Exposure and Cognitive Restructuring for Panic Disorder

1. Cognitive Behavior Therapy
for Panic Disorder
Dr. Preeti Singh
Consultant Clinical Psychologist
Pt. Jawahar Lal Nehru Memorial Medical College
Raipur (Chhattisgarh)

2. Topics will be covered
• Panic Disorder
• Case conceptualization of Panic Disorder
• Psycho-education
• Exposure
• Cognitive Restructuring
• Relapse prevention

3. Panic Attack – Panic Disorder - Agoraphobia

4. Case
Conceptualization

5. Perceived
threat
Apprehension
Body
sensations
Catastrophic
Interpretation
Trigger
Situational
Cues

6. Catastrophic thoughts
Fear of death or disability
• I am having a heart attack
• I am having a stroke
• I am going to suffocate
Fear of humiliation and
embarrassment
• People will think something
is wrong with me
• They will think I am a lunatic
• I will faint and embarrassed
Fear of losing control
• I am going to lose control
and scream
• I am having a nervous
breakdown
• If I don’t escape I will go
crazy.

7. Psycho-education

8. Perceive real
threat
Activated
SNS
Body
symptoms

9. Activities of ANS
SNS - Active
• Heart beat increased
• Respiration rate increase
• Pupil and lung dilated
• Increased level glucose in
body
• Digestion inhibited
• Blood circulation increased
in legs, hand, brain
PNS - Relax
• Heart beat decrease
• Respiration rate decrease
• Pupil and lung constrict
• Decrease level of glucose
• Digestion accelerated

10. Exposure

11. Steps of Exposure
Pick the trigger
Create a fear hierarchy with rating
Starting exposure
Ending Exposure

12. Interoceptive Exposure (Internal cues)
• Spinning chair (Dizziness or light headache)
• Hyperventilation (Respiration)
• Running on stairs (Heartbeat)
• Tense all Muscles (Tremor or Shaking)
• Sit on a hot room or drink hot water (Sweating)
• Tie the tight scarf near neck (Tightness in throat)
• Place a tongue depressor on the back of the tongue
(Choking)
• Stare at a light on the ceiling for 1 minute, then try
• to read for 1 minute (Derealisation)

13. Situational Exposure
• Mall
• Lift
• Train
• Room
• Market
• Crowded place
• Driving in car
• Dark place

14. Cognitive
Restructuring

15. Goal of CR
• Increased awareness of thinking patterns
• Monitor relationship between thinking and panic
episodes
• Challenge maladaptive thinking

16. CBT techniques
• Monitoring of Panic attack
• Evidence Analysis
• Behavioral Experiment
• Pie Chart
• Role Reversal
• Survey Method
• Cost analysis of Panic

17. Monitoring of Panic attack
Day Trigger Situation Body
symptoms
Severity
(0-100)/
Frequency
Negative
interpretation
(0-100)
Rational
Response
(0-100)
Severity
(0-100)
Mon Lightening At home Heartbeat,
breathing,
tremor,
sweating
70/1 I am having a
panic attack
(80)
It’s just a
body
symptoms,
which
appears
many time
before (90)
10

18. Evidence Analysis
Symptoms of crazy person How many your symptoms
Match
How Many your symptoms
didn't Match
1. Liable mood
2. Irritability
3. Abusive behaviour
4. Aggressive behaviour
5. Irregular eating
6. Irregular sleep
7. Delusion
8. Hallucination
9. Socially inappropriate
behaviour
10. Socially inappropriate
dressing
1. Irritability
2. Irregular sleep
1. Liable mood
2. Abusive behaviour
3. Aggressive behaviour
4. Irregular eating
5. Delusion
6. Hallucination
7. Socially inappropriate
behaviour
8. Socially inappropriate
dressing

19. Behavioral Experiment
Prediction (0-100) Experiment Outcome (0-100) Learning
If I will walk then I
will have panic
attack, will result in
heart attack (90)
Walk for 15 minutes No attack (0) Walking will not
result in panic
attack or heart
attack

20. Pie Chart
• Heart attack – causes of heart attack (0-100)
Cholestrol
Spasm
Substance abuse
Shock
Other

21. Role Reversal
• What will you think about the person if you see
them having a panic attack?

22. Survey Method
• How many people die with panic attack?
• How many people had heart attacks due to panic
attack?
• How many people become crazy due to panic attack?
• How many people think that you are lunatic
(Observed your panic attack)?

23. Cost analysis of Panic
• Motivation for treatment

24. Relapse Prevention
• Problem Solving
• Breathing Retraining
• Refocusing
• Mindfulness

25. ?

26. Thanks you so much