Specific phobia
Diagnostic features
The defining characteristics of specific phobia are intense fear of anxiety in the presence of a
specific stimulus or situation, where this fear results in impairment or discomfort, and the individual
realizes that the fear is excessive. Typical specific phobias include fears of animals, blood or
injection, heights, water, insects, rats, and other stimuli or experiences. About 11% of the general
population has a lifetime prevalence of specific phobia (Wittchen et al., 1994).
Evaluation
Specific phobia is intense fear and arousal in the presence of a specific stimulus or feared object
(such as heights, animals, water). This is distinguished from panic disorder (where the fear is that
the individual's arousal will go out of control and cause a medical emergency or insanity) and from
SAD where the individual fears that the symptoms of anxiety will be observed by others resulting in
humiliation or embarrassment. Specific phobia is also distinguished from PTSD in that patients
with PTSD fear intrusive memories or images. Specific phobia can be evaluated by use of a variety
of instruments, including the Fear Questionnaire (Marks and Mathews, 1979) and the Fear Survey
Schedule (Wolpe and Lang, 1964).
Theoretical models
The most widely used theoretical model of specific phobia is based on learning theory. Since
Watson's (1919) observations of a conditioned fear of furry objects in a young child (by pairing
shock with a rabbit), behavior therapy has viewed specific phobia as resulting from a learned
association of a negative consequence paired with a neutral stimulus. This classical, or Pavlovian,
model was later modified in the two-factor theory of conservation of fear proposed by Mowrer
(1960). According to Mowrer, the initial fear was established through classical conditioning (e.g.,
the neutral stimulus of the stove was paired with the negative experience of being burned).
However, avoidance of the stove in the future was based on operant conditioningthat is, when the
individual approached the stove there was an increase of fear. Avoiding or escaping was associated
with reduction of fear (thereby negatively reinforcing the operant of escape or avoidance through
the consequence of fear reduction). The two-factor model thus accounted for the acquisition of fear
through classical conditioning and the avoidance of feared stimuli through the negative
reinforcement of reducing fear through the operants of escape of avoidance. Fear was thereby
conserved.
The implication of the classical and operant models was that fear could be overcome by direct
exposure without escape. In addition, Wolpe (1958) introduced the idea of responses incompatible
with fear or anxiety with the concept of reciprocal inhibition. This refers to the fact that certain
responses (or experiences) (e.g., relaxation, sexual behavior, and assertiveness) are incompatible
with the response of fear. By pairing these incompatible responses (e.g., inducing relaxation in the
presence of the feared stimulus) the individual can decondition the learned fear. Related to this
model is the use of habituation techniques and extinctionthat is, repeated exposure of the stimulus
will reduce its potentiating effect (habituation) or repeated exposure without reinforcement (e.g.,
escape is negatively reinforcing) reduces the acquired associative link of the conditioned stimulus
(CS) (e.g., the stove) with the learned (conditioned) response (e.g., fear).
While recognizing the value of conditioning and negative reinforcement for escape and avoidance,
there has been a growing recognition of the importance of prepared behaviors (Seligman, 1971),
innate fears, or innate predispositions. According to these Darwinian influenced ethological models
there are certain stimuli that the human infant is predisposed to fear. These stimuli reflect dangers in
the evolutionary expected environmentthat is, the primitive environment of danger from predators,
natural catastrophes, and abandonment. For example, research on the distribution of fears in various
cultures reveals that the same stimuli are largely equally feared and that these stimuli reflect
primitive dangers. This nonrandom distribution of fears, with heights, water, animals,
thunder/lightening topping the list, suggests that human infants and children are preadapted to fear
events that confer danger. The Dunedin study in New Zealand offers further support to the
ethological model of fear. In this study a large number of children were followed from early infancy
to early adulthood and records of their fears and their experiences with feared events was obtained.
Contrary to the learned fear model proposed by associationist and operant theories, children who
previously have suffered injuries from falling were less afraid of falling in the future. The learning
models would have predicted the oppositebut the ethological model suggests that fears may be
protective and innately predisposed. Moreover, an overwhelming high percentage of parents of
children who feared water were afraid of the water on the very first presentation of a pool of water.
Now, despite the argument that fears may be predisposed through evolution, the ethological model
argues for some plasticity that is, fears can be unlearned through exposure.
The cognitive model of specific phobia suggests that, in addition to the two-factor theory and the
ethological model, there are specific cognitions and behaviors that may add to fear and avoidance.
These include beliefs that the threat/danger of a stimulus is related to the fear that it elicits (see Ost,
1997; Ost and Hugdahl, 1981) and that safety behaviors may protect the individual from the threat.
Examples of these cognitive distortions in fear include the following: If I am anxious, then it must
be dangerous and I must get rid of the anxiety immediately. Safety behaviors include superstitious
behaviors or thoughts that attempt to neutralize the fear or provide some protection from the fear.
