimilarsituationsinthepast.Leslienotedthatshewasinexperiencedinansweringquestionsonthespot in class,but therehadneverbeenanepisodewhen


hermindwentblankandwhenshehadtoleavetheclassoutofembarrassment.

2.WhataresomeotherwaysthatIcanviewthissituation?

Lesliebelievedthatherfearsofsocialevaluationwouldcausehertomakeafoolofherselfinclass,andthatshewouldbesoembarrassed that she'd run out of the room screaming.However, thereweremanyotherplausibleways toviewthe situation. First, Leslie’s anxiety might be barelynoticeable to others, and though she might struggle toanswer the questions, she might very well succeed inansweringcorrectly.Second,evenifshedidn’tknowhowto answer the professor’s questions, the other studentsmight be sympathetic, rather than hostile and rejecting.Third, even if the other students chuckled at Leslie’sanswer, they might forget about the matter in a fewminutes, and still remain on friendly terms with her.Fourth,ifLeslieweretotrytoparticipatemoreactivelyinclass discussions, she conceivably could improve herperformance,thusresultinginbettergradesandincreasedself-confidence.

3.Realistically, what is the worst case scenario, and how would itultimatelyaffectmylife?

Though Leslie visualized academic and social catastrophe, theactual worst case scenario was less noxious. When thepatientponderedthisquestion,sherealizedthattheworstthatcouldhappenwouldbethatshewouldfailtoanswer


the question, and that she would blush and feelembarrassed. While this would make her feel uneasy, itwouldnotportendfailureandlonelinessfortherestofherlife.

4.WhatactivestepscanItaketosolvethisproblem?

Sincemanyclinicallyanxiouspatientsspendmoretimeandenergyworrying about problems than trying to do somethingaboutthem,thisquestionbecomesquiteusefulinturningtheir attention to the issue of problem solving. Thetherapist taught Leslie to recognize when she wascatastrophizing, and to use this as her cue to “shift intoproblem-solving mode.” In the present example, Lesliedealt activelywith her concerns by increasing her studytime,practicingansweringquestionsinrole-playexerciseswithboththetherapistandherboyfriend,andbymakingasmall foray into theareaof speaking in classbyaskingquestions. Later, she would agree to begin to answerquestions by volunteering to comment on the topicsinwhichshehadthemostknowledge.Thisgraded-hierarchywas a vital part of her treatment, as it helped her totolerateincrementsofsocialdiscomfortalittleatatime.

AsLesliebegantoutilizethefourquestionsoutlinedabove,sheagreed

tocomposeahierarchyoffearedsocialsituationsthatshewouldtacklestep

by step. She practiced her use of the four questions in order to prepare

mentally for the exercise, and then experimented with the new behaviors

(e.g., asking questions in class). Her anxiety persisted at first, but shewas


pleasantly surprisedby thepositive resultsofherattempts to confronther

fearedsituationsdirectly.Thesepositiveoutcomesinstilledamoreoptimistic

viewofherselfandherabilities,andheravoidancedecreasedfurther.

At present, Leslie's social phobia has markedly diminished, and she

continues to work in cognitive therapy in order to deal with her simple

phobias of going to see the dentist and physician. The same principles of

adaptiveresponding(throughtheuseoftheDTRandthefourquestions)and

behavioralexperimentsarebeingutilizedintheseareasofconcernaswell.

AssessmentandTreatmentofPanicDisorder:Penny

Penny’sresponsestothePanicBeliefsQuestionnaire(Greenberg,1989)

indicatedthatshestronglybelievedthat:

1.Shewasespeciallyvulnerabletopanicattacksifshewerealone.

2.Intenseemotionsweredangerousandneededtobeavoided.

3.Itwasimportanttobevigilantinmonitoringherbodilysensations(seeFigure18.2).

In spite of the fact that this patientwas a successful businesswoman

(and therefore seemed to be quite independent), shemet DSM-III-R (APA,

1987) criteria for the diagnosis of dependent personality disorder (DPD).

Furthercomplicatingtheclinicalpicturewerethepatient’sproblematicover-


relianceonhermedication,aswellasherdiscord,ambivalence,andguiltin

herrelationshipwithherboyfriend.

PanicBeliefQuestionnaire

NAME:Penny DATE:October27

Pleaseratehowstronglyyoubelieveeachstatementonascalefrom1-6,asfollows:

1=TotallyDisagree 3=DisagreeSlightly 5=AgreeVeryMuch

2=DisagreeVeryMuch 4=AgreeSlightly 6=TotallyAgree

51. HavingabadpanicattackinasituationmeansIwilldefinitelyhave

onethereagain.

