Understanding psychopathology
Artikel 1. A cognitive approach to panic
Summary
Introduction
- It is only relatively recently that panic attacks have become a focus of research interest in
their own right. This shift in emphasis is largely a result of the work of Donald Klein.
The phenomenology of panic attacks
- 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.
- Spontaneous panic attacks = attacks are perceived by patients as occurring out of the blue.
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
- Studies investigated the effects of two panic-inducing agents – hyperventilation and CO2
inhalation in normal SS. It was found that individuals varied considerably in their affective
response to the procedures and there was tentative evidence that the extent to which
individuals experienced the procedures as pleasurable or aversive was determined by
cognitive factors such as expectation and the recall of previous experiences with the induced
sensations. This suggests that the various pharmacological and 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.
- Figure 1 illustrates the sequence of events that it is suggested occurs in a panic attack. These
stimuli can be external (such as a supermarket for an agoraphobic who has previously had an
attack in a supermarket) but more often are internal (body sensation, 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. In the first the heightened anxiety which precedes the attack is
concerned with the anticipation of an attack. In other cases the heightened anxiety which
precedes an attack may be quite unconnected with anticipation of an attack.
- In the case of panic attacks which are not preceded by a period of heightened anxiety, 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 as suddenly getting up from the sitting position (dizziness), exercise (breathlessness,
palpitations) or drinking coffee (palpitations).
- So far our discussion of the sensations whose misinterpretation results in a panic attack has
mainly concentrated on sensations which arise from the perception of internal physical
processes. These are the most common sensations involved in the production of panic
attacks. However, sensations which arise from the perception of mental processes can also
contribute to the vicious circle which culminates in a panic attack. For example, for some
patients the belief that they are about to go mad is partly based on moments when their
mind suddenly goes blank. These moments are interpreted as evidence of impending loss of
control over thinking and consequent insanity.
- A final aspect of the cognitive model which requires comment concerns the temporal
stability of patients’ catastrophic interpretations of bodily sensations.
A brief review of research on panic attacks
- Having presented a cognitive model of panic, I will now briefly review the literature on panic
to determine the extent to which it is consistent with the proposed model
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 has provided data which is broadly consistent with this hypothesis.
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 sensations would be one of the first things which individuals notice
during an attack
, 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. The observations suggest that hyperventilation plays a role in some panic
attacks. However, it is clear that hyperventilation per se does not produce panic. It is
therefore suggested that 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.
5. Effects of psychological treatment; the proposal that panic attacks result from the
catastrophic interpretation of certain bodily sensations suggests both a cognitive-
behavioral and a behavioral approach to the treatment of panic attacks;
- The cognitive-behavioral approach = would involve identifying patients’ negative
interpretations of the bodily sensations which they experience in panic attacks, suggesting
alternative non-catastrophic interpretations of the sensations and then helping the patient to
test the validity of these alternative interpretations through discussion and behavioral
experiments
- The behavioral approach = would capitalize on the observation that fear of specific stimuli
can often be treated by repeated, controlled exposure to those stimuli and would consist of
graded exposure to the body sensations which accompany panic.
6. The role of biological factors in panic; it would be wrong to assume that biological factors
have no role to play in panic attacks. In principle, there are, at least three ways in which
biological factors might increase an individual’s vulnerability to the vicious circle shown
in Figure I.
- First, biological factors may contribute to the triggering of an attack.
- Second, biological factors are likely to influence the extent to which a perceived threat
produces an increase in bodily sensations.
- Finally, the extent to which bodily sensations which accompany anxiety are interpreted in a
catastrophic fashion will largely be determined by psychological factors. However, biological
factors may also have a role to play in this aspect of the vicious circle. For example, the
hypothesized deficiency in central a2-adreneregic autoreceptors would mean that individuals
would be more likely to experience sudden surges in sympathetic activity and surges in
activity may be more likely to be interpreted in a catastrophic fashion than gradual build-ups.
7. Effects of pharmacological treatment; within the model shown in Fig. 1, there are several
ways in which drugs could be effective in reducing the frequency of panic attacks.
Blockade of, or exposure to the bodily sensations which accompany anxiety, and a
reduction in the frequency of bodily fluctuations which can trigger panic could all have
short term effects on panic. However, if patients’ tendency to interpret bodily sensations
in a catastrophic fashion is not changed, discontinuation of drug treatment should be
associated with a high rate of relapse.
, Artikel 2. EMDR; eye movements superior to beeps in taxing working
memory and reducing vividness of recollections
Introduction
- It has been questioned whether the eye movements involved in EMDR add anything to its
effects.
- Recalling an episode depends on working memory (WM) resources that are limited. If a
secondary task is executed during recall that shares this dependence, fewer resources will be
available for recalling an episode and the memory will be experienced as less vivid and
emotional.
- Interestingly, memories are not only blurred during the eye movements, but also during
recollections immediately after the eye movements session or one week later.
- EMDR seems to therapeutically exploit the fact that memories become labile during recall
and that reconsolidation is affected by the nature of the recall.
- Whereas EMDR has been advocated as treatment for past trauma, the WM theory implies
that negative images about future events (‘flashforwards’) can be treated as well.