Examples of safety behaviors that fearful individuals may utilize include repeated self-assurance
(praying, self-talk), magical rituals (wearing specific clothing on an airplane), hypervigilant
scanning of the environment (e.g., checking for sounds and movements on an airplane), collecting
information about danger (e.g., checking the weather forecasts or safety records of airlines), and
requiring someone to accompany them when in the presence of a feared stimulus. The cognitive
model of specific phobia suggests that these safety behaviors act as a disattribution errorthat is, The
only reason that I am safe is that I engaged in my safety behaviors. Thus, safety behaviors might
reduce the efficacy of the exposure used in behavioral treatmenta supposition now supported by
empirical data.
Empirical support for treatments
There is overwhelming support for the efficacy of behavioral exposure treatment for specific
phobiain some cases, over 90% of patients being effectively treated with exposure treatment with
some use of anxiety management techniques (Ost, 1997). Most fears can be successfully treated in
fewer than five sessions, with massed practice or prolonged exposure yielding more rapid results.
Rationale for treatment and interventions
Given the importance of the role of avoidance and escape in the maintenance of fear, behavioral
treatments rely on repeated exposure to feared stimuli. The rationale for treatment is to identify the
feared situations or stimuli, introduce the use of relaxation techniques (if needed), and engage the
patient in gradual but prolonged exposure to the stimulus. We have found it helpful to educate the
patient about the evolutionary significance of phobiasthat is, that most of the stimuli that are feared
(e.g., heights, water, insects, animals) would confer danger in a primitive environment where these
feared stimuli were present and dangerous. This preparedness of phobia leads to the emergence of a
fear later, but that the use of behavioral exposure can reverse this process. The two-factor theory of
anxiety conservation outlined by Mowrer (1939, 1960) can be helpful in understanding that fears
may be acquired through being paired with a noxious experience, but that they are maintained or
conserved through the anxiety reduction of escape or avoidance.
Strategies and techniques
Behavioral treatment of specific phobia follows a set pattern of interventions. During the
assessment phase the therapist evaluates which stimuli or situations are avoided or experienced with
discomfort. The Fear Survey is a useful assessment measure as is the Initial Fear Evaluation for
Patients (Leahy and Holland, 2000). The patient's Fear Hierarchy (see Leahy and Holland) provides
information for the assessment of a ranking or hierarchy of feared situations as well as the rating of
degree of fear and whether the situation is actually avoided. Although anxiety management (such as
breathing exercises and relaxation) are helpful, they are not necessary for exposure to the feared
stimulus.
Brief plan of treatment
Socialization to treatment begins with providing the patient with the Information for Patients about
Specific Phobia (Leahy and Holland, 2000) or by informing the patient of the nature of acquired
and predisposed fear. Patients often find the Darwinian model provides them with a demystifying
and nonstigmatizing explanation of their fear. Initial interventions involve training the patient in
relaxation techniques (deep muscle relaxation, breathing, meditative techniques). Patients are
trained in identifying Subjective Units of Distress (SUDs), rating their fear or anxiety from 0 to
100% (or 010), with higher numbers corresponding to greater fear. Imaginal exposure is used
whereby the patient begins with imagining, in session, the least feared situation in the hierarchy and
holding this image in mind until SUDs are reduced by 50% or more and then moving up the
hierarchy to gradually more feared stimuli. In vivo exposure involves actual exposure to the feared
stimulus. It is useful to obtain initial SUDs right before, during, and after the exposure and to elicit
predictions from the patient about what he or she fears will happen (e.g., the elevator will crash or I
will drive off the bridge).
Safety behaviors are important impediments to exposure efficacy and these can be identified by
asking patients if they do anything to make themselves feel safer. For example, asking the patient,
When you drive across the bridge, when you are afraid, do you do any of the following to make
yourself feel safertalk to yourself, avoid looking to the side, clench the steering wheel, slow down,
or anything else?
As the patient is able to tolerate situations higher in the hierarchy the therapist can indicate that
continued exposure far beyond normal experiences with the stimulus should be continued after
treatment has been completed. For example, a patient with a fear of elevators should be told to
continue taking elevators up and down for weekseven when it is not necessary in order to
overpractice exposure. Any setbacks or relapses should be followed by re-initiating the program of
exposure. Relaxation should be continued on a daily basis in order to reduce physiological arousal.
Case example
The patient was an executive in his fifties who had suffered from fear of heights for 9 yearswith this
fear increasing in the past 3 years. The patient indicated that he feared crossing bridges, climbing
mountains, driving in the mountains, and standing close to the edge of precipices. He indicated very
little fear of flying and pointed out that his fear of heights was due to his fear that he might lose
control of the vehicle or himself and fall over the side. He utilized a number of safety behaviors that
he believed lessened his fear, including having his wife drive or accompany him as a passenger (She
could take over the driving), planning far ahead so as to anticipate trouble, avoiding looking to the
side of the bridge, clenching the steering wheel, driving very slowly, alternating with the break and
accelerator, talking to himself, avoiding the rear-view mirror, and avoiding bridges or heights
totally.
