$3.00+ 0.00 0005-7967/91 Copyrightc 1991Pergamon Press plc
Behar. Rec. Thu. Vol.29, No. 2, pp. 161-166,1991 Printedin Great Bntain. All nghts reserved
TREATMENT THERAPY
OF PANIC ATTACKS WITHOUT EXPOSURE RETRAINING
USING COGNITIVE OR BREATHING
PAUL M. SALKOVSKIS,DAVID M. CLARK and ANN HACKMANN Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, England (Received 23 September 1990) Summary-Cognitive treatment of panic attacks is based on the hypothesis that panic results from the catastrophic misinterpretation of bodily sensations, and that changing such misinterpretations will block the occurrence of panic. The treatment normally involves an integrated set of cognitive and behavioural techniques. In a consecutive series of panic patients, a multiple baseline across subjects design was used to investigate whether a modified form of treatment involving only cognitive procedures could reduce panic attack frequency. The results provide preliminary evidence that cognitive procedures directed at changing misinterpretations of bodily sensations can reduce panic attack frequency, and also that cognitive procedures which do not target misinterpretations may not reduce panic.
INTRODUCTION
Successful treatment of panic attacks using various types of cognitive-behavioural therapy has now been widely reported (Barlow, Craske, Cerny & Klosko, 1989; Beck, 1988; Clark, Salkovskis & Chalkley, 1985; Klosko, Barlow, Tassinari & Cerny, 1990; Kopp, Mihaly, Tringer & Vasadz, 1986; Michelson, Marchione, Greenwald, Glanz, Testa & Marchione, 1990; Salkovskis, Jones & Clark, 1986; Sokol, Beck, Greenberg, Wright & Berchick, 1990). In many of these studies, treatment was based on recent cognitive theories of panic. These theories (Clark, 1986, 1988; Beck, Emery & Greenberg, 1985) state that panic attacks result from the catastrophic misinterpretation of certain bodily sensations. In particular, it is suggested that patients misinterpret largely benign sensations as signs of an imminent physical and mental disaster, such as having a heart attack, going mad or losing control of behaviour. This misinterpretation results in further anxiety, causing further and/or more intense bodily sensations which strengthen the misinterpretation, producing a vicious circle which culminates in a panic attack. Treatment based on the cognitive approach to panic aims to change patients’ catastrophic misinterpretations by helping them to identify and test alternative, more accurate explanations of their symptoms. One of the ways of doing this involves the use of behavioural experiments in which the therapist encourages the patient to engage in procedures which reproduce the sensations which occur in panic attacks. A variety of strategies are used to reproduce sensations; including imagery, bodily focussing, reading pairs of words (representing a symptom and an associated catastrophe) and voluntary hyperventilation (Clark & Salkovskis, 1991). Given the suggestion that hyperventilation may be associated with panic in a substantial proportion of panic patients (Garssen, Van Veenendaal & Bloemink, 1983; Rapee, 1986), early treatment studies particularly emphasized the use of voluntary hyperventilation, followed by training in controlled breathing as an efficient way of establishing a non-catastrophic interpretation of some patients’ symptoms (cf. Salkovskis & Clark, 1986). As cognitive therapy for panic includes behavioural techniques such as those described above, it could be argued that the effectiveness of the treatment is unrelated to the use of purely cognitive procedures. For example, it has been argued (Marks, 1987) that the treatment is only effective because it includes exposure to feared situations and/or sensations. It seems unlikely that exposure to feared situations alone can entirely account for the effectiveness of treatment because Clark et al. (1985) and Salkovskis et al. (1986) observed significant improvements in panic during a phase of treatment in which patients were asked not to go into situations which they had previously avoided (anti-exposure instructions). However, it is more difficult to exclude exposure to feared 161
PAUL M. SALKOVSKIS et al.
