Understanding Psychopathology literature week 1
A Cogntive Approach to Panic – David M. Clark
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Summary
A cognitive model of panic is described. Within this model panic attacks arc said to result from the
catastrophic misinterpretation of certain bodily sensations. The sensations which are misinterpreted
are mainly those involved in normal anxiety responses (e.g. palpitations, breathlessness. dizziness
etc.) but also include some other sensations. The catastrophic misinterpretation involves perceiving
these sensations as much more dangerous than they really are (e.g. perceiving palpitations as
evidence of an impending heart attack). A review of the literature indicates that the proposed model
is consistent with the major features of panic. In particular, it is consistent with the nature of the
cognitive disturbance in panic patients, the perceived sequence of events in an attack, the
occurrence of ‘spontaneous’ attacks, the role of hyperventilation in attacks, the effects of sodium
lactate and the literature on psychological and pharmacological treatments. Finally, a series of direct
tests of the model are proposed.
Introduction
Ever since Freud’s (1894) classic essay on anxiety neurosis, it has been accepted that panic attacks
are frequently accompanied by certain types of anxiety disorder. In a series of studies which started
in the 1960s Klein and his colleagues appeared to demonstrate that anxiety disorders which are
characterized by panic attacks respond to imipramine while anxiety disorders which are not
characterized by panic attacks fail to respond to imipramine. This ‘pharmacological dissociation’ led
Klein (1981) to propose that panic anxiety is qualitatively different from non-panic anxiety.
The phenomenology of panic attacks
A panic attack consists of an intense feeling of apprehension or impending doom which is of sudden
onset and which is associated with a wide range of distressing physical sensations. These sensations
include breathlessness, palpitations, chest pain, choking, dizziness, tingling in the hands and feet, hot
and cold flushes, sweating, faintness, trembling and feelings of unreality. Panic attacks occur in both
phobic and non-phobic anxiety disorders.
DSM-III: In order to be diagnosed as suffering from panic disorder an individual must have had at
least three panic attacks in the last 3 weeks and these attacks must not be restricted to circumscribed
phobic situations. In order to be diagnosed as suffering from agoraphobia with panic, an individual
must show marked fear and avoidance of the agoraphobic cluster of situations and also have a
history of panic attacks.
A cognitive model of panic attacks
Paradoxically, the cognitive model of panic attacks is perhaps most easily introduced by discussing
work which has focused on neurochemical and pharmacological approaches to the understanding of
panic. This work has established that in patients, panic attacks can be provoked by a wide range of
,pharmacological and physiological agents including: infusions of lactate, yohimbine and
isoproterenol, oral administration of caffeine, voluntary hyperventilation, and inhalation of carbon
dioxide. These agents rarely provoke panic attacks in individuals without a history of panic. This may
be an indication that people who are vulnerable to the agents have a biochemical disorder.
However, two recent studies suggest an alternative,
psychological, explanation for the panic-inducing effects of
these diverse agents. These studies investigated the
effects of two panic-inducing agents-hyperventilation
(Clark and Hemsley, 1982) and COz inhalation (van den
Hout and Griez, 1982)-in normal Ss. This study suggested
that the various pharmacological and physiological agents
which have been shown to promote panic in patients may
not have direct panic-inducing effects but instead may
provoke panic only if the bodily sensations which they
induce are interpreted in a particular fashion. This is the
central notion behind the cognitive theory of panic which
is described below.
It is proposed that panic attacks result from the
catastrophic misinterpretation of certain bodily
sensations. The sensations which are misinterpreted are
mainly those which are involved in normal anxiety
responses (e.g. palpitations, breathlessness, dizziness etc.)
but also include some other bodily sensations. The
catastrophic misinterpretation involves perceiving these
sensations as much more dangerous than they really are.