3 2. HavingpanicattacksmeansI'mweak,defectiveorinferior.

5 3. Ifpeopleseemehavingapanicattack,they’llloserespectforme.

5 4. I'llhavedisablingpanicattacksfortherestofmylife.

45. Exertingmyselfphysicallyduringapanicattackcouldcausemeto

haveaheartattackanddie.

46. IfIhavepanicattacks,itmeansthere’ssomethingterriblywrongwith

me.

4 7. I’monlysafeifIcancontroleverysituationI’min.

58. I'llneverbeabletoforgetaboutpanicattacksandenjoymyself.


4

9. IfIhavetowaitinlineorsitstill,there'sagoodchanceI’lllosecontrol,scream,faint,orstartcrying.

3 10. There'ssomethingwrongwithmethatthedoctorshaven’tfoundyet.

5 11. Imustbewatchfulorsomethingterriblewillhappen.

312. IfIlosemyfearofpanicattacks,Imightoverlookothersymptomsthat

aredangerous.

313. Ifmychildren(orothersclosetome)seemehavingpanicattacks,

they’llbecomefearfulandinsecure.

*614. IhavetokeepcheckinghowmybodyisreactingorImighthavea

panicattack.

2 15. Cryingtoomuchcouldcauseaheartattack.

416. IhavetoescapethesituationwhenIstarthavingsymptomsor

somethingterriblecouldhappen.

4 17. There’sonlysomuchanxietymyheartcantake.

4 18. There’sonlysomuchanxietymynervoussystemcantake.

519. Anxietycanleadtolossofcontrolanddoingsomethingawfulor

embarrassing.

*6

20. Myemotions(anxiety,anger,sadness,orloneliness)couldbecomesostrongIwouldn'tbeabletotoleratethem.

321. Panickingwhiledrivingorwhilestuckintrafficislikelytocausean

accident.


5 22. Apanicattackcangivemeaheartattack.

*6 23. Apanicattackcankillme.

4 24. Apanicattackcandrivemeinsane.

2 25. AlittleanxietymeansI'llbeasbadasIwasatmyworst.

*6 26. Icouldexperienceterribleemotionthatneverends.

*6 27. Expressingangerislikelytoleadtolosingcontrolorprovokingafight.

528. Icouldlosecontrolofmyanxietyandbecometrappedinmyown

mind.

429. Itcouldbedangeroustocarryonmyusualactivitiesduringapanic

attack.

*6 30. Imustbenearmycompaniontobeprotectedfrompanic.

Figure18.2

Penny’spanicbeliefsatintake.(Notetheimportanceoftheasteriskedbeliefs.)

A review of the etiology of Penny’s panic attacks revealed that they

began approximately four years earlier, ten months after her mother died

suddenlyofasevereasthmaattack.Thepatienthadbeenextremelycloseto

her mother, who had served as the patient’s best friend, confidante, and

guidance counselor. At the time of the mother’s death, Penny alternated

between a catatonic-like state of shock, and fits of anxiety and rage. Her


physiciansedatedherheavilyonlargedosesofXanax,whichwereeffectivein

helpingPenny to functionsociallyandvocationally in themonths following

thetragedy.

Ten months after her mother’s death, Penny decided to go off the

medicationallatonceand,asaconsequence,experiencednumerous,intense

panicattacks.Sheimmediatelyresumeduseoftheanxiolyticmedication,and

continued todoso for fouryears.At thesame time, shebegana friendship

withamanatworkwhoseemedverynurturing.Althoughshedidn’tlovehim,

Pennybelieved thatsheneededsomeone to takecareofherashermother

alwayshad.

Intheyearstocome.Pennysettledintoa“comfortable”routinewiththe

boyfriend.Shebelievedsheneededhiminordertopreventherpanicattacks

fromruiningherlife,yetshewasvaguelyawarethattherelationshiphadno

future.Thisrealization increasedheranxietyandpanicattacks to thepoint

where even high dosages of Xanax (e.g., 4 mg/day) were insufficient

treatment.Atthistime,shesoughthelpattheCenterforCognitiveTherapy.

Itwas noted that Penny’smost salient catastrophic fearwas that her

panicattackswouldmakehersuffocateanddie.Thisfearclearlywastiedto

thefactthathermotherasphyxiatedastheresultofasevereasthmaattack.