162
sensations as a possible explanation because all studies to date have included behavioural experiments which involve the induction of feared sensations. A further possible explanation for the effectiveness of treatment is physiological. Ley (1985) suggests that panic attacks are largely the result of hyperventilation and that treatment should centre on the control of breathing. It could therefore be argued that the cognitive treatment package is effective because it includes training in controlled breathing. In the case series reported here, cognitive therapy was conducted without any exposure to feared situations or sensations and without training in controlled breathing. Instead, purely cognitive procedures were used to modify patients’ catastrophic misinterpretations of bodily sensations. By restricting therapy in this way we attempted to obtain a preliminary indication of whether panic attacks can be reduced by purely cognitive means. If this is possible, then it seems likely that at least part of the effectiveness of the full cognitive treatment package is due to its cognitive elements. METHOD
Putients Seven patients referred to the Oxford University Department of Psychiatry for the treatment of panic were included in the series. All fulfilled DSM III-R (American Psychiatric Association, 1987) criteria for panic disorder with moderate or severe avoidance. Eleven consecutive patients were screened, of whom four were not suitable for the series; one patient had no panic attacks during the baseline period, one had a steeply descending baseline, one filled out his panic diary incorrectly and one only attended a single treatment session because of illness in her family. E.xperirncntal
design
A multiple baseline across Ss design was used (Hersen & Barlow, 1976). Five patients were randomly allocated to baselines of differing lengths, followed by a brief (two sessions within a week) cognitive treatment designed to change catastrophic interpretations of bodily sensations (focal treatment). After the treatment, a further baseline was instituted. At the end of this second baseline, patients were offered unrestricted further treatment as appropriate (data after this point is not reported, as exposure and other behavioural elements were added to treatment as considered necessary by the therapist). Two further patients were allocated to differing length baselines followed by another cognitive treatment (non-focal treatment) which did not focus on misinterpretations of bodily sensations but had a structure and duration comparable to the focal treatment. Non-focal treatment was followed by a return to baseline, then the focal treatment was conducted as in the first five patients, followed by a further baseline. In order to exclude the possibility that any improvements during treatment might be due to exposure to feared situations, patients were asked not to increase or decrease the extent to which they went into situations which they would tend to avoid (anti-exposure instructions) during the pre-treatment baseline, treatment periods, and the post-treatment baselines. Each time patients were seen for assessments or treatment sessions anti-exposure instructions were reiterated. In order to exclude the possibility that improvements during treatment might be due to exposure to feared sensations or breathing retraining no patient was given breathing retraining or asked to hyperventilate and no attempts were made to expose patients to feared sensations. Measures The hypothesis under examination was that frequency of panic attacks would be reduced by cognitive techniques which targeted and changed catastrophic misinterpretations of bodily sensations but not by cognitive techniques which did not target and bring about such changes. Accordingly, the therapists identified catastrophic misinterpretations at the start of therapy, and asked patients to rate their belief in these thoughts at the beginning and end of each treatment session and during the baseline periods. &lo0 scales were used to rate thoughts with 0 representing not believing the thought at all and 100 representing being totally convinced that the thought was true. Two ratings for each thought were taken: the now rating, ‘how much do you believe. right
Cognitive therapy without exposure
163
now’ and the then rating, ‘if you had all the symptoms that you have in a panic attack, how much would you believe. . . .‘. The main dependent variable was panic attack frequency which was derived from a daily panic diary (see Clark, 1989 for details of the diary). At the start of the pre-treatment baseline period, patients were given diary sheets and asked to record their panic attacks and limited symptom attacks each day. Recording continued throughout treatment and post-treatment baselines. Treatments Patients had two sessions of the assigned treatment within a period of 7 days. The sessions totalled not more than 2 hr 30 min. The first 30 min of session one were devoted to assessment. In the assessment the therapist tried to elicit details of any thoughts which represented catastrophic misinterpretations of panic-related bodily sensations. Once such thoughts were identified, patients rated their belief in the thoughts and these belief ratings were repeated at the end of session one and again at the beginning and end of session two. Each therapy session was audiotaped, and patients were given the audiotape to listen to and comment on as homework. Sessions were also video taped for supervision purposes. In both treatments, therapy was structured round an agenda set at the beginning of each session. Both treatments focused on thoughts but differed in the types of thoughts they attempted to modify. Focal treatment. In focal cognitive therapy sessions discussion exclusively focused on bringing about re-attribution of bodily sensations. Typically, treatment started by identifying the exact sequence of sensations, catastrophic interpretations, anxiety, further sensations and so on that occurred in a panic attack. Evidence for and against the catastrophic interpretations was reviewed and challenged. Evidence for and against the alternative cognitive account of the patient’s panic attacks was reviewed. The techniques employed were predominantly verbal. In many instances, this meant helping patients to understand the significance of experiences and information they already had which was inconsistent with their catastrophic explanations and which tended to support the alternative, cognitive formulation of their panic attacks. These discussions were supplemented by homework involving an extended version of the panic diary in which patients recorded the principal sensations experienced, any misinterpretations of these sensations and belief in them at that time, and alternative explanations (rational responses), followed by a rating of belief in the rational response and re-rating of belief in the catastrophic interpretation. For example, during the second session of focal treatment, patient six described the thought that she might pass out or die during a panic attack. Her principal evidence for this was the intensity and strangeness of the sensations she experienced, (tingling, heart pounding and a feeling of unreality) and she thought that such sensations must mean that there was something physically wrong. The therapist asked her if she had ever felt pleasantly excited. She recalled a recent occasion when she thought she had won a very large amount of money on the football pools. When describing the feelings experienced on that occasion she realised they were exactly the same as those which occurred during a panic, although she had not panicked on that occasion, but instead had been intensely excited. With further discussion she then concluded that this was convincing support for the idea that “the sensations themselves are not dangerous, it’s just that what you think about them can make them frightening”. Non:focal treatment. In non-focal treatment sessions discussion concentrated on issues of particular concern to the patient but excluding misinterpretations of bodily sensations. The rationale given to patients was that panic attacks are often the result of anxiety arising from life stresses, and that the first stage in the treatment of panic is the identification and modification of stressors. It was explained that reduced stress would be helpful in reducing the occurrence of panic attacks. Therapists were not constrained in their use of cognitive therapy techniques other than the exposure and breathing retraining exclusions described above and used a wide range of standard techniques (see Beck, Rush, Shaw & Emery, 1979; Beck, Emery & Greenberg, 1985; Burns, 1980). In session discussions were supplemented by homework assignments in which patients identified and challenged their negative thoughts using the Daily Record of Negative Automatic Thoughts (Beck et al., 1979). For example, during the first two sessions of non-focal treatment, patient 7 outlined her problems at work. She and her fiancee worked together, and lived in accommodation which was linked to
164
PAUL
Table
1. Belief
ratings
for panic-related
thoughts
before,
M. SALKOVSKIS during,
et
and after
ai.
