This paper reviews cognitive therapy's theoretical, conceptual, and practical application in treating anxiety disorders. The specific case application to be reviewed is a 17-year-old female who identifies as African American and suffers from panic attacks. The current advances in cognitive therapy as an effective treatment for anxiety disorders will be reviewed with evidence from different studies that have demonstrated this approach to be highly robust. The article will outline the benefits of this approach, specifically when used in non-majority individuals. Additionally, challenges that could be experienced in the future use of this method in terms of effectiveness, cost, and reliability will be examined and discussed. Given the recent increase in demand for this approach, some recommendations on how to meet some of these challenges will also be analyzed in depth.
Case
Susan, a senior in high school, lives with her mother in a low-income part of town with her 17-year-old sister. After a 3-year history of panic disorder and significant social avoidance, she came to the ER for treatment. Anxiety, fear of panic attacks, and avoidance of everyday activities such as going to school and social events were all present at the assessment. She was enduring approximately six full-blown panic attacks a day, with elevated levels of generalized anxiety and considerable trepidation about having panic attacks. She has no close friends and spends most of her time with her mother and younger sister, whom she regards as her only family.
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Before being asked to compete in her high school's annual modeling competition at the age of 14, her panic attacks were few and far between. She suffered from intense acute anxiety for seven days, which manifested itself in physical symptoms such as heart palpitations and stomach cramps. In addition to the bodily symptoms, she was also plagued by increased fear of cardiac arrest. At the time, she did not seek medical assistance or consult anybody about her concerns. To alleviate some of the symptoms, she tried resting and doing breathing exercises and taking over-the-counter pain medicine. She confided in her mother, who helped her get the medical attention she needed. It did not help much that she was taken antidepressants and told to relax.
According to an initial medical evaluation, her panic attacks were characterized by physical sensations. Even while she was still terrified of having a heart attack or going insane, she began to feel a new kind of threat: the dread that she might suffocate and die as a result of her panic attack-induced episodes of breathlessness. To the point where Susan became obsessed with keeping medical facilities within easy reach whenever she felt panicky or worried, she would make frequent trips to her doctor and local hospital to get examined. Often she sought reassurance from her close family members who were leading to social dependency and threatening to become a social disability. Having a flawless appearance convinced her that she was competent, a more assured and less worried individual.
A hyperventilating breathing pattern was all Susan used when she became nervous in the presence of other people, which was too noticeable. Post-event processing was a big part of her life, and she would spend a lot of time thinking about how she performed in social situations. She also had difficulty keeping a conversation since she was so preoccupied with her anxieties. As a result of her constant struggle with anxiety and the perception that she was socially inept, Susan became gloomy and pessimistic, losing her self-esteem and worth. A high level of worry, panic, and obsession meant performing poorly in social situations.
Diagnosis and Evaluation
The following psychological tests were used in the examination of the patient to accurately identify her anxiety disorder so that a suitable treatment approach could be implemented. There was a gross score of 27 on the Beck Depression Inventory, indicating mild depression. A global score of 46 on the Hamilton Anxiety Rating Scale indicates significant anxiety with the following symptoms: extreme emotional states of uncertainty ranging from irritability, nervousness, mood swings and apprehension to uncontrollable terror; restlessness, inability to relax, nervousness and body tension; tremors; inability to sit and do nothing and fatigue and insomnia. With a score of 60 for overall stress and a high score of negative dysfunctional emotions like anxiety, panic, hopelessness, and depression on the 26-item Profile of Emotional Distress self-report instrument, it is clear that many people are suffering from a wide range of functional and dysfunctional emotions. It is also important to note that, according to the DSM-IV-TR, there are avoidant and dependent personality traits that do not qualify as a condition but rather as a person's characteristic.
Using the DSM-IV-TR criteria for panic disorder, it was assessed that the patient had experienced a series of panic episodes and obsessive worry about the future, which has continued for more than three years and satisfies the diagnostic criteria. There is also a subsequent depressive aspect that leads to a dependent personality. When it comes to her mental and physical health, she suffers from exhaustion and exhaustion, which is a consequence of the aforementioned mental health issues. During the discussion with the patient, a number of personalization-distorted cognitions surfaced, such as belittling herself, having utterly negative views about the future, a focus on the bad, and a sense of approaching doom. She was always carefully anticipating for anything terrible to happen. She was always afraid of having a heart attack and needed to be sent to the emergency room many times was evident that she was suffering a panic attack.
