Within the clash of underlying theory explaining the cause

Within this essay, I
firstly intend to outline and consider the nature of panic attacks, the
cognition behind them and to consider the possible maintenance of attacks, in
order to begin to reflect on different treatment strategies. A central theme to
this essay is the use of Clark’s model of panic disorder, established in 1986.
I will use it as an accepted explanation of conceptualisation and maintenance
of panic disorder, however I will briefly consider other models. Following
this, I aim to examine different interventions used in Cognitive Behavioural
Therapy (CBT) in the treatment of panic disorder. Specifically, I will consider
the possible treatment plan and outcome if the patient experienced chest
tightening as his symptom. I will explore the interventions; socialisation (Wells,
2013), behavioural experiments (Bennett-Levy, 2004), mindfulness-based cognitive therapy (Hayes, 2004.;
Branch and Dryden, 2012) and verbal reattribution (Grant, 2010.; Wells, 2013), whilst considering the efficacy of
their use to treat panic disorder. More broadly, I intend to discuss the clash
of underlying theory explaining the cause of bodily symptoms, between Cognitive
Behavioural Therapy and Psychoanalysis and contemplate how the cause affects the
treatment options available.

Panic
disorder is a form of anxiety, and the National Institute of Health and Care
Excellence (NICE, 1991) recommends
that Cognitive Behavioural Therapy (CBT) is one of the most effective
psychological treatments for the condition. The essential feature of panic
disorder is the occurrence of recurrent panic attacks, many of which are
unexpected (Clark, 1996). DSM-IV defines a panic attack as a sudden onset of
intense fear and discomfort associated with at least four of the following
symptoms: breathlessness, palpitations, trembling, a feeling of choking,
nausea, derealisation, chest pain and paresthesias (American Psychiatric
Association, 2013).

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CBT therapy
aims to modify beliefs at the level of negative automatic though (NAT) and schema’s
(Wells, 2013, p.67). The most widely used model for the case conceptualisation
and treatment of panic disorder was proposed by Clark (1986). Clark (1988,
p.149) states that individuals with panic disorder frequently misinterpret the
bodily symptoms (e.g. palpitations, chest pain and dizziness) in a catastrophic
manner. The catastrophic misinterpretation involves perceiving the bodily
sensations as dangerous and suggestive of immediate impending physical harm.
For example, an individual who is having a panic attack and experiencing his
chest tightening and palpitations as a bodily symptom, may perceive the
sensation as a symptom of an impending heart attack and consequent death
(Clark, 1988, p.149). Consequently, the catastrophic misinterpretation produces
a further, heightened state of apprehension and anxiety (Clark, 1986; Clark,
1996), therefore more bodily sensations are produced and a vicious cycle
begins. However, Goldstein and Chambless (1978) offer a more learning theory
based account of Clark’s ‘fear of fear’ concept. Their approach corresponds
with the concept of interoceptive conditioning (Razran, 1961), in which bodily
sensations become conditioned stimuli for the conditioned response of panic. Additionally,
Beck (Beck, Emery
and Greenberg, 1985) proposed a similar model to Clark. However,
Beck et al. emphasises the notion of
predisposing factors, such as; trauma, physical conditions and coping skills,
all of which, the authors argue, make some individual’s vulnerable to the
effects of the precipitating factors, i.e. loss, drug use and exposure to
anxiety. Due to Clark’s model of panic being so widely used, I will focus on it
for the conceptualisation aspect of panic disorder, which is necessary for
identifying treatment options.