focal
cognitive
therapy
and non-focal
Asse~ment
cognitive
therapy
occasion End
Post
Pre Patient
(1)
Belief
Context
I am going
suffocate
non-focal
focal
focal
therapy
therapy
therapy
therapy
baseline
-
-
0
0 IO 0
SO
20
0
50
0
0
panic
95
50
10
now
45
0
0
panic
100
50
10
now
(3)
I will
lose my mind
I will
bave a stroke
f amgoing
-
I
am going
now
mad
(41
I am going
_-
to lose control
-
I amgoing (5)
1 am
I am
having going
to pass out or faint to go mad a heart
attack
I am going
2s
50
10
20
80
40
30
no
40
IO
30
panic
90
60
40
now
25
IO
10
panic
70
40
15
-
-
now
to pass out
f am a danger (when (7)
to others
driving)
I am going I am going
to die
in thoughts
in thought
was rated
if you were
on O--l00 experiencing
scale. ‘Now’
rating
all the symptoms
IO
0
0
80 -
40
50
0
0
-
10
10
now
70
80
60
40
30
90
90
80
50
30
now
60
70
70
40
30
panic
60
90
9Q
40
30
now
78
80
55
50
0
78
80
80
55
0
SO
80
x5
70
75
panic Belief
-
panic
now
to faini
0 0 40
panic (6)
0 30 0
now
to pass out
60 100
50
now
attack
0
50
panic
to have a heart
-
0 10
80
now
panic I am going
-
now
of my behaviour
10 70
panic
(2)
of
post focal
therapy
panic I will
Post
non-focal
now
to faint
Pte
refers to belief
70
100
in thought
you have in a panic
while
sitting
85 In the clinic.
70 ‘Then’
75 rating
refers to belief
attack.
the job and very unsatisfactory. They were frequently exploited by their boss over issues such as holidays, pay, insurance and free time. The patient often felt angry with her boss, but was afraid to assert herself in case she and her fiance were thrown out of their apartment. She also often felt sad, and had thoughts such as “it’s all my fault, I never do anything right”. The therapist gave her “Coping with Depression” (Beck & Greenberg, 1974) to read, and helped her to record and challenge her negative thoughts. She also discussed ways of being appropriately assertive with the boss, and recorded both the immediate and the long-term results of doing this. Therapy also involved encouraging her to take practical steps to look for alternative employment and accommodation. Therapists
The three therapists were all experienced cognitive therapists trained in the treatment of panic. During treatment the therapists viewed and commented on each other’s video tapes as part of mutual supervision. RESULTS Be&f change
Table 1 shows belief ratings for patients’ misinterpretations of bodily sensations. The extent to which therapy resulted in change in behef in these thoughts is indicated by the comparison of belief ratings at the end of the pre-treatment baseline period with belief ratings at the end of the second treatment session and at the end of the post-treatment baseline. In all patients focal cognitive treatment resulted in a reduction in belief ratings for each of the thoughts identified during the two sessions of focal treatment. However, in one case (patient 4) several additional panic relevant misinterpretations were identified in subsequent sessions. As expected, non-focal cognitive treatment did not result in reductions in belief ratings in Ss 6 and 7, even though focal cognitive treatment did. Overall, the belief ratings suggest that the two
.:.:.: /L
165
Cognitive therapy without exposure
Pattent
‘a
6
B
4
iJf$
:::::: *:.;.:
::::::
i$j;
0
Patient
7
6
I#$
$2 :I
Patient
1
fP 8
\
-1
~::l:~,liilz~ii!l~,~~
-4
-3
2
il-~.‘~~
-5 Pstient
_*
_,
3
. 2 3 ‘$ ::::i:;:::::f ii&.,
.:::::: ::::::
~~~“:~,,,,,
it;@
.fj
-5
-4
-3
-2
_,
~~
F
iii’i’. ,, ,2 .:: :..::::.:.::::.. . . .._s... . . . . . :::.;: ::::::
3
4
5
,~n
t
I
-3
-2
t
1 -1
TR,
+l
t +2
I +3
TFl2
1
f
i
2
3
Fig. 2. Panic attack frequency for patients 6 and 7 during baseline. non-focal treatment. further baseline. focal treatment and the final baseline periods consecutively. The stippled areas represent the week during which the two sessions of non-focal treatment (TR,) and focal treatment (TR,) were carried out.