Clinical Features of Panic Attacks
Panic attacks are defined as brief episodes of severe dread or discomfort characterized by the sudden emergence of four distinct symptoms, all of which peak within ten minutes of the onset of the attack. Even after a panic attack has passed, many people continue to feel anxious for days or even weeks afterward. The DSM-IV-TR defines panic as palpitations, tremors, difficulty in breathing, chest discomfort, irrational anxiety, abdominal distress, and excessive negative thoughts, all of which are symptoms of the disorder.
Repeated panic attacks are the most common symptom of panic disorder. It is not uncommon for people to feel well between episodes, but many suffer from constant concern about the prospect of another attack; this can lead to agoraphobia in the long run. Autonomic arousal, as well as an incorrect verbal or visual depiction of an imminent calamity, extreme uncontrolled fear, and a strong desire to flee, are all hallmarks of panic. Most panic attack victims develop a fear of recurrence and obsessively avoid situations that they believe could provoke a panic attack.
A prodrome usually precedes the onset of panic attacks, but some patients report feeling ill days before their first attack, although most do not. Many patients have clear memories of this event, and they may be able to recount the exact conditions in which it occurred. Late adolescence or early adulthood is the most prevalent period for the first episode; however, later onsets are not unusual.
Case Evaluation
There had to be a distinction between Susan's panic disorder and normal worries or anxieties. Analyze significant psychosocial stresses and trauma to identify how they may influence to the development or progression of anxiety symptoms. Though there has been inadequate research in this area, using visual imagery to communicate during a diagnostic session can be useful. Despite the fact that standard psychological testing or routine questionnaires are not required to examine panic disorders, the various instruments used to enhance the clinical interview with the 17-year-old Susan and to identify the specific anxiety condition were beneficial. DSM-IV-Child Version was crucial in determining the severity of the disorder in this case. Assessment and follow-up measures for anxiety disorders such as selective mutism was also made available in this study.
As part of the evaluation for childhood anxiety disorders, the clinician also inquired about Susan's mother's symptom severity and functional limitations. The Alcohol and Other Drug Information School (ADIS) uses a Feelings Thermometer to assist students in measuring and monitoring degrees of fear and its distortion to normal functioning. The clinician used this tool to inquire about how Susan's panic disorder has affected her daily life. It was crucial to distinguish between other illnesses that could cause comparable symptoms in a teenager. The doctor performed a series of tests to rule out the likelihood of these illnesses. Attention-deficit/hyperactivity disorder, psychotic illnesses, and pervasive developmental abnormalities, such as Asperger's disorder, all have symptoms similar to those with panic disorders. Hyperthyroidism, migraine, and seizure disorders are all physical illnesses that can present with panic symptoms.
Pheochromocytomas, hypoglycemia, and CNS disorders are less common in young people. Anti-asthmatics, steroids, antipsychotics, pimozide, and atypical antipsychotics all have side effects that may resemble episodes of a panic attack. Antihistamines and some flu drugs also have side effects that may cause panic-like symptoms. The most frequent somatic complaints connected with adolescent panic disorders are headaches and stomach problems. Early consideration of the patient's mental health should be given during any medical examination.
Cognitive therapy treatment for panic disorder
Panic disorders can be effectively managed by the cognitive therapy approach, which has been shown to respond to the main symptoms associated with episodes of panic attacks and the longer-lasting residual symptoms caused by the condition. These after-effects of panic attacks include agoraphobia, social aversiveness, and nervousness due to anticipated but unrealistic danger (Hannesdottir et al., 2018). Effective application of cognitive therapy has shown immediate changes by lengthening the duration between episodes of attacks (Matsumoto et al., 2019). Cognitive therapy has proven to alter the course and development of panic attack disorder and avoid relapses in cured patients
Clinicians use different modes of cognitive therapy treatments to manage panic disorders. Short treatment plans usually include 12 sessions of therapy and have proven to be effective in eliminating panic attacks in 75% of the clients in who the treatment was applied (Racey et al., 2018). These efficiency rates are much better than even pharmacology used in panic disorders. Even with just this brief version of the treatment, 85% of patients report having no attacks for more than one year and 78% for at least two years (Racey et al., 2018). The cognitive therapy approach also demonstrated better management of comorbid conditions associated with panic attacks, ensuring a higher quality of life. It is argued that managing the symptoms of panic disorders is more crucial than even reducing the regularity of episodes.