The therapist explained to the patient both the Darwinian model and the learning theory model and
provided him with the information sheet from Leahy and Holland (2000). He was quite skeptical of
both models and said he would take a wait and see attitude. The therapist encouraged this and
suggested, Let's collect some data about what happens with your fear as we proceed. A fear
hierarchy for heights was obtained and the first intervention was imaginal exposure for thinking
about specific bridges. The in-session imaginal exposure suggested little initial fear, so the imagined
stimulus was changed to thinking about himself standing at the edge of a cliff. This immediately
increased fear, which abated with prolonged exposure.
Specific safety behaviors were targeted. The therapist explained how these safety behaviors made
him believe that he could not face the situation without these magical behaviors and thoughts and
then relinquishing them would be important. The therapist utilized a role-play where the therapist
played the role of the safety behavior thoughts (e.g., You need to clench the steering wheel or you
will go over the side) while the patient argued against these thoughts. Furthermore, the patient was
asked to imagine and later actually produce the opposite behaviors of his safety behaviors. For
example, rather than clenching the wheel, he was asked to loosen his grip, rather than driving
slower, he was to drive normally, rather than avoid the rear view mirror, he was to look at it on and
off, and rather than avoiding looking over the side, he was to gaze on and off over the side. These
were first practiced with imaginal training and later with in vivo training. Finally, he was to write
out his predictions of what would happen and the actual outcome for various exposures.
Closer questioning revealed that the patient was inadvertently hyperventilating by taking very deep
breaths during these experiences. Apparently he had heard that you should take deep breaths to calm
yourself. It was explained that this might add to his sense of light-headedness and that he should
breathe normally.
After seven sessions (spaced over a 3-month period) after the initial intake, the patient had engaged
in all of the feared behaviors in his hierarchy, including driving across numerous long bridges,
driving for hours in the mountains, and standing at the edge of cliffs. These exposures became
boring in themselves, but he was encouraged to continue to look for further opportunities after his
treatment was completed.
Psychodynamic model for specific phobia
From the psychodynamic viewpoint, specific phobias develop from the ego's response to the
threatened emergence of forbidden aggressive or sexual wishes. When these wishes trigger signal
anxiety, certain defense mechanisms characteristic of phobias are activated to repress and disguise
these wishes: displacement, projection, and avoidance (Gabbard, 2000). For example, in Freud's
case of Little Hans (Freud, 1909/1955), a child developed a phobia of horses, which in Freud's view
had come to symbolically represent his father. The child's fear of aggressive and competitive wishes
toward his father was displaced (to horses) and projected: the horse was going to damage him,
rather than that he was going to damage the horse (father). Then the anxiety could be diminished by
the avoidance of horses. Thus, the phobic symptom symbolically replaced the anxiety from
unconscious wishes.
Psychodynamic treatment of specific phobia
In psychodynamic psychotherapy, the therapist seeks to elucidate the meanings of the specific
symptom, and the defenses that contribute to it, and uses them as guides for disentangling the
unconscious threatening wishes. Exploring the circumstances surrounding symptom onset and what
comes to mind about a specific symptom aids in this process. In this context the frightening
unconscious wishes can be brought into consciousness and rendered less threatening. For example,
when Freud communicated to Hans his aggressive and competitive wishes toward his father, his
phobic symptoms resolved.
Obsessive-compulsive disorder
Diagnostic features
The DSM-IV [American Psychiatric Association (APA), 1994] defines obsessions as
persistent and recurrent thoughts, ideas, images, or impulses that are experienced as intrusive and
inappropriate, that are not simply excessive worries about real-life problems, and that cause marked
anxiety or distress (e.g., thoughts of killing a child, becoming contaminated). The person recognizes
that they are a product of his own mind and attempts to suppress or ignore the obsessions or to
neutralize them with some other thought or action.
Compulsions are defined as repetitive behaviors (e.g., checking the stove, handwashing) or mental
acts (e.g., counting numbers) that the person feels driven to perform in response to an obsession or
according to rigid rules. The compulsion is aimed at preventing or reducing distress or preventing
some dreaded situation; however, the compulsions are either unrealistic or clearly excessive.
Insight into illness is no longer necessary for the diagnosis so long as the excessiveness or
senselessness of obsessions and compulsions is recognized at some point during the course of the
disorder.
Diagnostic and assessment measures
OCD may be diagnosed using semistructured clinical interviews such as the Structured Interview
for the DSM (SCID-P; Spitzer et al., 1987) or the Anxiety Disorders Interview Schedule (ADIS-IV;
DiNardo and Barlow, 1988; DiNardo et al., 1993). Dimensional measures may also be used to
assess for the severity and content of symptoms. The Yale-Brown Obsessive-Compulsive Scale is
the most widely used rating scale in assessing severity of OCD symptoms (Y-BOCS; Goodman et
al., 1989a,b). Other rating scales include the Mandsley Obsessive Compulsive Inventory (Hodgson
and Rachman, 1977), the Padua Inventory (Sanavio, 1988), the Obsessive-Compulsive Inventory
(Foa et al., 1998b), and the Compulsive Activity Checklist (Freund et al., 1987). Finally, two recent
questionnaires, the Obsessional Beliefs Questionnaire and the Interpretation of Intrusions Inventory,
have been developed by an international consortium of researchers to identify and rate cognitive
aspects of intrusive thoughts and obsessions (Obsessive Compulsive Cognitions Working Group,
1997, 2001).