Fig. 1. Panic attack frequency for patients 1-5 before, during and after focal cognitive treatment. The stippled area (TR) corresponds to the week during which the two treatment sessions were carried out.
treatments were successful in achieving their intended effects on misinte~retations sensations.
of bodily
Panic attack frequency For the five patients who only received focal cognitive treatment, panic attack frequencies are shown in Fig. 1, Panic attacks ceased completely in patient 2, while patients 1, 3 and 5 showed marked reductions in panic following the focal cognitive treatment. Patient 4 failed to show a change in panic frequency. For the two patients who received non-focal cognitive treatment followed by focal cognitive treatment panic attack frequencies are shown in Fig. 2. Non-focal treatment did not reduce panic attack frequency but focal treatment did. After focal treatment panic attacks stopped completely in patient 6, and patient 7 showed a substantial reduction in panic frequency. DISCUSSION The data reported here suggest that it is possible to substantially reduce panic using a brief cognitive treatment which excludes breathing retraining and exposure to feared situations or sensations. Of the seven patients reported, six showed a marked reduction in panic frequency
PAUL M. SALKOVSKISet al.
166
following focal cognitive treatment. In two instances this amounted to rapid and complete resolution of panic attacks. In the two patients who were first given a cognitive treatment which did not focus on misinterpretations of bodily sensations, belief in such thoughts and panic attack frequencies were unchanged until focal cognitive treatment was introduced. Then belief ratings and panic frequency reduced in the expected way. One S did not show a reduction in panic frequency after focal cognitive treatment, despite appropriate change in belief ratings for thoughts identified during the two sessions of treatment. There were several possible reasons for this. The patient’s baseline panic frequency was low and highly variable. During treatment, he had a two major independent life events. Finally, he had a particularly large number of misinterpretations and some of these were only elicited after the 2; hr allocated for focal treatment and so could not be changed during that treatment. The misinterpretations that were subsequently identified concerned feared loss of identity or death in a panic attack. The apparent success of focal cognitive treatment in bringing about short-term reductions in panic frequency suggests that at least part of the success of the full cognitive therapy package is likely to be due to its cognitive elements. This is an encouraging finding for cognitive approaches to the understanding and treatment of panic. However, we would not wish to suggest that therapists should rely entirely on cognitive procedures in routine clinical practice. Behavioural experiments are an effective way of bringing about belief change, and the majority of chronic patients with extensive avoidance are likely to need some exposure practice in order to achieve substantial and sustained improvement. Clinically it often seems that the most rapid and significant improvements are obtained when cognitive and exposure techniques are combined in an integrated approach to the modification of specific misinterpretations. A&nor~ledgemetr-The
authors
are grateful
to the Medical
Research
Council
of the United
Kingdom
for its support.
REFERENCES American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (3rd edn revised). Washington, D.C.: APA. Barlow, D. H., Craske, M. G., Cerny, J. A. & Klosko, J. S. (1989). Behavioural treatment of panic disorder. Behaviour Therapy, 20, 261-282. Beck, A. T. (1988). Cognitive approaches to panic disorder: theory and therapy. In Rachman, S. & Maser, J. (Ed.). Panic: Psychological perspectioes. Hillsdale, N.J.: Erlbaum. Beck. A. T. & Greenberg, R. L. (1974). Coping with depression. Booklet available from Center for Cognitive Therapy, University of Pennsylvania, Pa. Beck, A. T.,.Emery, G: & Greenberg, R. L. (1985). Anxiety disorders and phobias. New York: Basic Books. Beck, A. T.. Rush, A. J., Shaw, B. F. & Emergy, G. (1979). Cognifiue therapy of depression. New York: Guildford Press. Burns, D. (1980). Feeling good. New York: New American Library. Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461-470. Clark. D. M. (1988). A cognitive model of panic. In Rachman. S. & Maser, J. (Eds), Panic: ._ psychological perspectives. -.. Hillsdale, N.J.: Erlbaum. Clark, D. M. (1989). Anxiety States: Panic and generalized anxiety. In Hawton, K., Salkovskis, P., Kirk, J. & Clark, D. M. (Ed.), Cognifioe behaoiour therapy for psychiatric problems: A practical guide. Oxford: Oxford University Press. Clark, D. M. & Salkovskis, P. M. (1991). Cogniriue therapy for panic and hypochondriasis. New York: Pergamon Press. Clark, D. M., Salkovskis, P. M. & Chalkley, A. J. (1985). Respiratory control as a treatment for panic attacks. Journal of Behaniour Therapy and E.xperimental Psychiatry, 16, 23-30. Garssen. B., van Veenendaal, W. V. & Bloemink, R. (1988). Agoraphobia and the hyperventilation syndrome. Behariour Research and Therapy, 21, 643-649. Hersen, M. & Barlow, D. H. (1976). Single case experimental designs. New York: Pergamon Press. Klosko, J. S.. Barlow, D. H., Tassinari, R. & Cerny, J. A. (1990). A comparison of alprazolam and behaviour therapy in the treatment of panic disorder. Journal of Consulting