A wide range of stimuli appear to provoke the attacks. The stimuli can be external (e.g., an
agoraphobic in a supermarket) but more often are internal (body sensations, thought or image). If
these stimuli are perceived as a threat, a state of mild apprehension results. This state is
accompanied by a wide range of body sensations. If these anxiety-produced sensations are
interpreted in a catastrophic fashion, a further increase in apprehension occurs. This produces a
further increase in body sensations and so on round in a vicious circle which culminates in a panic
attack.
In the case of attacks which are preceded by heightened anxiety two distinct types of attack can be
distinguished.
1. The heightened anxiety which precedes the attack is concerned with the anticipation of an
attack. This is often the case when agoraphobics experience an attack in a situation (such as a
supermarket) where they have previously panicked.
2. The heightened anxiety which precedes an attack may be quite unconnected with
anticipation of an attack. For example, an individual may become nervous as a result of the
particular topics which are being discussed in a dispute with a spouse, notice their bodily
reaction to the argument, catastrophically interpret these sensations and then panic. The
trigger for an attack often seems to be the perception of a bodily sensation which itself is
caused by a different emotional state (excitement, anger) or by some quite innocuous event
such a suddenly getting up from the sitting position (dizziness), exercise (breathlessness,
palpitations) or drinking coffee (palpitations). Often thought of as attacks ‘out of the blue’.
, In figure one it is hypothesized that the misinterpretation of bodily symptoms of anxiety is always
involved in the vicious circle which culminates in a panic attack. However, occasionally panic attacks
are triggered by sensations which are never part of an anxiety response. We have mainly focussed on
sensations which arise from the perception of internal physical processes (e.g., palpitation).
However, sensations which arise from the perception of mental processes can also contribute to the
vicious circle which culminates a panic attack.
A final aspect of the cognitive model which requires comment concerns the temporal stability of
patients’ catastrophic interpretations of bodily sensations. For some patients the panic-triggering
sensations and their interpretations of those sensations remain fairly constant across time. However,
in other patients both the sensations and interpretations change over time.
A brief review of research on panic attacks
1. ideational components of panic anxiety
If the above model is correct, one would expect that the thinking of patients who suffer from panic
attacks would be dominated by thoughts which relate to the catastrophic interpretation of bodily
sensations. A recent interview study (Hibbert, 1984) has provided data which is broadly consistent
with this hypothesis. Hibbert (1984a, p. 622) concluded that “the ideational content of those
experiencing panic attacks can be understood as a reaction to the somatic symptoms.’
2. Perceived sequence of events in a panic attack
As the cognitive model specifies that panic attacks result from the catastrophic interpretation of
bodily sensations, one would expect that a bodily sensation would be one of the first things which
individuals notice during an attack. Two studies (Hibbert and Ley) have asked patients about the
perceived sequence of events in an attack and both have provided results consistent with this
expectation.
3. The role of hyperventilation in panic attacks
The bodily sensations which are produced by voluntary hyperventilation are very similar to those
experienced in naturally occurring panic attacks. In some panic patients (i) voluntary hyperventilation
produces a panic-like state (Clark et al., 1985) and (ii) hyperventilation accompanies naturally
occurring panic attacks, panic attacks produced by contrived psychological stress and panic attacks
induced by sodium lactate. However, it is clear that hyperventilation per se does not produce panic.
Hyperventilation only induces panic if the bodily sensations which it induces are (a) perceived as
unpleasant and (b) interpreted in a catastrophic fashion.
4. Lactate-induced panic
Infusions of sodium lactate are the most frequently used technique for inducing panic attacks in the
laboratory. As some of the changes in bodily function are likely to be perceived, the cognitive model
could account for the panic-inducing effects of lactate by proposing that individuals who panic do so
because they catastrophically interpret the induced sensations.