Clark’s
model of panic (1986) is on the most suitable for the cognitive
conceptualisation and the treatment of the disorder (Wells, 2013) and has
many intersecting features with Beck et
al.(1985) cognitive theory of anxiety. It deals especially with the
cognitive factors involved in aetiology and maintenance. It is outlined and predicted
by Clark (1986, 1988) that panic attacks can be prevented by reducing the
patients’ tendency to interpret bodily functions catastrophically. It is noted
by Clark (1986, 1996) that we must consider how the patients distorted beliefs
about bodily sensations are maintained, when the impending danger that is
feared, did not happen. Similarly, Seligman (1988) highlights that in the lack of treatment, individuals persist in
maintaining their distorted beliefs, despite outwardly apparent disconfirmations.
It has been suggested that at least three factors are involved in the
maintenance of distorted beliefs (Clark, 1988; Ehlers & Margraf, 1989;
Salkovskis, 1988). Firstly, due to the individual being frightened of certain
sensations, they might become hypervigilant and begin to check their body for
the perceived signs of danger, allowing their internal focus to notice
sensations that can be perceived as additional evidence of a severe physical or
mental disorder. Secondly, Clark (Salkovskis, 1996) states
that several types of avoidance behaviours are present to inhibit the
individual from disconfirming their negative beliefs. These avoidances are
called ‘safety behaviours’ and it is thought that they could maintain the
individual’s negative beliefs (Salkovskis, Clark and Gelder 1996). In my
example symptom, chest tightening, the safety seeking behaviours could go as
following; the individual preoccupied with the idea that he is on the road to a
heart attack may whenever his chest begins to feel tight and he is in a panic.
The individual will then feel that the avoidant behaviours has prevented him
from suffering a deadly heart attack. However, because he does not actually
have heart disease, the behaviour has only stopped the individual from gathering
disconformity evidence and therefore, maintain the negative beliefs and somatic
preoccupation. This highlights the link between cognition and behaviour (Salkovskis,
1996). Lastly, avoidance is considered a maintaining factor in
panic disorder. Avoidance of anxiety provoking situations, such as exercise, limits the individuals’ opportunity to
experience anxiety and realise that it does not lead to the feared event. The
maintaining factors should be considered in case conceptualisation (Wells, 2013)
and therefore, future intervention.

Socialisation
refers to providing a basis mental set for understanding the nature of
treatment, through which constructing and presenting the panic cycle is the
start (Wells, 2013).
This involves educating the patient about the nature of
cognitive therapy, discussing the role of the patient in their treatment and
presenting the case conceptualisation (Wells, 2013). In
order to assist socialisation, providing a rationale for the understanding of
the treatment and reading material is provided and the models are demonstrated
to show the links between cognition, anxiety and behaviour (Wells, 2013). The purpose of socialisation for panic disorder is to propose an
alternative explanation of panic attacks as catastrophic misinterpretation. To
demonstrate to the client that all panic attacks fit the alternative
explanation, this must be done for several panic attacks (Wells, 2013). Wells states that, at this stage in the intervention, it is
important to determine the client’s reaction to the model (Wells, 2013, p.109). Wells states that this explanation can be linked by explaining
that the belief in catastrophe leads to an adrenalin rush which intensifies
anxiety (Wells, 2013, p.109). An example of socialisation
intervention for panic disorder, specifically for bodily symptoms a body-focus
task. This demonstrates the effect of cognitions and selective attention on
symptom perception and intensity with “self-focused attention manipulations” (Wells, 2013). Patients are asked to focus their attention
on a specific part of the body for a matter of minutes and are then asked to
report what they notice, in conjunction with questions that frame to results in
the context of the panic model. However, socialisation as a concept is very
difficult to measure and operationalize (Mahoney-Davies et al., 2017).