Other measures to assess for general severity of illness include the Beck Anxiety Inventory (BAI;
Beck et al., 1988a) and the Beck Depression Inventory (BDI; Beck et al., 1988b). Patients may also
be given general measures of disability such as the Sheehan Disability Scale (Leon et al., 1992) to
assess the degree to which the symptoms are interfering with the patient's functioning.
Treatment forms utilized over the course of treatment included the automatic and revised thought
log, the obsession-compulsion monitoring form, the imaginal and in vivo exposure form, and the
exposure monitoring form (McGinn and Sanderson, 1999).
Cognitive-behavioral models of obsessive-compulsive disorder
Behavioral models: two-stage theory
Mowrer's two-stage theoretical model of the acquisition and maintenance of fear and avoidance
behaviors (Mowrer, 1939, 1960) has been further elaborated to explain the onset and maintenance
of symptoms in OCD (Dollard and Miller, 1950). This model proposes that a stimulus that does not
automatically elicit anxiety or fear (a neutral stimulus) becomes associated with a stimulus (an
unconditioned stimulus or UCS) that naturally elicits anxiety or fear (an unconditioned response or
UCR) by being paired with it. Through this pairing, the previously neutral stimulus (the CS) now
becomes capable of eliciting fear or anxiety on its own (the conditioned response or CR). Obsessive
fears, which take the form of recurrent and intrusive thoughts, images, ideas, or impulses are
proposed to develop via this conditioning process. For example, Jim may become anxious about
eating meat if he develops salmonella poisoning. Eating meat (NS) becomes associated with
salmonella poisoning (UCS) and becomes capable of eliciting fear on its own (CS).
In explaining how fear or anxiety maintains itself, the model proposes that individuals develop
avoidance and escape behaviors (e.g., avoid eating meat, repetitively wash hands if they come into
contact with meat) to reduce the anxiety elicited by the CS (e.g., meat), and by doing so, become
negatively reinforced by the cessation of anxiety that follows. In other words, despite the fact that
the CS (e.g., meat) is no longer paired with the initial traumatic stimulus or UCS (e.g., salmonella
poisoning), the conditioned fear response continues because the individual is negatively reinforced
by the experience of reduced anxiety that follows the escape or avoidance behaviors, including
compulsive rituals. As a result, the fear response does not extinguish because the individual does
not learn that the CS is no longer paired with the UCS and that it is not dangerous in and of itself.
Compulsive rituals are conceptualized as avoidance behaviors that are developed to reduce this
elicited anxiety. Because obsessions are intrusive, passive avoidance and escape behaviors are
usually insufficient in alleviating the anxiety associated with their arousal. Hence, active avoidance
behaviors (compulsions) are developed by individuals in order to reduce the anxiety created by the
CS (in this case, meat), and are maintained by their success in doing so.
Evidence for Mowrer's two-stage theory of the development of fear is insufficient. Not only do a
majority of patients with anxiety disorders, including OCD, deny a link between symptom onset and
specific traumatic events (Rachman and Wilson, 1980), this model does not take into account other
modes of onset reported by patients such as informational learning (e.g., becoming fearful of germs
after hearing about a news report on the breakout of Escherichia coli among school children) or
observational learning (e.g., growing up with a parent who is constantly afraid of catching a
disease) (Foa and Kozak, 1986).
By contrast, there is far more support for Mowrer's two-stage conceptualization of the maintenance
of fear. Studies have demonstrated that environmental cues trigger anxiety and that obsessions
increase distress. Research has also demonstrated that performing handwashing and checking rituals
following an urge to ritualize leads to decreases in anxiety.
Other models to explain OCD
Cognitive Model
Defect in Information Processing Model (Foa)
Salzman describes the obsessive and compulsive dynamism as a need to control all aspects of life.
A meta-analysis by Abramowitz (1997) examining only controlled trials confirms the finding that
combined exposure and response prevention leads to a substantial improvement in patients with
OCD, and finds that the effectiveness of behavioral treatments increase with therapist-guided, direct
exposure (Abramowitz, 1997).
Overall, recent controlled trials demonstrate that behavior therapy may be as or more effective than
medication alone, and that behavior therapy is associated with a comparably lower rate of relapse .
Further confirmation comes from a meta-analysis conducted by Abramowitz (1997) who found an
overall advantage of behavior therapy over selective serotonin reuptake inhibitors in the studies
reviewed. Studies also suggest that combining medication and behavior therapy may not confer a
benefit over behavior therapy alone but may be more beneficial than medication alone, especially in
preventing relapse.