and Clinical Psychology, 58, 77-84. Kopp. M., Milhaly, K.. Tringer, A. & Vadasz, P. (1986). Agoraphobics es panikneurotikus betegek legzesi kontroll keyelese. Ideggyogyaszati Szemle, 39, 185-196. Ley, R. (1985). Agoraphobia, the panic attack and the hyperventilation syndrome. Behapiour Research and Therapy, 23, 79-82. Marks, I. M. (1987). Fears, phobias and rituals. Oxford: Oxford University Press. Michelson, L., Marchione, K., Greenwald, Glanz, L., Testa, S. & Marchione, N. (1990). Panic disorder: Cognitivebehavioural treatment. Behaciour Research and Therapy, 28, 141-153. Rapee, R. (1986). Differential response to hyperventilation in panic disorder and generalized anxiety disorder. Journal of Abnormal Psychology, 95, 24428. Salkovskis, P. M. & Clark, D. M. (1986). Cognitive and physiological processes in the maintenance and treatment of panic attacks. In Hand, I. Wittchen,‘U. H. (Eds), Panic and- Phobias. cew York: Springer. Salkovskis. P. M.. Jones, D. R. 0. & Clark. D. M. (1986). Respiratory control in the treatment of panic attacks: Replication and extension’ with concurrent measurement of bedaviour and pCOz. British Journal of Psychiatry, 148, 526-532. Sokol. L., Beck, A. T., Greenberg, R. L., Wright, F. D. & Berchick, R. J. (1989). Cognitive therapy of panic disorder: A non-pharmacological alternative. Journal of Nervous and Mental Disease. 177, 71 I-716.
Behar. Rec. Thu. Vol.29, No. 2, pp. 161-166,1991 Printedin Great Bntain. All nghts reserved
TREATMENT THERAPY
OF PANIC ATTACKS WITHOUT EXPOSURE RETRAINING
USING COGNITIVE OR BREATHING
PAUL M. SALKOVSKIS,DAVID M. CLARK and ANN HACKMANN Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, England (Received 23 September 1990) Summary-Cognitive treatment of panic attacks is based on the hypothesis that panic results from the catastrophic misinterpretation of bodily sensations, and that changing such misinterpretations will block the occurrence of panic. The treatment normally involves an integrated set of cognitive and behavioural techniques. In a consecutive series of panic patients, a multiple baseline across subjects design was used to investigate whether a modified form of treatment involving only cognitive procedures could reduce panic attack frequency. The results provide preliminary evidence that cognitive procedures directed at changing misinterpretations of bodily sensations can reduce panic attack frequency, and also that cognitive procedures which do not target misinterpretations may not reduce panic.
INTRODUCTION
Successful treatment of panic attacks using various types of cognitive-behavioural therapy has now been widely reported (Barlow, Craske, Cerny & Klosko, 1989; Beck, 1988; Clark, Salkovskis & Chalkley, 1985; Klosko, Barlow, Tassinari & Cerny, 1990; Kopp, Mihaly, Tringer & Vasadz, 1986; Michelson, Marchione, Greenwald, Glanz, Testa & Marchione, 1990; Salkovskis, Jones & Clark, 1986; Sokol, Beck, Greenberg, Wright & Berchick, 1990). In many of these studies, treatment was based on recent cognitive theories of panic. These theories (Clark, 1986, 1988; Beck, Emery & Greenberg, 1985) state that panic attacks result from the catastrophic misinterpretation of certain bodily sensations. In particular, it is suggested that patients misinterpret largely benign sensations as signs of an imminent physical and mental disaster, such as having a heart attack, going mad or losing control of behaviour. This misinterpretation results in further anxiety, causing further and/or more intense bodily sensations which strengthen the misinterpretation, producing a vicious circle which culminates in a panic attack. Treatment based on the cognitive approach to panic aims to change patients’ catastrophic misinterpretations by helping them to identify and test alternative, more accurate explanations of their symptoms. One of the ways of doing this involves the use of behavioural experiments in which the therapist encourages the patient to engage in procedures which reproduce the sensations which occur in panic attacks. A variety of strategies are used to reproduce sensations; including imagery, bodily focussing, reading pairs of words (representing a symptom and an associated catastrophe) and voluntary hyperventilation (Clark & Salkovskis, 1991). Given the suggestion that hyperventilation may be associated with panic in a substantial proportion of panic patients (Garssen, Van Veenendaal & Bloemink, 1983; Rapee, 1986), early treatment studies particularly emphasized the use of voluntary hyperventilation, followed by training in controlled breathing as an efficient way of establishing a non-catastrophic interpretation of some patients’ symptoms (cf. Salkovskis & Clark, 1986). As cognitive therapy for panic includes behavioural techniques such as those described above, it could be argued that the effectiveness of the treatment is unrelated to the use of purely cognitive procedures. For example, it has been argued (Marks, 1987) that the treatment is only effective because it includes exposure to feared situations and/or sensations. It seems unlikely that exposure to feared situations alone can entirely account for the effectiveness of treatment because Clark et al. (1985) and Salkovskis et al. (1986) observed significant improvements in panic during a phase of treatment in which patients were asked not to go into situations which they had previously avoided (anti-exposure instructions). However, it is more difficult to exclude exposure to feared 161
PAUL M. SALKOVSKIS et al.