Therefore, Penny was extremely aware of any changes in her breathing


patterns,tothepointthatshewouldbegintoworryifherrateofbreathing

changed even in reaction to natural and innocuous physical activity. The

therapist initiallyhypothesized that thiswasoneof the reasons thatPenny

hadpanic attacks during sexual encounterswith her boyfriend. Later, both

thetherapistandpatientwouldcometorealizethatPenny’sfeelingsofguilt

playedasignificantroleaswell.

The therapist asked Penny to keep records of her panic attacks on a

paniclog(seeFigure18.3).Thisdevicehelpstospotpatternsthatpertainto

the disorder, including the role of various stressful situations, catastrophic

thoughts that typically occur, medications onwhich the patient relies, and

behavioralconsequencesoftheattacks.Penny’spaniclogsindicatedthather

attackshadanumberofinterestingthingsincommon:

1.Theyoccurredinassociationwithextremeinterpersonalsituations—lonelinessatoneextremeandsexualfeelingsoractivityattheotherextreme.

2.Heragoraphobicsymptomswererecentphenomena,andher“safe”distancewasjustalittleshyofthedistanceshewouldhavetotravelinordertospendthenightatthehomeofthemanshetrulyloved,Tim.

3. Each panic attack involved symptoms of hyperventilation, andconcomitantfearsofsuddendeath.

4. Each attack was “cured” by the presence of another person,


includingherboyfriend.TheuseofXanaxwasthenextbestchoiceifnobodywasnearby.

5.FeelingsofangerandguiltalsotypicallyprecededPenny’sattacks.

Name:Penny Date:November3-9

Instructions:Pleaserecordallinstancesofpanicoverthepastweek.Apanicattackisdefinedasasuddenrushofanxietyinwhichthesymptomsbuildupquickly.Thesepanicattacksareaccompaniedbyfearorapprehensionandatleastfoursymptoms.

WeeklyPanicLog

Date,Time,andDurationofPanicAttack

SituationinWhichPanicAttackOccurredandSeverityofthePanicAttack(1-10)

DescriptionofPanicAttackSymptomsandSensationsExperienced

InterpretationsofSensationsandAccompanyingThoughtsandImages

WasThisaFull-BlownAttack(Yes/No)IfNo,ExplainWhy

YourResponsetoPanicAttackWhatDidYouDo?(Specifyanymedicationtakenanddosageinmgs.)

1.Monday7:00PM40minutes

Eatingdinneraloneathome.Feelingscaredandlonely9

Dizziness.Fainting.Rapidbreathing.Heavinessinchest.Choking.Fearofdying.

AfraidIwouldfaintandstopbreathing.Nobodywouldbetheretosaveme.

Yes Icalledmyboyfriendandaskedhimtoleavework.

2.Friday8:00PMAnhour

Drivingtotheofficepartyat

Rapidbreathing.Choking.

Ican'tdriveanymore.Ihavetostop.I

Yes Itook1mgtabletXanaxand


Mary'splace.10

Heartpalpitations.

can'tcopewithseeingTimattheparty.

wenttotheparty

3.Saturday2:00PMAnhour

Inthecarwithmyboyfriend.Ifeeltrappedwithhim.10

Choking.Sweating.Fearoflosingcontrol.

I'mabadpersonforwantingtoendthisrelationship.He'ssogoodtome.Ifeelsoguilty.

Yes Itook1mgtabletXanaxandtriedtosleep,butIwascrying.

4.Sunday10:00PM

Watchingthemovie"TermsofEndearment"athome.

Fearofdying.Heartpalpitations.Rapidbreathing.Fainting.

Whydidmymotherdie?Ilovedhersomuch.I'llprobablydiethesameway.

Yes Icriedandtalkeditoutwithmyboyfriend.HeunderstandsmyfeelingsaboutMom.

Figure18.3

Penny'spaniclog

These data were invaluable in devising a strategy for treatment. The

therapist chose a two-pronged approach that is commonly used in the

treatmentofpanicdisorder.Onemainstrategydealtwiththephenomenology

of the acute panic attack itself—examining the thoughts, beliefs, emotions,

behaviors,andphysiologicalchangesthattookplacebefore,during,andafter

the attacks. The goal of this strategy was to modify these aspects of the

patient’s functioning in order to de-escalate the catastrophic


misinterpretations,fears,andphysiologicalarousal.