An examination of the relative efficacy of behavioral techniques for the treatment of obsessive
thoughts indicates that obsessive thoughts respond primarily to exposure (Mills et al., 1973; Foa et
al., 1980a, 1984) and that combined in vivo and imaginal exposure appear to be superior at
maintaining long-term gains, particularly for those patients who cognitively avoid their catastrophic
fears (Foa et al., 1980b). Exposure appears somewhat less effective in the treatment of pure
obsessionals (patients who present with obsessive ruminations but no compulsions). However,
experts believe that many pure obsessionals may present with covert rituals that are not classified as
such and hence the untreated rituals may serve to hinder the treatment of obsessions . Efficacy
studies also indicate that ritualized behaviors and thoughts respond primarily to response
prevention.
PART II
Panic disorder and agoraphobia
Diagnostic features
Panic disorder is defined by the occurrence of panic attacks, which are marked by intense physical
sensations (heart palpitations, shakiness, sweating, shortness of breath, sensation of choking, chest
pain, nausea, dizziness, feelings of detachment or unreality (depersonalization or derealization), fear
of losing control or going insane, fear of a medical crisis (e.g., heart attack), numbness or tingling,
and hot or cold flashes (APA, DSM IV)). Agoraphobia is characterized by fear of open spaces,
places where exit is blocked or other stimuli (such as heights, bright sunlight), where the fear is that
the situation may elicit a panic attack. The lifetime prevalence of panic disorder is 1.5-3.8%, with
females twice as likely to manifest this disorder. Age of onset for panic disorder with agoraphobia is
in the early twenties.
Evaluation
Panic disorder is distinguished from SAD in that in SAD the main fear is that others will see the
individual's anxiety and that this will be a humiliating experience. Panic disorder is distinguished
from OCD in that in OCD the main fear is of making mistakes or being contaminated or leaving
something undone rather than the fear of the consequences of one's own anxiety, as is characteristic
of panic disorder. Although in the general population there are many individuals who manifest
agoraphobia without prior history of panic disorder, it is individuals with both panic disorder and
agoraphobia who are more likely seek treatment.
People with panic disorder and agoraphobia are 18 times more likely to try to commit suicide than
people without any psychiatric disorder and are more likely to have an increased risk of
cardiovascular disease, including aneurysm, congestive heart failure, and pulmonary embolism .
These people eventually have a risk of stroke that is twice the rate for other psychiatric disorder
Theoretical models
Many of the situations that are feared by the agoraphobic are situations that might confer greater
danger in an evolutionary adaptive environment (Leahy and Holland, 2000). For example, situations
that might elicit panic attacks are open spaces (greater vulnerability to predators), closed spaces
(vulnerability to suffocation or being trapped), bright sunlight (more visible to predators), and
heights (danger of falling). Although the fear in panic disorder is of the consequences of one's own
anxiety symptoms (that is, the fear of going insane, losing control, or a medical crisis) it may be that
this fear of fearelicited in these specific situations was adaptive to primitive ancestors. There is a
reasonably high heritability component for panic disorder, suggesting a genetic link of some
importance.
The cognitive-behavioral theoretical model is derived from the work of A. T. Beck et al. (1985),
Clark (1986), and Barlow (1988). The initial physiological arousal rapid breathing, dizziness, or
sweatingmay, in some cases, be due to greater exertion, fatigue, undiagnosed illness, life stressors
that are often underestimated by the panicker. This initial panic attack is accompanied by a
catastrophic interpretation I am going crazyleading to hypervigilance for other signs of anxious
arousal. This increased self-focus on one's own arousal increases the likelihood of arousal being
detected or escalated leading to false confirmations that another panic attack is imminent. Many
panickers rely on safety behaviors such as being accompanied by another person, stiffening one's
posture, taking deep breaths (that augment the hyperventilation syndrome). Situations that trigger
increased arousal such as open spaces, heights, closed spaces, or behaviors that trigger arousal
(exercise) are anticipated with dread or tolerated with increased discomfort.
Empirical support for treatment
Gould et al. (1995) have provided a meta-analysis of 48 controlled studies of cognitive-behavioral
treatment of panic disorder with agoraphobia. The authors concluded from this analysis that CBT
was highly effective in yielding panic-free outcomes, with an effect size of 0.88 (compared with an
effect size of 0.47 for pharmacological treatment). The range of percent of patients who received
CBT who were panic free after treatment was between 32% and 100%. In most of the studies
reviewed, the percentage of panic free exceeded 80%. When CBT was compared with an emotionfocused approach, the former was significantly more effective than the latter (Shear et al., 2001).
Rationale for treatment and interventions
Strategies and techniques
The plan of treatment involves a variety of interventions including socialization to treatment
(explaining the CBT model of panic and agoraphobia and the use of bibliotherapy), anxiety
management techniques (rebreathing, PMR, time-management), construction of a fear hierarchy
(including external stimuli for example, open areas, heights, closed spaces, and interoceptive
stimulifeelings of dizziness or hyperventilation sensations), and gradual exposure to stimuli in the
hierarchy. In addition, identifying catastrophic predictions, eliminating safety behaviors, and setting
up behavioral experiments to disconfirm negative predictions about anxious arousal are important
cognitive components of treatment.