Cognitive therapy models identify the unrealistic, negative, and calamitic perceptions of physiological symptoms that are primarily responsible for triggering panic attacks. Palpitations and drowsiness are perceived to be signs of an oncoming cardiac arrest in the patient (Petrowski et al., 2017). The patient experienced heightened sensations from such distorted perception, thus leading to a downward spiral of paranoia. These extreme reactions are likely to be experienced by individuals who are vulnerable physiologically or genetically. The first attack should be managed with urgency because it often leads to a series of episodes since the patient develops an irrational awareness of the slightest physical sensation. Cognitive therapy aims to stop this trajectory by assuring the patient that the physical symptoms are normal (Petrowski et al., 2017). It is also important that exercises are applied that help control some of these symptoms in the patients. Cognitive therapy applies breathing and muscle relaxation exercises in its techniques to treat the patients.
Features of Cognitive Therapy Treatment
It is common for cognitive therapy to last between 10 and 20 scheduled sessions, with a set of pre-determined outcomes in mind (Matsumoto et al., 2019). Reducing bodily feelings and avoidance is the primary goal here. It is a hands-on, task-oriented approach, and both the patient and the therapist are involved in the process. Individual or group cognitive therapy sessions are both possible. A larger number of in-person sessions has been linked to a stronger response to cognitive therapy in recent studies, despite previous research indicating that cognitive therapy ought to be short. The use of a six-session course of therapy in medical settings has yielded positive results (Matsumoto et al., 2019). When a patient is resistant to conventional therapies, cognitive therapy can be used as an adjunct treatment or as a main preventative strategy (Matsumoto et al., 2019). Muscle relaxation, psychoeducation, interoceptive and cognitive restructuring are some of the approaches used.
Anxiety and panic disorder may be broken down into their component parts via psychoeducation, which lays the foundation for treatment. It is important to identify and define the source of anxiety and panic symptoms, as well as to introduce a set of techniques that help manage the fear and nervousness (Petrowski et al., 2017). Additionally, social aversiveness should be tackled appropriately by educating the patients on how to participate in social gatherings in a normal and confident manner. The patient should be made to understand avoidance only acts to increase the disease. Initial sessions are often characterized by psychoeducation, which can also be during different stages during the therapy period.
Dizziness, breathlessness, and a rapid heartbeat are all indications of hyperventilation, which is caused by incorrect breathing patterns. Anxiety can be exacerbated by tension in the muscles, which can result in physical symptoms, including aches and paresthesias (Petrowski et al., 2017). As with a panic attack, these feelings can be alleviated with adequate breathing and muscular relaxation. Diaphragmatic breathing is a type of breathing in which the abdomen is used to regulate the airflow (Petrowski et al., 2017). Progressive muscle relaxation is a kind of physical exercise in which the primary muscle groups are practiced in tension and relaxation. Both methods can be used sequentially or separately, especially when anxiety is present due to a looming event. In both cognitive and interoceptive exposure therapies, removing fear is the primary goal of the treatment process.
Panic disorders are characterized by false and exaggerated negative predication about circumstances, as well as the patient's feelings of lack of hope or ability to manage the anxiety. Because of this factor, the objective of cognitive therapy is to restructure the mind to appropriately perceive reality and deal with any negative thoughts that arise (Petrowski et al., 2017). Cognitive therapy's primary assumptions are critical for patients to comprehend before commencing treatment (Matsumoto et al., 2019). The probability of success in the treatment of panic disorder depends on this major factor.