The second strategy involved examining the patient’s entire life

situation forbroader issues thatneeded tobe addressed.Aspanicpatients

often avoid recognizing or dealing with strong emotions other than fear

(Chambless & Goldstein, 1982), this approach attempted to focus Penny’s

attentionontheissuesthatthepanicattacksoftendisguised.

Consistentwith the first strategy, the therapist taught Penny the role

thathyperventilation(Clark,Salkovskis,&Chalkley,1985;Salkovskis&Clark,

1991)andhypersensitivitytobodilysensations(Ehlers,1991)playedinher

panicattacks.Specifically,byworryingaboutchanges inherbreathing(e.g.,

breathing too hard, or feeling constricted and asthmatic) Penny over

activatedhersympatheticnervoussystem,whichexacerbatedthebreathing

problem by pumping adrenalin into her system so that hyperventilation

increased. The resultant symptoms, including dizziness and breathlessness,

mimicked oxygen debt, thus inducing Penny to try to breath harder. The

therapistexplainedthat thisreactionwas indirectoppositiontothebody’s

natural tendency to return to homeostasis— in this case by reducing

respirationinordertoachievetheappropriatebalanceofoxygenandcarbon

dioxideinthebloodstream.TheresultwasPenny’ssubjectivesensethatshe

was unable to breathe freely, thus spurring more of her catastrophic

misinterpretations about asphyxiating as did hermother. In reality, Penny


wasinnodanger.

Thetherapistutilizedmanyofthetechniquesthathavebeendescribed

previouslyinthecasesofRoyandLeslie,butaddedanimportanttechnique

that is specifically geared to the panic patient. This technique involves the

deliberate induction of a panic attack in session via overbreathing (Beck&

Greenberg,1988;Salkovskis&Clark,1989).Here,thepatientisinstructedto

breathe deeply and quickly for up to two minutes, while the therapist

providescoachingandsupport(Note:Thetherapistobtainspermissionfrom

thepatient’sprimary carephysicianbeforeundertaking thisprocedure). In

manycases,thisexerciseprecipitatessymptomsthatmimicpanicsymptoms.

Whenthebreathingtrialisover,thetherapistasksthepatient:

1.Whatareyourthoughtsrightnow?

Thisquestionoftenelicits thekindsof“hotcognitions”thatshedlightonthereasonsbehindthepatient’sfears.

2.Howsimilaristhisexperiencetoanactualpanicattack?

Inmostcases,patients rate theoverbreathingexercisetobehighlyreminiscentofafull-blownpanicattack.

3.Whatcanyouconcludeabouttheroleofhyperventilationinthesepanicsymptoms?

Most patientswill come to see that overbreathing is a


majorphysiological factor in theonsetandexacerbationoftheattacks.Althoughtheymayarguethattheydonotbreathinsuchanexaggeratedfashionineverydaylife,thetherapistcan point out thatwhile the real-life process is a bitmoreprolonged and gradual than in the present exercise, thecumulativeresultisverysimilar.

4.Howdoyoufeelrightnow?

Mostpatientsreportfeeling“recovered”fromtheeffectsof this exercise (e.g., breathlessness, dizziness, heartpalpitations,nausea)withinaminuteafternormalbreathingisrestored.Thisisusually insharpcontrasttotheirtypicalexperiences with panic, when their catastrophic thinkingfuels the attack for a more prolonged period. When thetherapistprovidesdistraction in the formofquestions, thepatients often feel better quite quickly. This serves as animportant in vivo learning experience that teaches thepatients that they can “turnoff” the symptomsby “turningoff”theconcomitantworries.

5.Whatdoes this experience teachyouabout thedegreeof controlthatyouhaveoveryourpanicattacks?

Aftertakingpartinapanicinductionexercise,patientscometoseethattheirattacksaremoreundertheircontrolthan they had realized. They can deliberately induce theattacks via overbreathing, and they can facilitate theirdiminutionbydistractingthemselvesfromtheircatastrophicworries.


Penny responded very well to the panic induction, as well as the

concomitant techniques of distraction (e.g., focus attention on a task, or a

pleasantmemory, or anadaptive cognitive response) andbreathingcontrol

(learningtobreatheslowlyandgraduallyinresponsetoanxietyandpanic,so

as to restore the oxygen/carbon dioxide balance in the bloodstream and

thereforereducethesymptoms.)

The therapistalsohelpedPenny todealwithher issuesofunresolved

griefoverhermother’sdeath,aswellasherguiltandsexualfrustrationover

her inability to end an over-dependent relationshipwith aman she didn't

want tomarry,whileshewas forfeitingapotential relationshipwithaman

thatshedidwanttomarry.