We utilize the patient information forms from the Leahy and Holland (2000) manual on treatment of
depression and anxiety disorders. Many patients find the schematic presented above to be especially
useful in demystifying the nature of panic disorder. Behavioral anxiety management techniques
(such as relaxation training, activity scheduling, and rebreathing) are helpful in reducing overall
level of arousal, but are not sufficient in themselves to eliminate panic disorder or anticipatory
anxiety about having panic attacks. It is important to convey to the patient that reducing anxious
arousal is not the same thing as decastrophizing anxietyas some anxious arousal will be inevitable,
it is important to develop a different interpretation and response to the anxiety. Indeed, in explaining
the cognitive-behavioral treatment plan, the therapist should be careful to inform the patient that
increasing anxious arousalthrough exposureand even inducing panic attacks in sessionwill be
essential components of therapy.
The process of exposure, and the role of safety behaviors, is explained to the patient as an
opportunity to learn (with new tools that are available) that panic attacks can be induced,
experienced, and naturally come to a swift conclusion. This will help disconfirm the belief that
panic attacks will lead to something more adversesuch as insanity or medical emergencies.
Furthermore, safety behaviors will need to be eliminated as they do not allow disconfirmation of the
panic beliefs. Thus, as illustrated in the schematic, the patient utilizing the superstitious safety
behaviors (such as holding on to a chair in order to avoid falling) will not experience the liberating
experience of learning that his dizziness does not lead to a collapse response even when he is not
holding on to the chair.
We utilize imaginal exposure early in treatment to afford the patient with the opportunity of
experiencing the feared stimuli within a more comfortable presentation. During imaginal exposure
to the situations and sensations of panic, the therapist engages in role-plays with the patient to either
elicit the catastrophic predictions (e.g., I am losing control and I will die) or to challenge these
catastrophic predictions (e.g., I have had numerous panic attacks and nothing terrible has
happened). Many patients are assisted by using flash cards (e.g., index cards) on which catastrophic
predictions are written on one side while rational or calming responses are listed on the other side.
Subsequent to imaginal exposure the therapist and patient will move on to more threatening stimuli
and will engage in exposure to these situations in vivo.
Inducing panic attacks in session, with the explanation of this technique and its rationale, can allow
the patient to engage in experiencing the interoceptive stimuli (shortness of breath, dizziness,
sweating, or heart racing)and learn that these sensations are self-limiting. Induction of panic
symptoms can be accomplished by practicing rapid breathing or spinning in a chair with the
therapist noting the patient's report of subjective units of distress (anxiety level) at short periodic
intervals. Some clinicians find it useful to provide the patient with panic-reversal behaviorssuch as
breathing into a bag slowly, practicing diaphragmatic breathing, or running in place (all of which
will establish a balance of carbon dioxide and reduce hyperventilation or dizziness). However, it is
also effective to allow the patient the opportunity that riding out a panic attack without utilizing
these anxiety management techniques can also be effective.
Case example
The patient was a single woman in her mid-twenties who complained of fearing panic attacks in
shopping malls. She indicated that her first panic attack occurred 2 months after her breakup in a
relationship when she became intensely anxious while at an indoor shopping mall where she had
previously had a discussion about a breakup with her boyfriend. During the initial panic attack she
experienced shortness of breath, dizziness, sweating, and a sense that she was about to collapse and
feared that she would not be able to get out of the mall without being accompanied by someone.
Subsequent to the initial panic attack she began to experience intense anxiety while walking along
wide avenues in New York City. As a result of her panic disorder she avoided malls and tried to
walk close to buildings to which she could escape from the open space in the event of a panic
attack.
The first phase of treatment focused on socialization to the CBT model of panic. This involved
providing her with an evolutionary rationale for innately predisposed fears of open spaces. In
addition, further evaluation indicated that her safety behaviors included scanning the street or
building for quick exits or escape routes, tightening her body while walking, narrowing her focus on
specific signs of danger, sitting in a chair, exiting the street into a taxi, and trying to take deep
breaths (which was based on the incorrect advice of another therapist). She was instructed in
diaphragmatic breathingwhich she practiced as an initial homework assignment. A fear hierarchy
was constructed that consisted of being at the center of a mall (most feared), walking into a mall,
walking into a crowded hotel lobby, walking along a wide avenue, fluorescent lights, and bright
sunlight. The therapist indicated that these feared stimuli might be related to situations that
conferred danger in a primitive environment (being trappedno exit availableand bright light making
her more visible and vulnerable to predators). Initially, she was quite skeptical of this
interpretationbut she noted over the week following the first meeting that she felt considerably less
anxious.