In the case of panic disorder, wrong interpretations of reality result from distorted thoughts. Patients suffering from panic are taught how to identify already existing, pessimistic thoughts about their existence. Later, the patient is guided on how to maintain track of their beliefs, recognize logical flaws in pessimistic interpretations, and develop positive and realistic thoughts. Overestimation of the likelihood of tragic occurrences, as well as their magnitude, are key features of panic disorders that cognitive therapy handles (Petrowski et al., 2017). Behavioral tests meant to assist patients in testing the accuracy of their negative predictions in real-life performance situations are often used to challenge these negative sets of beliefs through rational questioning. Exposure treatments' gradual approach to learning is most akin to this later technique.
It is a goal of interoceptive exposure to alter a patient's pessimistic interpretation of physical sensations experienced due to episodes of panic attacks. Interoceptive exposure develops the patient's tolerance by steadily exposing them to the triggering stimuli within a controlled environment (Early & Grady, 2016). One of the methods used to achieve this is intentional induction of symptoms which ensures the patient is exposed to physical activities to acquire the desired level of exposure. Some of the exercises may include spinning to reproduce symptoms like vertigo and dizziness. Interoceptive exposure also modifies the thought process by making the patient more conscious and not responding automatically to events and sensations.
In vivo exposure is another technique used in cognitive therapy, often alongside interoceptive exposure (Early & Grady, 2016). In this technique, the therapist works with their patient to assist them in being passive and inactive so as to regulate the symptoms. This can occur twice during a session of cognitive therapy. This technique is extended by the use of assignments given to the patient to help them practice them on their own frequently until they become accustomed to dealing with sensation in this manner. Repetition of this exercise numbs the patient's overreaction to physical symptoms, which usually triggers panic attacks in vulnerable individuals.
There is a basic paradigm developed for cognitive therapy sessions for panic disorder. Psychoeducation and skills for dealing with anxiety are taught to patients during their first sessions (Early & Grady, 2016). These interventions become increasingly important as sessions go. During the last sessions, the focus is on maintaining progress and avoiding a relapse. Relapse prevention is made easier by having patients practice interoceptive exposure in a variety of contexts so that they can avoid complete exposures in circumstances they are afraid to face. There were further parts of relapse prevention that included rehearsals of possible future issues and suitable responses, as well as a review of the ways that the patient had previously found success in dealing with them. To prevent relapses and chronicity, it is necessary to recognize factors that increase psychological susceptibility.
When it comes to treating panic disorders, research has demonstrated that a multidisciplinary approach is appropriate in handling the disorder. However, there is also evidence that the reliability of combination treatment conditions is negatively affected when the medicine is discontinued; this is, though, not the case when using cognitive therapy. On the contrary, long-term use of drugs may affect the effectiveness and cost of cognitive therapy, even if there may be some short-term benefits of this combinative approach (Blackwell & Heidenreich, 2021). To properly tackle this problem, medication should be decreased gradually while cognitive therapy is advanced at the same time resulting in a desirable level of treatment outcomes.
Anticipatory anxiety and avoidances are predisposed to and exacerbated by the instinctive catastrophic ideas that underlie this therapy. The patients' quality of life improves as a result of techniques to alleviate anxiety, cognitive changes, and interoceptive exposures, which assist in their overcoming agoraphobia and social dependency, which may lead to social disability. With promising results, new techniques to treat panic disorder have been tried out, such as Internet treatment and two-day intense cognitive therapy sessions. In addition, novel therapy tactics that combine extinction learning with memory enhancers have the potential to extend treatment outcomes. For proper comprehension of treatment of recurrent rates of panic disorder, more studies should be done to ensure this reliable, proven method becomes even more effective.