Artikel 1. A cognitive approach to panic
Summary
Introduction
- It is only relatively recently that panic attacks have become a focus of research interest in
their own right. This shift in emphasis is largely a result of the work of Donald Klein.
The phenomenology of panic attacks
- 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.
- Spontaneous panic attacks = attacks are perceived by patients as occurring out of the blue.
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
- Studies investigated the effects of two panic-inducing agents – hyperventilation and CO2
inhalation in normal SS. It was found that individuals varied considerably in their affective
response to the procedures and there was tentative evidence that the extent to which
individuals experienced the procedures as pleasurable or aversive was determined by
cognitive factors such as expectation and the recall of previous experiences with the induced
sensations. This suggests that the various pharmacological and 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.
- Figure 1 illustrates the sequence of events that it is suggested occurs in a panic attack. These
stimuli can be external (such as a supermarket for an agoraphobic who has previously had an
attack in a supermarket) but more often are internal (body sensation, 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. In the first the heightened anxiety which precedes the attack is
concerned with the anticipation of an attack. In other cases the heightened anxiety which
precedes an attack may be quite unconnected with anticipation of an attack.
- In the case of panic attacks which are not preceded by a period of heightened anxiety, 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 as suddenly getting up from the sitting position (dizziness), exercise (breathlessness,
palpitations) or drinking coffee (palpitations).
- So far our discussion of the sensations whose misinterpretation results in a panic attack has
mainly concentrated on sensations which arise from the perception of internal physical
processes. These are the most common sensations involved in the production of panic
attacks. However, sensations which arise from the perception of mental processes can also
contribute to the vicious circle which culminates in a panic attack. For example, for some
patients the belief that they are about to go mad is partly based on moments when their
mind suddenly goes blank. These moments are interpreted as evidence of impending loss of
control over thinking and consequent insanity.
- A final aspect of the cognitive model which requires comment concerns the temporal
stability of patients’ catastrophic interpretations of bodily sensations.
A brief review of research on panic attacks
- Having presented a cognitive model of panic, I will now briefly review the literature on panic
to determine the extent to which it is consistent with the proposed model
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 has provided data which is broadly consistent with this hypothesis.
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 sensations would be one of the first things which individuals notice
during an attack
, 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. The observations suggest that hyperventilation plays a role in some panic
attacks. However, it is clear that hyperventilation per se does not produce panic. It is
therefore suggested that 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.
5. Effects of psychological treatment; the proposal that panic attacks result from the
catastrophic interpretation of certain bodily sensations suggests both a cognitive-
behavioral and a behavioral approach to the treatment of panic attacks;
- The cognitive-behavioral approach = would involve identifying patients’ negative
interpretations of the bodily sensations which they experience in panic attacks, suggesting
alternative non-catastrophic interpretations of the sensations and then helping the patient to
test the validity of these alternative interpretations through discussion and behavioral
experiments
- The behavioral approach = would capitalize on the observation that fear of specific stimuli
can often be treated by repeated, controlled exposure to those stimuli and would consist of
graded exposure to the body sensations which accompany panic.
6. The role of biological factors in panic; it would be wrong to assume that biological factors
have no role to play in panic attacks. In principle, there are, at least three ways in which
biological factors might increase an individual’s vulnerability to the vicious circle shown
in Figure I.
- First, biological factors may contribute to the triggering of an attack.
- Second, biological factors are likely to influence the extent to which a perceived threat
produces an increase in bodily sensations.
- Finally, the extent to which bodily sensations which accompany anxiety are interpreted in a
catastrophic fashion will largely be determined by psychological factors. However, biological
factors may also have a role to play in this aspect of the vicious circle. For example, the
hypothesized deficiency in central a2-adreneregic autoreceptors would mean that individuals
would be more likely to experience sudden surges in sympathetic activity and surges in
activity may be more likely to be interpreted in a catastrophic fashion than gradual build-ups.
7. Effects of pharmacological treatment; within the model shown in Fig. 1, there are several
ways in which drugs could be effective in reducing the frequency of panic attacks.
Blockade of, or exposure to the bodily sensations which accompany anxiety, and a
reduction in the frequency of bodily fluctuations which can trigger panic could all have
short term effects on panic. However, if patients’ tendency to interpret bodily sensations
in a catastrophic fashion is not changed, discontinuation of drug treatment should be
associated with a high rate of relapse.
, Artikel 2. EMDR; eye movements superior to beeps in taxing working
memory and reducing vividness of recollections
Introduction
- It has been questioned whether the eye movements involved in EMDR add anything to its
effects.
- Recalling an episode depends on working memory (WM) resources that are limited. If a
secondary task is executed during recall that shares this dependence, fewer resources will be
available for recalling an episode and the memory will be experienced as less vivid and
emotional.
- Interestingly, memories are not only blurred during the eye movements, but also during
recollections immediately after the eye movements session or one week later.
- EMDR seems to therapeutically exploit the fact that memories become labile during recall
and that reconsolidation is affected by the nature of the recall.
- Whereas EMDR has been advocated as treatment for past trauma, the WM theory implies
that negative images about future events (‘flashforwards’) can be treated as well.