Noting her safety behaviors was also valuable for her, as it helped explain why she still maintained
her fears even after she had experienced some exposure. Specifically, the therapist indicated that she
might be inclined to attribute a successful exposure experience to her safety behaviorsrather than to
the safety of the situation. She was instructed to keep track of her use of safety behaviors, identify
her predictions of what would happen if she relinquished these behaviors (e.g., I will collapse or If I
do not tighten my body when I am walking, I will lose control and run out). These predictions were
subsequently tested out by either deliberately relinquishing the safety behaviors or actually doing
the opposite of her safety behaviors (e.g., purposefully trying to make her body as loose as possible
or avoiding looking at any exits and scanning the sidewalk rather than the buildings for safety
places).
Gradual exposure to avenues and crowded streets was followed by exposure to hotel lobbies. She
was instructed to repeat these exposures for 30 minutes each dayand to view her experience of
anxiety as a successful component of her exposure. This was considered important as she had
perfectionistic expectations about her anxietyI shouldn't feel any anxiety. This idealized view was
challenged by You need to have some anxiety or fear during exposure for you to learn that your
anxiety will diminish.
At termination of treatment after 3 months the patient was able to enter and walk through malls with
mild anxiety and to cross wide avenues without anxiety. Her mood and confidence had improved
substantially and she reported greater confidence in being able to handle any threat of panic in the
future.
Psychodynamic model of panic disorder
The model for panic disorder described by Busch et al. (1991) and Shear et al. (1993) weaves
neurophysiological factors with psychodynamic concepts and data to develop a psychodynamic
formulation for panic disorder. This model was employed for the development of treatment
interventions and manualization (Milrod et al., 1997). The authors describe that an inherent
tendency toward fearfulness in unfamiliar situations results in a state of fearful dependency on
significant others in the child's environment to provide a sense of safety. This anxious attachment
causes a narcissistic humiliation for the child, as he cannot feel safe without the help of others, and
a propensity toward anger at others for being unable to provide sufficient comfort to relieve his
anxious state. Children may also develop a state of fearful dependency in environments in which
parents behave in a critical, threatening, or rejecting manner.
Thus these children develop representations of others as abandoning, rejecting, and controlling.
Anger at others is fueled by these perceptions, but the child is fearful of experiencing or expressing
anger for fear of driving away or damaging the needed parent. Fearful dependency can be triggered
again in adulthood by life events that represent danger or separation from a significant other. Angry
feelings, which are often unconscious, are experienced as a danger to centrally important
relationships, and signal anxiety is triggered. Defenses such as reaction formation, in which anger is
converted into positive or helping feelings, or undoing, in which any negative feelings that do
emerge into consciousness are taken back, attempt to quell the danger experienced from frightening
angry feelings. However, these defenses fail, and patients experience the onset of traumatic anxiety
in the form of a panic attack. The panic attack represents a compromise formation, in which the
patient can express anger via demands for help from others, can desperately seek help in the setting
of feared loss or separation, and can shut out angry feelings considered to be dangerous with a focus
on intense, overwhelming anxiety. From the standpoint of the pleasure principle, patients
experience a panic attack as less painful than the potential risk of loss of an important attachment
figure, or of a conscious awareness of other symbolic meanings that the panic attack carries.
Empirical support for psychodynamic treatment of panic disorder
Case reports and psychological assessments of patients with panic disorder formed the basis for the
development of a systematic approach to the psychodynamic treatment for panic disorder (Busch et
al., 1991; Milrod et al., 1997). Milrod and Shear (1991) found 35 case reports of successful
treatment of panic with psychodynamic psychotherapy or psychoanalysis in the psychoanalytic
literature. A 15-session manualized psychodynamic psychotherapy for panic disorder, when
combined with clomipramine treatment, was found to reduce the risk of relapse over an 18-month
period following treatment termination compared with a group treated with clomipramine alone
(Wiborg and Dahl, 1996). This study did not match treatment groups for frequency of therapist
contact.
Milrod et al. (2000, 2001) conducted an open trial of panic-focused psychodynamic psychotherapy
(PFPP) (Milrod et al., 1997), a manualized psychodynamic treatment that focuses on exploring the
underlying unconscious meanings of panic symptoms and associated psychodynamic conflicts. This
therapeutic approach was employed as a 24-session, twice weekly treatment intervention for 21
patients with DSM-IV panic disorder, using standardized panic disorder assessment measures
recommended by the National Institute of Mental Health Collaborative Report (Shear and Maser,
1994). At study entry, patients had significant panic disorder and agoraphobia, along with functional
impairment. Of 17 treatment completers (four patients were dropouts), 16 experienced remission of
panic disorder and agoraphobia, and also experienced statistically significant, clinically meaningful
improvements in phobic symptoms and psychosocial function, both at treatment termination and at
6-month follow-up following a 6-month no-treatment interval. The results of the open trial
suggested that PFPP is a promising treatment for panic disorder. A randomized controlled trial of
PFPP in comparison with applied relaxation training (ART) is in progress.