Behavioural
treatment for panic disorder involves generating alternative, less catastrophic
explanations for both the causes and the consequences of the symptom the
patient fear (Bennett-Levy,
2004).  This is achieved
by asking the patient to do something in order to invoke the symptom, inducing
panic, and test their consequences. Examples of behaviour experiments include; experiments
to discover the true causes of the symptom, experiments to uncover the true
consequence of not carrying out safety behaviours, experiments to discover the
consequence of exaggerating symptoms and experiments to test whether safety
behaviours are making things worse (Bennett-Levy, 2004). In
order to assess the efficacy of the induction, patent belief in the feared
catastrophe should be rated before and after the experiment. Physical exercise
tasks are used in cases where strenuous activity may be avoided and for challenging
cardiac concerns (Wells, 2013), such as my example of chest
tightness. In cases of panic disorder and the misinterpretation of chest
tightness, it has been suggested that hypothesis testing, which has three
subtypes, may be effective (Bennett-Levy, 2004). The
first sub type tests the validity of the misinterpretation – hypothesis A, e.g.
by mean of an in-session hyperventilation test. The second subtype compares and
contrasts hypothesis A with a new, potentially more helpful perspective –
hypothesis B. For example, by the end of the set time for therapy, the
therapist should have assisted the patient in generating hypothesis B, e.g.
‘This could be anxiety and adrenaline’. Then, a series of in vivo experiments
could then be designed to see which hypothesis better accounts for the symptom.
Lastly, the third subtype specifically directs attention towards to situations
or behaviours that reaffirm hypothesis B and lead to a new understanding and
meaning of symptoms. E.g. the patient may wish to test this new understanding
that ‘physical symptoms are normal and nothing to be afraid of’ in a series of
new experiments, in a variety of circumstances to reaffirm hypothesis B. However,
it may be more useful to use a more discovery-orientated method eventually to
be more investigative (Branch and Dryden, 2012).

The
third wave of CBT emphasises contextual experimental change strategies (Hayes,
2004), one new approach that emerged from the holistic, reflexive and
experiential themes seen in the third wave is Mindfulness-based cognitive therapy
(MBCT). MBCT integrates mindfulness meditation with Beck’s cognitive therapy (Segal, Teasdale and Williams, 2001). The approach teaches mindfulness meditation, which develops the
skill of being able to accept whatever we are experiencing in the moment
without trying to repair or change it. Through learning to be conscious of what
is happening in the present, we can make skilful choices about how we act, so
as not to enact unhelpful behavioural patterns (Branch and Dryden, 2012). By contrast to the earlier mentioned forms of interventions and
earlier CBT, which aims to help a client change unhelpful cognitions,
mindfulness is not forcing a change to take place, rather, it is promoting
awareness and acceptance (Segal, Teasdale and Williams, 2001). Therefore, if a panicked or depressive state activates negatively
biased interpretations or experience, additional negatively biased processing
takes place and is followed by a downward spiral. MBCT aids the individual in
altering their relationship to the initial experience and therefore the
negatively biased interpretations, limiting rumination. In 2009, research was
conducted into the effectiveness of MBCT as an adjuvant to pharmacotherapy in
patients with panic disorder (Kim et al., 2009). The
authors found that while MBCT demonstrated significantly higher improvement level
than anxiety disorder education, across general anxiety, obsessive-compulsive
and phobic subscales and depression (Kim et al., 2009).
However, it was not found that MBCT significantly improved panic disorder in
terms of somatisation, which is a substantial aspect of the symptoms found in
panic disorder. Hence, whilst MBCT may
be effective in reducing some symptoms of panic disorder, such as rumination,
it is not an effective intervention for bodily symptoms, such as chest
tightening.

Verbal
reattribution for panic disorder focuses mainly on challenging catastrophic misinterpretations
(Grant, 2010.; Wells, 2013). Primarily, the aim is to normalise the experience for
the patient, in order to illustrate that anyone facing a perceived danger would
react with heightened anxiety and would enact behaviour to keep them safe (Casey, Oei and Newcombe, 2004). Suitable modification of belief in the catastrophic
misinterpretation through verbal reattribution techniques depends upon an accurate
understanding of the misinterpretation and the evidence upon which it is based
(Wells, 2013). Evidence should be subject to a detailed analysis which enables
the patient to discover that their responses, previously thought to be
involuntary, are actually safety responses. Panic and anxiety responses can
then be contrasted with actual symptoms of the feared catastrophe (e.g. heart
attack), in order to produce reattribution (Wells, 2013). Examples of verbal
reattribution techniques include; a panic cognition diary, selected educational
scenarios in panic and symptom contrast technique (Wells, 2013). However, Morrison et al. state that there are some
cognitions that are not amendable to checks on their accuracy, that is to say
that standard verbal reattribution is not feasible or useful (Morrison
et al., 2003). Rather, the authors argue that it is more useful
to examine the advantages and disadvantages of holding the belief (Morrison
et al., 2003).