5. Effects of psychological treatment
The proposal that panic attacks result from the catastrophic interpretation of certain bodily
sensations suggests both a cognitive-behavioural and a behavioural approach to the treatment of
panic attacks. The cognitive-behavioural approach would involve identifying patients’ negative
A Cogntive Approach to Panic – David M. Clark
http://proxy-ub.rug.nl/login?url=http://dx.doi.org/10.1016/0005-7967(86)90011-2
Summary
A cognitive model of panic is described. Within this model panic attacks arc said to result from the
catastrophic misinterpretation of certain bodily sensations. The sensations which are misinterpreted
are mainly those involved in normal anxiety responses (e.g. palpitations, breathlessness. dizziness
etc.) but also include some other sensations. The catastrophic misinterpretation involves perceiving
these sensations as much more dangerous than they really are (e.g. perceiving palpitations as
evidence of an impending heart attack). A review of the literature indicates that the proposed model
is consistent with the major features of panic. In particular, it is consistent with the nature of the
cognitive disturbance in panic patients, the perceived sequence of events in an attack, the
occurrence of ‘spontaneous’ attacks, the role of hyperventilation in attacks, the effects of sodium
lactate and the literature on psychological and pharmacological treatments. Finally, a series of direct
tests of the model are proposed.
Introduction
Ever since Freud’s (1894) classic essay on anxiety neurosis, it has been accepted that panic attacks
are frequently accompanied by certain types of anxiety disorder. In a series of studies which started
in the 1960s Klein and his colleagues appeared to demonstrate that anxiety disorders which are
characterized by panic attacks respond to imipramine while anxiety disorders which are not
characterized by panic attacks fail to respond to imipramine. This ‘pharmacological dissociation’ led
Klein (1981) to propose that panic anxiety is qualitatively different from non-panic anxiety.
The phenomenology of panic attacks
A panic attack consists of an intense feeling of apprehension or impending doom which is of sudden
onset and which is associated with a wide range of distressing physical sensations. These sensations
include breathlessness, palpitations, chest pain, choking, dizziness, tingling in the hands and feet, hot
and cold flushes, sweating, faintness, trembling and feelings of unreality. Panic attacks occur in both
phobic and non-phobic anxiety disorders.
DSM-III: In order to be diagnosed as suffering from panic disorder an individual must have had at
least three panic attacks in the last 3 weeks and these attacks must not be restricted to circumscribed
phobic situations. In order to be diagnosed as suffering from agoraphobia with panic, an individual
must show marked fear and avoidance of the agoraphobic cluster of situations and also have a
history of panic attacks.
A cognitive model of panic attacks
Paradoxically, the cognitive model of panic attacks is perhaps most easily introduced by discussing
work which has focused on neurochemical and pharmacological approaches to the understanding of
panic. This work has established that in patients, panic attacks can be provoked by a wide range of
,pharmacological and physiological agents including: infusions of lactate, yohimbine and
isoproterenol, oral administration of caffeine, voluntary hyperventilation, and inhalation of carbon
dioxide. These agents rarely provoke panic attacks in individuals without a history of panic. This may
be an indication that people who are vulnerable to the agents have a biochemical disorder.
However, two recent studies suggest an alternative,
psychological, explanation for the panic-inducing effects of
these diverse agents. These studies investigated the
effects of two panic-inducing agents-hyperventilation
(Clark and Hemsley, 1982) and COz inhalation (van den
Hout and Griez, 1982)-in normal Ss. This study suggested
that the various pharmacological and physiological agents
which have been shown to promote panic in patients may
not have direct panic-inducing effects but instead may
provoke panic only if the bodily sensations which they
induce are interpreted in a particular fashion. This is the
central notion behind the cognitive theory of panic which
is described below.
It is proposed that panic attacks result from the
catastrophic misinterpretation of certain bodily
sensations. The sensations which are misinterpreted are
mainly those which are involved in normal anxiety
responses (e.g. palpitations, breathlessness, dizziness etc.)
but also include some other bodily sensations. The
catastrophic misinterpretation involves perceiving these
sensations as much more dangerous than they really are.