162
sensations as a possible explanation because all studies to date have included behavioural experiments which involve the induction of feared sensations. A further possible explanation for the effectiveness of treatment is physiological. Ley (1985) suggests that panic attacks are largely the result of hyperventilation and that treatment should centre on the control of breathing. It could therefore be argued that the cognitive treatment package is effective because it includes training in controlled breathing. In the case series reported here, cognitive therapy was conducted without any exposure to feared situations or sensations and without training in controlled breathing. Instead, purely cognitive procedures were used to modify patients’ catastrophic misinterpretations of bodily sensations. By restricting therapy in this way we attempted to obtain a preliminary indication of whether panic attacks can be reduced by purely cognitive means. If this is possible, then it seems likely that at least part of the effectiveness of the full cognitive treatment package is due to its cognitive elements. METHOD
Putients Seven patients referred to the Oxford University Department of Psychiatry for the treatment of panic were included in the series. All fulfilled DSM III-R (American Psychiatric Association, 1987) criteria for panic disorder with moderate or severe avoidance. Eleven consecutive patients were screened, of whom four were not suitable for the series; one patient had no panic attacks during the baseline period, one had a steeply descending baseline, one filled out his panic diary incorrectly and one only attended a single treatment session because of illness in her family. E.xperirncntal
design
A multiple baseline across Ss design was used (Hersen & Barlow, 1976). Five patients were randomly allocated to baselines of differing lengths, followed by a brief (two sessions within a week) cognitive treatment designed to change catastrophic interpretations of bodily sensations (focal treatment). After the treatment, a further baseline was instituted. At the end of this second baseline, patients were offered unrestricted further treatment as appropriate (data after this point is not reported, as exposure and other behavioural elements were added to treatment as considered necessary by the therapist). Two further patients were allocated to differing length baselines followed by another cognitive treatment (non-focal treatment) which did not focus on misinterpretations of bodily sensations but had a structure and duration comparable to the focal treatment. Non-focal treatment was followed by a return to baseline, then the focal treatment was conducted as in the first five patients, followed by a further baseline. In order to exclude the possibility that any improvements during treatment might be due to exposure to feared situations, patients were asked not to increase or decrease the extent to which they went into situations which they would tend to avoid (anti-exposure instructions) during the pre-treatment baseline, treatment periods, and the post-treatment baselines. Each time patients were seen for assessments or treatment sessions anti-exposure instructions were reiterated. In order to exclude the possibility that improvements during treatment might be due to exposure to feared sensations or breathing retraining no patient was given breathing retraining or asked to hyperventilate and no attempts were made to expose patients to feared sensations. Measures The hypothesis under examination was that frequency of panic attacks would be reduced by cognitive techniques which targeted and changed catastrophic misinterpretations of bodily sensations but not by cognitive techniques which did not target and bring about such changes. Accordingly, the therapists identified catastrophic misinterpretations at the start of therapy, and asked patients to rate their belief in these thoughts at the beginning and end of each treatment session and during the baseline periods. &lo0 scales were used to rate thoughts with 0 representing not believing the thought at all and 100 representing being totally convinced that the thought was true. Two ratings for each thought were taken: the now rating, ‘how much do you believe. right
Cognitive therapy without exposure
163
now’ and the then rating, ‘if you had all the symptoms that you have in a panic attack, how much would you believe. . . .‘. The main dependent variable was panic attack frequency which was derived from a daily panic diary (see Clark, 1989 for details of the diary). At the start of the pre-treatment baseline period, patients were given diary sheets and asked to record their panic attacks and limited symptom attacks each day. Recording continued throughout treatment and post-treatment baselines. Treatments Patients had two sessions of the assigned treatment within a period of 7 days. The sessions totalled not more than 2 hr 30 min. The first 30 min of session one were devoted to assessment. In the assessment the therapist tried to elicit details of any thoughts which represented catastrophic misinterpretations of panic-related bodily sensations. Once such thoughts were identified, patients rated their belief in the thoughts and these belief ratings