References
Blackwell, S. E., & Heidenreich, T. (2021). Cognitive behavior therapy at the Crossroads. International Journal of Cognitive Therapy, 14(1), 1–22. https://doi.org/10.1007/s41811-021-00104-y
Early, B. P., & Grady, M. D. (2016). Embracing the contribution of both behavioral and cognitive theories to cognitive behavioral therapy: Maximizing the richness. Clinical Social Work Journal, 45(1), 39–48. https://doi.org/10.1007/s10615-016-0590-5
Hannesdottir, D. K., Sigurjonsdottir, S. B., Njardvik, U., & Ollendick, T. H. (2018). Do youth with separation anxiety disorder differ in anxiety sensitivity from youth with other anxiety disorders? Child Psychiatry & Human Development, 49(6), 888–896. https://doi.org/10.1007/s10578-018-0805-9
Matsumoto, K., Sato, K., Hamatani, S., Shirayama, Y., & Shimizu, E. (2019). Cognitive behavioral therapy for postpartum panic disorder: A case series. BMC Psychology, 7(1). https://doi.org/10.1186/s40359-019-0330-z
Petrowski, K., Wichmann, S., Siepmann, T., Wintermann, G.-B., Bornstein, S. R., & Siepmann, M. (2017). Erratum to: Effects of mental stress induction on heart rate variability in patients with panic disorder. Applied Psychophysiology and Biofeedback, 42(2), 95–95. https://doi.org/10.1007/s10484-017-9357-1
Racey, D. N., Fox, J., Berry, V. L., Blockley, K. V., Longridge, R. A., Simmons, J. L., Janssens, A., Kuyken, W., & Ford, T. J. (2018). Correction to: Mindfulness-based cognitive therapy for young people and their carers: A mixed-method feasibility study. Mindfulness, 9(4), 1315–1315. https://doi.org/10.1007/s12671-017-0875-y
Transcript of Session
Therapist: So, hello Susan, my name is Pat, and I am a therapist that works with people who suffer from panic attacks to help them live a better life. What is new with you today? [open-ended question]
Client: (disappointed) Not so good.
Therapist: Oh uh, that is sad. I am assuming you have been visiting our primary care physician? [empathetic statement]
Client: Sure, yeah, I have been visiting the doctor for over a year for my breathing issues and heart palpitations, and she prescribed some medications that have helped a little.
Therapist: (softly) Uh-huh [empathic statement].
Client: I would like to add the nurse practitioner to the mix.
Therapist: Okay, so... and we talked about confidentiality a little bit when we met; could you need any clarifications? [empathetic statement]
Client: No, I do not recall.
Therapist: (softly) Yeah, all we will discuss here is private, so it is vital that you become assured of absolute confidentiality. Also, feel free and open to discuss any sensitive matter. Do you feel comfortable with me meeting with you and working with you? [paraphrasing]
Client: That is all right.
Therapist: All right, that is excellent. Could you tell me a little about your current situation and what brings you in? [open-ended question]
Client: I am just feeling fairly horrible, (hesitantly) yes, I just feel like something bad is about to happen, and I am going to fall short of my professors', parents', and everyone's expectations. And everything terrifies me at times, like if something horrible is about to happen to me at any moment, so...
Therapist: Mm-hmm, so you are always worried about your future, and you are not sure what to do about it? [open-ended question]
Client: Yes.
Therapist: And you are experiencing a lot of worry and fear as a result of this. [summarization]
Therapist: Sure, and could you tell me a little bit about your life? [empathetic statement]
Client: It is nothing out of the usual. I currently live with my mother, so... I attend school and plan to enroll in acting classes in college, but I am afraid of appearing in front of an audience. I stay alone most of the time because I do not like to face others, and when I do, I panic and end up humiliating myself...
Therapist: You are right. Do you have any best friends? [open-ended question]
Client: Not right now; I used to have friends, but since I have been sick, I have decided to stay away from them since I do not sure how they would react to me...
I could be burdening them too much since I have too many attacks, and they would not understand.
Therapist: (softy) Mm-hmm... so, could you tell me just a little bit about your relationship? How do you relate to your mother? [open-ended question]
Client: She... she... she.
Therapist: How do you communicate with her? [open-ended question]
Client: Yeah, I mean, I am sure it is unpleasant for her to be ill all the time and worry about everything. But she is supportive and understands my situation, as well as reassuring me from time to time.
Therapist: Yes, it appears that she is quite important to you. So, to help you better achieve the desired state of a reduced panic attack and more confidence, we will use a method called cognitive therapy. Could you have any knowledge about it? [open-ended question]
Client: No, I do not believe so.