A wide range of stimuli appear to provoke the attacks. The stimuli can be external (e.g., an
agoraphobic in a supermarket) but more often are internal (body sensations, thought or image). If
these stimuli are perceived as a threat, a state of mild apprehension results. This state is
accompanied by a wide range of body sensations. If these anxiety-produced sensations are
interpreted in a catastrophic fashion, a further increase in apprehension occurs. This produces a
further increase in body sensations and so on round in a vicious circle which culminates in a panic
attack.
In the case of attacks which are preceded by heightened anxiety two distinct types of attack can be
distinguished.
1. The heightened anxiety which precedes the attack is concerned with the anticipation of an
attack. This is often the case when agoraphobics experience an attack in a situation (such as a
supermarket) where they have previously panicked.
2. The heightened anxiety which precedes an attack may be quite unconnected with
anticipation of an attack. For example, an individual may become nervous as a result of the
particular topics which are being discussed in a dispute with a spouse, notice their bodily
reaction to the argument, catastrophically interpret these sensations and then panic. The
trigger for an attack often seems to be the perception of a bodily sensation which itself is
caused by a different emotional state (excitement, anger) or by some quite innocuous event
such a suddenly getting up from the sitting position (dizziness), exercise (breathlessness,
palpitations) or drinking coffee (palpitations). Often thought of as attacks ‘out of the blue’.
, In figure one it is hypothesized that the misinterpretation of bodily symptoms of anxiety is always
involved in the vicious circle which culminates in a panic attack. However, occasionally panic attacks
are triggered by sensations which are never part of an anxiety response. We have mainly focussed on
sensations which arise from the perception of internal physical processes (e.g., palpitation).
However, sensations which arise from the perception of mental processes can also contribute to the
vicious circle which culminates a panic attack.
A final aspect of the cognitive model which requires comment concerns the temporal stability of
patients’ catastrophic interpretations of bodily sensations. For some patients the panic-triggering
sensations and their interpretations of those sensations remain fairly constant across time. However,
in other patients both the sensations and interpretations change over time.
A brief review of research on panic attacks
1. ideational components of panic anxiety
If the above model is correct, one would expect that the thinking of patients who suffer from panic
attacks would be dominated by thoughts which relate to the catastrophic interpretation of bodily
sensations. A recent interview study (Hibbert, 1984) has provided data which is broadly consistent
with this hypothesis. Hibbert (1984a, p. 622) concluded that “the ideational content of those
experiencing panic attacks can be understood as a reaction to the somatic symptoms.’
2. Perceived sequence of events in a panic attack
As the cognitive model specifies that panic attacks result from the catastrophic interpretation of
bodily sensations, one would expect that a bodily sensation would be one of the first things which
individuals notice during an attack. Two studies (Hibbert and Ley) have asked patients about the
perceived sequence of events in an attack and both have provided results consistent with this
expectation.
3. The role of hyperventilation in panic attacks
The bodily sensations which are produced by voluntary hyperventilation are very similar to those
experienced in naturally occurring panic attacks. In some panic patients (i) voluntary hyperventilation
produces a panic-like state (Clark et al., 1985) and (ii) hyperventilation accompanies naturally
occurring panic attacks, panic attacks produced by contrived psychological stress and panic attacks
induced by sodium lactate. However, it is clear that hyperventilation per se does not produce panic.
Hyperventilation only induces panic if the bodily sensations which it induces are (a) perceived as
unpleasant and (b) interpreted in a catastrophic fashion.
4. Lactate-induced panic
Infusions of sodium lactate are the most frequently used technique for inducing panic attacks in the
laboratory. As some of the changes in bodily function are likely to be perceived, the cognitive model
could account for the panic-inducing effects of lactate by proposing that individuals who panic do so
because they catastrophically interpret the induced sensations.
5. Effects of psychological treatment
The proposal that panic attacks result from the catastrophic interpretation of certain bodily
sensations suggests both a cognitive-behavioural and a behavioural approach to the treatment of
panic attacks. The cognitive-behavioural approach would involve identifying patients’ negative