CBT
therapy has often been critiqued through the notions and ideas that psychoanalysis
teaches. A key idea in psychoanalytic thinking is that repression of conflicts,
desires and wishes can manifest as bodily symptoms (Breuer et al., 1991). Therefore,
following psychoanalytic thinking, the only way to treat physical symptoms is
to access the unconscious in psychoanalytic therapy. In line with this, the CBT
interventions stated in this essay are not a viable form of therapy to treat
the somatic because instead of bringing the repressed to the conscious, they
aim to reform cognitions. On a broader level, instead of viewing the
psychological pain itself as something that needs immediate extinction,
psychoanalysis is far more interested in what brought about the psychological
pain, in order to move forward from it (Breuer et al., 1991).
Psychoanalytic thought would question how symptoms, both bodily
and cognitive, could be
lessened when their underlying psychic cause is not being addressed. However, due
to the evidence-based nature of the practice of CBT theory, the efficacy of it
in use for panic disorder, in the long term, is well documented (Craske, Brown
& Barlow, 1991; Sokol et al.,
1989). Cognitive analytic therapy (CAT) is an integrationist approach which
incorporates cognitive therapy, psychoanalysis and developmental psychology (Mcleod, 2013, p.372-3). This
approach begins with an examination of life history, present functioning and
leads on to a reformulation of struggles experienced by the patient, in which
the therapist identifies targets for change (Mcleod, 2013, p.373). The integration of these two
approaches may lead to more effective treatment in the future.

While
CBT is demonstrated to be an effective treatment for panic
disorder, it typically requires between twelve to fifteen hours of
face-to-face treatment with
a practitioner (Kiropoulos et al., 2008). The major barriers to accessing CBT
include; lack of skilled therapists, long waiting times and expense (National Institutes of Health, 1991). Therefore, a major
challenge has been to increase accessibility so that the evidence-based
intervention is a feasible solution (Kiropoulos
et al., 2008). Computerised CBT has several feasible advantages
(Greist et al., 2000). It aids the diffusion
of protocoled but personalised treatment for each patient. The costs accompanying
computer-based treatments could potentially be smaller than those accompanying face-to-face
treatment (Ferriter et al., 2008). Computer-based
treatment can also be used 24 hours a day, seven days a week, without any consequence
on the efficiency. Moreover, computer-based treatment is not subject to some of
the flaws of human therapists, such as memory problems and fatigue (Ghosh &
Greist, 1988). Kiropoulos et al.
argues that internet based CBT offers a solution to the accessibility of
treatments for panic disorder. In their study, focusing on the effectiveness of
internet based CBT versus face-to-face, the authors found evidence that
internet-based CBT for panic disorder is as effective as face-to-face CBT in
alleviating panic disorder (Kiropoulos
et al., 2008). Therefore, the barriers to this treatment intervention
may be overcome, through computerised CBT, and CBT interventions could become a
feasible, applicable option for panic disorder.

 

To conclude, there a number of CBT separate interventions
suggested for the treatment for panic disorders physical and bodily symptoms. However,
whilst each intervention has merit on its own, it seems that the best treatment
involves employing a range of interventions, used together. Whilst the theory
behind each intervention differs, the intervention itself often seems to come
back to a behavioural experiment. Each intervention, excluding MBCT, values the
psychoeducation of the patient in order to alter cognitions. This learning and
altering, combined with the practice of awareness and acceptance that is taught
in MBCT, I believe would lay the foundations of overcoming panic disorder using
CBT. I have outlined the way in which CBT is attempting to tackle the barriers
to accessibility to treatment with computerised CBT. I have also considered a
non-CBT alternative to bodily symptoms and whilst CBT is rooted in
evidence-based practice, and therefore should have high efficacy, I appreciate the
value of considering an integrative approach to treatment. By this, I mean drawing
on psychoanalysis by attempting to get to the root of the disorder, not the
root of the symptoms.