Therapist: No, Okay, so it is basically a therapeutical approach to dealing with emotional and psychological problems that people often experience in their lives. This method was developed by a psychiatrist called Dr. beck way back in the 60s. So since then, it has proven time and again to be effective in helping people handle their feeling and emotions in the desired manner so as to improve the quality of their lives. Typically, we convene for weekly sessions that last about an hour in which we practice different techniques to help you manage your feelings better and reduce the frequent panic attack episodes you've been experiencing. [paraphrase]
Client: All okay.
Therapist: Does it seem like something you would be interested in doing? [answer to an open-ended query]
Client: I will give it a go.
Therapist: Give it a shot, do something little every day to cope with your emotions and thoughts to the conditions you are experiencing. [summarization]
Client: I agree.
Therapist: Yeah, I also want to point out is that it is not unusual for teenagers to suffer from anxiety, which may lead to problems like panic attacks. It is quite tough to manage all of the expectations that you face, as well as how others view you. So we have thoughts that are constantly running through our heads, and they have a significant influence on how we feel emotionally. So, to give you an idea of how it works, I will give you an example... You have been chosen to compete in a statewide talent show. So, what would your views be if you were in that situation? [open-ended question]
Client: Well, I am scared I may do something dumb to disgrace myself, and the rest of the world will laugh at me because the internet is everywhere.
Therapist: Mmm-hmm, says the therapist. [empathetic statement]
Client: That would be the worst thing that could happen to me; I would never leave the house again after that.
Therapist: Okay, that is it. So you are afraid you are going to make a blunder and that everyone is out to disgrace you? [paraphrase]
Therapist: Yes, it is correct.
Therapist: So you do not think you should go because there is a chance of a major disaster? [summarization]
Client: Yes, it is correct.
Therapist: This will serve as an example of the five-point model. So we start with thinking, and then emotion may be tied to our thoughts, so what type of feelings would you experience if you had these kinds of thoughts in this situation? [open-ended question]
Client: I am nervous, I am really nervous...
Therapist: I see. [empathetic statement]
Client: I also feel unworthy of any love from friends and family because I think I am just afraid of all these horrible things happening to me all the time.
Therapist: Yes, those feelings are triggered by those thoughts— [summarization]
Client: Yes, it is correct.
Therapist: So, what are your thoughts about this? Okay. So I am going to add two additional circles to this design; one will represent our actions, and the other will represent a bodily response. So, what kinds of behaviors do you realize that you may begin to conduct or partake in when this type of circumstance occurs? [open-ended question]
Client: Well, I would feel as if I am going to pass out or suffocate and die...
Therapist: Okay, that is it. So you are afraid you may perish? [open-ended question]
Client: Yes, it is correct.
Therapist. Okay. How about... do you observe what type of bodily reaction you have, what occurs in your body, what do you experience in your body whenever this arises? [open-ended question]
Client: Yeah, I think when she and I are fighting at each other, I start getting breathing issues, and my heart starts racing. I am afraid I am going to be sick.
Therapist: Alright. So you can see that in every circumstance, it is extremely stressful because our emotions are connected with our bodies, and then there are the surroundings, which adds another layer. So our surroundings may impact how we feel, and our surroundings can be supporting or non-supportive, which can influence, influence things. Do you see the logic in this model? [open-ended question]
Client: Yeah, I see how everything is related.
Therapist: Mmm-hmm, says the therapist. So, during our therapy sessions, we will be attempting to figure out how all of these things are related, as well as how you can begin to make some adjustments so that your emotions may begin to shift, okay? [empathetic statement]
Client: I understand
Therapist: So, as I indicated last week, I am going to request you to accomplish some assignments. For this week, I request that you log your mood, anxiety, and panic attacks hour by hour during the day. So you would want to evaluate how severe your emotional responses are on a scale of 0 to 100, so you can see if there is a pattern in terms of what you do and how you feel. Is that something you can handle? [open-ended question]
Client: Yes, it is correct.
Therapist: That is okay. So, there is your homework activity for the week, and I believe that will be the conclusion of our discussion for today. Do you have any final questions? [open-ended question]
Client: No, I do not believe that is correct.
Therapist: All right, that is fine. So, we will set up a meeting for the following week. [summarization]