Psychodynamic treatment of panic disorder
In treatment of panic disorder, therapists focus on the conflicts surrounding separation and anger as
they emerge in precipitating events, interpersonal relationships, and in the transference. Examining
the use of defenses is of value in bringing frightening feelings and fantasies to consciousness
(Busch et al., 1995; Milrod et al., 1997). For example, the therapist treating a panic patient can
identify the use of reaction formation when a patient is avoiding the experience of anger by being
overly helpful to those with whom they are actually angry. For instance, a patient may refer to
loving to death a boyfriend whom she actually experiences as depriving and hurtful. Undoing, in
which angry feelings are expressed and then taken back, provides an important opportunity to
identify and explore the threat the patient experiences from angry feelings. By examining these
defenses the therapist can help the patient with the core conflicts in panic, and with the fear of
disrupting attachment to others who are considered essential to safety.
Case example
Sarah was a 29-year-old single administrative assistant who presented with the onset of panic
disorder 4 months prior to evaluation. In addition to typical symptoms of panic disorder she
described clenching her teeth and stomach pain. The symptoms recurred after she returned from a
trip abroad with her boyfriend, Dan, that had lasted several months. When they returned they moved
to their usual homes in separate towns, which were about a 3-hour drive apart. Although Sarah
hoped to marry Dan she became aware of the limitations in his availability to her. They planned to
get together every weekend, but he often missed coming to visit her because his job kept him very
busy. She became frustrated because she did not feel he was making the effort to set the necessary
limits at his job to make sure he could see her. She became increasingly anxious during her
discussions with Dan about these issues, leading ultimately to panic attacks. When they were
together she described him as very nice to her, and said that they got along quite well. Thus she
struggled with whether she was right to see him as putting her secondary to his work, and whether
he could be trusted.
Sarah was also struggling with other stresses. She had been laid off prior to the trip and began to
feel financial pressure. She also felt lonely, as most of her friends were in the city she had left 2
years previously. Even more so than with her boyfriend, she complained that friends in her new
location did not follow up with plans and were not responsive when she needed them.
Sarah described a difficult and tumultuous upbringing. The youngest of four siblings, her father was
an alcoholic who withdrew from the family when drunk. Her mother was temperamental, and easily
overwhelmed by her children's demands. When she was 7 years old, conflicts between her parents
intensified, with her father ultimately leaving the house for a year. Her father's drinking increased
when Sarah was an adolescent, and she struggled with rage and her hurt feelings about his behavior.
She feared that her father would injure himself in a fall or car accident. At times during her
adolescence, she was recruited to bring him home from the bar or take him to a rehabilitation
program. She was extremely embarrassed by her father's behavior and worried about what her
friends thought of both of them. In her view, he was a caring and interested father during his sober
periods who disappeared emotionally and sometimes physically when he was drinking. In part
related to her father's alcoholism, the family was in constant financial turmoil. Sarah recalled
feeling frightened about whether the family would be able to meet monthly payments.
Sarah entered into a 24-session psychodynamic psychotherapeutic treatment that was part of a
research protocol. In the first few sessions it became evident that her panic attacks were precipitated
by her separations from Dan. The panic attacks began after their return from their trip and would
intensify when he left after they spent the weekend together. In addition, the panic became more
severe when he would cancel a visit with her.
Exploration of her relationship with her father provided clues about the difficulty she had with
separations. When the therapist was questioning her about her father's disappearances when
drinking, she became tearful when expressing anger at her father. Then she suddenly became
disparaging of the psychotherapy: I dealt with my anger a long time ago. There's no point in
dredging it all up again. It's just going to make me feel worse. The therapist replied that trying to
sweep her anger under the rug would not be helpful to her, and her ongoing struggles with her anger
likely emerged in her panic. Sarah then revealed that she was fearful that her anger at Dan, when
she was disappointed with him, would cause him to reject her. Similarly, she felt that any expression
of her own and her mother's and siblings frustration with her father set off his drinking bouts, and
triggered his extended disappearances.
Sarah viewed her needs as potentially driving away her boyfriend and father. After separations from
Dan she struggled with her wishes to call him, presuming she would come across as too needy. She
feared that Dan would see her as high maintenance and abandon her. She felt that expressions of
need were another factor that triggered her father's drinking. Panic occurring at these times included
a feeling of desperate aloneness and wishes to contact her mother and others for comfort. However,
she attempted to avoid being needy by acting more self-sufficient, leaving her feeling even more
isolated. Examining the patient's catastrophic fears of her anger and dependency when separated
helped to detoxify these feelings, rendering them less likely to trigger panic.
Discussion about termination, which began in session 16, indicated that she viewed the therapist as
another source of support who would suddenly disappear. She reacted to the approaching
termination initially with feelings of anger, hurt, rejection, and anxiety. She eventually was able to
see the similarities between her feelings about the treatment ending and those she experienced
toward her father and boyfriend. She was particularly worried that she would have a recurrence of
her panic with no one to help her. Her ability to safely work through these feelings with her
therapist added to a reduction in her fears, the resolution of her panic, and an increased ability to
manage separations.