Penny had never allowed herself to speak or think at any length or

depthabouthermother’sdeath.ShehadusedthecomfortingeffectsofXanax

andherboyfriendtoavoidtheissuealtogether.Now,however,shewantedto

terminate her relationshipwith her boyfriend, but reacted to these desires

with extreme guilt, as well as a sense of doom in that she would have to

relinquishher“safe”person.Now,Pennyreasoned,ifthingsdidnotworkout

withTim,shewouldbelefttodealwithhergrief,loneliness,andfearsonher

own.

Muchtherapeuticworkwasdoneinclarifyingthepatient’sgoalsforher


future. She realized that in order to achieve her life’s objectives shewould

have to: (1) leave her boyfriend, (2) travel more freely, (3) decrease or

eliminateherXanaxuse,(4)dealwithhergriefoverhermother,and(5)take

achanceonanewrelationship.Topicsthathadlongbeenavoidedwerenow

beingdiscussed.Theseissueswereveryanxiety-arousingforPenny,butshe

no longeravoideddiscussingthem,asshehad learnedsomepowerful tools

forcopingwiththeonsetofpanicattacks.

At this time, she has taken some major steps in changing her life,

including: (1) ending her relationshipwith her boyfriend (resulting in her

livingalone,asituationwithwhichshehascopedbeautifully);(2)spending

moretimewiththefriendswhomshehadpreviouslyneglectedinfavorofher

boyfriend, (3) taking things very slowly with Tim, so as not to foster

dependency once again; (4) significantly cutting back on her overuse of

Xanax,tothepointwhereshenowusesthemedicationonlyonanas-needed

basis;and,(5)talkingmorefreelyabouthermother’sdeathwiththetherapist

andwithher closest friends,whichmakesher feelmelancholy, but far less

anxiousaboutherownbreathingpatterns.

OUTCOMESTUDIES

There is a growing body of literature that collectively supports the

efficacyofthemethodsthathavebeenoutlinedinthischapter(e.g.,Brown,


Beck, Greenberg, Newman, et al., 1991; Butler, Fennel, Robson, & Gelder,

1991; Clark et al., 1985; Newman, Beck, Beck, Tran, & Brown, 1990;

Sanderson&Beck,1991;Sokol,Beck,Greenberg,Wright,&Berchick,1989).

The Butler et al. (1991) study demonstrated that patients receiving

cognitive-behavioral interventions benefited from treatment in terms of

diminishedanxietiesaswellasdecreaseddysphoria,thussuggestingthatthe

approachmaybesuccessfulintreatingpatientswhomeetcriteriaforbothan

affectivedisorderandananxietydisorder.

Sanderson & Beck's (1991) data stand out in that they indicate the

efficacyofcognitivetherapyforGADinanaturalpopulation,includingthose

patientswhowere diagnosed as having at least one concomitant personality

disorder (although the progress of the personality disordered patientswas

lesspronouncedthantheprogressofthenonpersonalitydisordergroup).

The Newman et al. (1990) findings are striking in that the patients

demonstrated marked reductions in panic frequency, general anxiety, and

depressedaffectacrosstheboardat terminationandatone-year follow-up,

including thosepatientswho taperedoff theiranxiolyticmedicationswhile in

cognitivetherapy(overhalfofthemedicatedsamplesucceededinbecoming

medication-free by the end of therapy). The importance of these findings

cannot be understated, as anxiety disorder patients who use medications


such as benzodiazepines often have great difficulty with physiological

dependence, tolerance effects, and rebound anxiety and panic upon

withdrawal(Rickels,Schweizer,Case,&Greenblatt,1990).

The data of Brown et al. (1991) provide further support for the

cognitivemodelofpanic.ThePanicBeliefQuestionnaire(Greenberg,1989),

having been found to be psychometrically sound, discriminated those

patients who responded extremely well to cognitive therapy from those

whose progresswas less complete. Specifically, the patientswho benefited

the most endorsed fewer dysfunctional beliefs about panic (e.g., “A panic

attackcangivemeaheartattack.”).Thosepatientswhoweremostsuccessful

in modifying their beliefs about panic evinced the most significant and

completerecoveryfromthedisorder.

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Cognitive Therapy of Anxiety Disorders · cognitive therapy for depressive disorders (Beck et al., 1979; Newman & Beck, 1990), cognitive therapy for anxiety disorders is a collaborative