were repeated at the end of session one and again at the beginning and end of session two. Each therapy session was audiotaped, and patients were given the audiotape to listen to and comment on as homework. Sessions were also video taped for supervision purposes. In both treatments, therapy was structured round an agenda set at the beginning of each session. Both treatments focused on thoughts but differed in the types of thoughts they attempted to modify. Focal treatment. In focal cognitive therapy sessions discussion exclusively focused on bringing about re-attribution of bodily sensations. Typically, treatment started by identifying the exact sequence of sensations, catastrophic interpretations, anxiety, further sensations and so on that occurred in a panic attack. Evidence for and against the catastrophic interpretations was reviewed and challenged. Evidence for and against the alternative cognitive account of the patient’s panic attacks was reviewed. The techniques employed were predominantly verbal. In many instances, this meant helping patients to understand the significance of experiences and information they already had which was inconsistent with their catastrophic explanations and which tended to support the alternative, cognitive formulation of their panic attacks. These discussions were supplemented by homework involving an extended version of the panic diary in which patients recorded the principal sensations experienced, any misinterpretations of these sensations and belief in them at that time, and alternative explanations (rational responses), followed by a rating of belief in the rational response and re-rating of belief in the catastrophic interpretation. For example, during the second session of focal treatment, patient six described the thought that she might pass out or die during a panic attack. Her principal evidence for this was the intensity and strangeness of the sensations she experienced, (tingling, heart pounding and a feeling of unreality) and she thought that such sensations must mean that there was something physically wrong. The therapist asked her if she had ever felt pleasantly excited. She recalled a recent occasion when she thought she had won a very large amount of money on the football pools. When describing the feelings experienced on that occasion she realised they were exactly the same as those which occurred during a panic, although she had not panicked on that occasion, but instead had been intensely excited. With further discussion she then concluded that this was convincing support for the idea that “the sensations themselves are not dangerous, it’s just that what you think about them can make them frightening”. Non:focal treatment. In non-focal treatment sessions discussion concentrated on issues of particular concern to the patient but excluding misinterpretations of bodily sensations. The rationale given to patients was that panic attacks are often the result of anxiety arising from life stresses, and that the first stage in the treatment of panic is the identification and modification of stressors. It was explained that reduced stress would be helpful in reducing the occurrence of panic attacks. Therapists were not constrained in their use of cognitive therapy techniques other than the exposure and breathing retraining exclusions described above and used a wide range of standard techniques (see Beck, Rush, Shaw & Emery, 1979; Beck, Emery & Greenberg, 1985; Burns, 1980). In session discussions were supplemented by homework assignments in which patients identified and challenged their negative thoughts using the Daily Record of Negative Automatic Thoughts (Beck et al., 1979). For example, during the first two sessions of non-focal treatment, patient 7 outlined her problems at work. She and her fiancee worked together, and lived in accommodation which was linked to
164
PAUL
Table
1. Belief
ratings
for panic-related
thoughts
before,
M. SALKOVSKIS during,
et
and after
ai.
focal
cognitive
therapy
and non-focal
Asse~ment
cognitive
therapy
occasion End
Post
Pre Patient
(1)
Belief
Context
I am going
suffocate
non-focal
focal
focal
therapy
therapy
therapy
therapy
baseline
-
-
0
0 IO 0
SO
20
0
50
0
0
panic
95
50
10
now
45
0
0
panic
100
50
10
now
(3)
I will
lose my mind
I will
bave a stroke
f amgoing
-
I
am going
now
mad
(41
I am going
_-
to lose control
-
I amgoing (5)
1 am
I am
having going
to pass out or faint to go mad a heart
attack
I am going
2s
50
10
20
80
40
30
no
40
IO
30
panic
90
60
40
now
25
IO
10
panic
70
40
15
-
-
now
to pass out
f am a danger (when (7)
to others
driving)
I am going I am going
to die
in thoughts
in thought
was rated
if you were
on O--l00 experiencing
scale. ‘Now’
rating
all the symptoms
IO
0
0
80 -
40
50
0
0
-
10
10
now
70
80
60
40
30
90
90
80
50
30
now
60
70
70
40
30
panic
60
90
9Q
40
30
now
78
80
55
50
0
78
80
80
55
0
SO
80
x5
70
75
panic Belief
-
panic
now
to faini
0 0 40
panic (6)
0 30 0
now
to pass out
60 100
50
now
attack
0
50
panic
to have a heart
-
0 10
80
now
panic I am going
-
now
of my behaviour
10 70
panic
(2)
of
post focal
therapy
panic I will
Post
non-focal
now
to faint
Pte
refers to belief
70
100
in thought
you have in a panic
while
sitting
85 In the clinic.
70 ‘Then’
75 rating
refers to belief
attack.
the job and very unsatisfactory. They were frequently exploited by their boss over issues such as holidays, pay, insurance and free time. The patient often felt angry with her boss, but was afraid to assert herself in case she and her fiance were thrown out of their apartment. She also often felt sad, and had thoughts such as “it’s all my fault, I never do anything right”. The therapist gave her “Coping with Depression” (Beck & Greenberg, 1974) to read, and helped her to record and challenge her negative thoughts. She also discussed ways of being appropriately assertive with the boss, and recorded both the immediate and the long-term results of doing this. Therapy also involved encouraging her to take practical steps to look for alternative employment and accommodation. Therapists
The three therapists were all experienced cognitive therapists trained in the treatment of panic. During treatment the therapists viewed and commented on each other’s video tapes as part of mutual supervision. RESULTS Be&f change
Table 1 shows belief ratings for patients’ misinterpretations of bodily sensations. The extent to which therapy resulted in change in behef in these thoughts is indicated by the comparison of belief ratings at the end of the pre-treatment baseline period with belief ratings at the end of the second treatment session and at the end of the post-treatment baseline. In all patients focal cognitive treatment resulted in a reduction in belief ratings for each of the thoughts identified during the two sessions of focal treatment. However, in one case (patient 4) several additional panic relevant misinterpretations were identified in subsequent sessions. As expected, non-focal cognitive treatment did not result in reductions in belief ratings in Ss 6 and 7, even though focal cognitive treatment did. Overall, the belief ratings suggest that the two
.:.:.: /L
165
Cognitive therapy without exposure
Pattent
‘a
6
B
4
iJf$
:::::: *:.;.:
::::::
i$j;
0
Patient
7
6
I#$
$2 :I
Patient
1
fP 8
\
-1
~::l:~,liilz~ii!l~,~~
-4
-3
2
il-~.‘~~
-5 Pstient
_*
_,
3
. 2 3 ‘$ ::::i:;:::::f ii&.,
.:::::: ::::::
~~~“:~,,,,,
it;@
.fj
-5
-4
-3
-2
_,
~~
F
iii’i’. ,, ,2 .:: :..::::.:.::::.. . . .._s... . . . . . :::.;: ::::::
3
4
5
,~n
t
I
-3
-2
t
1 -1
TR,
+l
t +2
I +3
TFl2
1
f
i
2
3
Fig. 2. Panic attack frequency for patients 6 and 7 during baseline. non-focal treatment. further baseline. focal treatment and the final baseline periods consecutively. The stippled areas represent the week during which the two sessions of non-focal treatment (TR,) and focal treatment (TR,) were carried out.
Fig. 1. Panic attack frequency for patients 1-5 before, during and after focal cognitive treatment. The stippled area (TR) corresponds to the week during which the two treatment sessions were carried out.
treatments were successful in achieving their intended effects on misinte~retations sensations.
of bodily
Panic attack frequency For the five patients who only received focal cognitive treatment, panic attack frequencies are shown in Fig. 1, Panic attacks ceased completely in patient 2, while patients 1, 3 and 5 showed marked reductions in panic following the focal cognitive treatment. Patient 4 failed to show a change in panic frequency. For the two patients who received non-focal cognitive treatment followed by focal cognitive treatment panic attack frequencies are shown in Fig. 2. Non-focal treatment did not reduce panic attack frequency but focal treatment did. After focal treatment panic attacks stopped completely in patient 6, and patient 7 showed a substantial reduction in panic frequency. DISCUSSION The data reported here suggest that it is possible to substantially reduce panic using a brief cognitive treatment which excludes breathing retraining and exposure to feared situations or sensations. Of the seven patients reported, six showed a marked reduction in panic frequency
PAUL M. SALKOVSKISet al.
166
following focal cognitive treatment. In two instances this amounted to rapid and complete resolution of panic attacks. In the two patients who were first given a cognitive treatment which did not focus on misinterpretations of bodily sensations, belief in such thoughts and panic attack frequencies were unchanged until focal cognitive treatment was introduced. Then belief ratings and panic frequency reduced in the expected way. One S did not show a reduction in panic frequency after focal cognitive treatment, despite appropriate change in belief ratings for thoughts identified during the two sessions of treatment. There were several possible reasons for this. The patient’s baseline panic frequency was low and highly variable. During treatment, he had a two major independent life events. Finally, he had a particularly large number of misinterpretations and some of these were only elicited after the 2; hr allocated for focal treatment and so could not be changed during that treatment. The misinterpretations that were subsequently identified concerned feared loss of identity or death in a panic attack. The apparent success of focal cognitive treatment in bringing about short-term reductions in panic frequency suggests that at least part of the success of the full cognitive therapy package is likely to be due to its cognitive elements. This is an encouraging finding for cognitive approaches to the understanding and treatment of panic. However, we would not wish to suggest that therapists should rely entirely on cognitive procedures in routine clinical practice. Behavioural experiments are an effective way of bringing about belief change, and the majority of chronic patients with extensive avoidance are likely to need some exposure practice in order to achieve substantial and sustained improvement. Clinically it often seems that the most rapid and significant improvements are obtained when cognitive and exposure techniques are combined in an integrated approach to the modification of specific misinterpretations. A&nor~ledgemetr-The
authors
are grateful
to the Medical
Research
Council
of the United
Kingdom
for its support.
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