Cognitive Models for Panic Disorder

Among cognitive models, there are Clark’s theory, Barlow’s false alarm theory and anxiety sensitivity theory. According to Clark’s theory, individuals who experience recurrent panic attacks have a relatively enduring tendency to interpret certain bodily sensations in a catastrophic fashion. The misinterpreted sensations are basically those involved in normal anxiety responses (e.g., palpitations, breathlessness, dizziness, paresthesias). The catastrophic misinterpretations involve perceiving these sensations as much more dangerous than they really are, and, in particular, interpreting the sensations as indicative of an immediately impending physical or mental disaster.

Examples are perceiving a slight feeling of breathlessness as evidence of impending cessation of breathing and consequent death, perceiving palpitations as evidence of an impending heart attack, perceiving a pulsing sensation in the forehead as evidence of a brain haemorrhage, or perceiving a shaky feeling as evidence of impending loss of control and insanity. Both external and internal stimuli can provoke panic attacks. The sequence culminating in an attack starts with the stimuli being interpreted as a sign of impending danger. This interpretation generates a state of apprehension, which is associated with a wide range of bodily sensation. If these anxiety-produced sensations are interpreted in a catastrophic fashion, a further increase in apprehension occurs, producing more bodily sensations, leading to a vicious circle that culminates in a panic attack. This theory accounts both for panic attacks preceded by raised anxiety and for panic attacks coming ‘‘out of the blue’’.

For both types of attack, it is argued that the critical event is the misinterpretation of certain bodily sensations, caused by anxiety in one case and by a different emotional state or by an innocuous event such as exercising, in the other. When applying the cognitive theory to individual patients, it is often useful to distinguish between the first panic attack and the subsequent development of repeated panic attacks and panic disorder. Community surveys indicate about 7–28% of the normal population will experience an occasional unexpected panic attack. The cognitive theory assumes that individuals only go on to develop repeated panic attacks and panic disorder if they develop a tendency to interpret these perceived autonomic events in a catastrophic fashion. Such a tendency could either be a consequence of learning experiences that pre-date the first attack, or could arise as a consequence of the way the patient, physicians and significant others respond to the first attack.

Barlow describes panic as the basic emotion of fear, which is considered to be an acute reaction to perceived imminent danger when no danger is present. He identifies three types of alarm: true alarms (immediate danger present), false alarms (panic attacks) and learned alarms (conditioned panic attacks). Barlow’s model of panic disorder includes a biological diathesis (propensity to experience arousal under stress) and a psychological vulnerability (influenced by factor such as early life events and parenting style). Psychologically vulnerable individuals fail to develop a sense of competence with respect to the world and themselves, and experience poor predictability and control over life events, such as intense emotional states. For biologically and psychologically vulnerable individuals, an initial false alarm may be followed by arousal and self-focused attention (anxious apprehension) centring on the possibility of experiencing further panic attacks and the belief that the attacks are dangerous.

In addition, internal somatic or cognitive cues and sensations can become associated with the experience of false alarm (interoceptive conditioning), so that the experience of somatic symptoms triggers a panic attack. Such interoceptive-cued attacks are supposed to be learned alarms. Interoceptive sensitivity and anxious apprehension may contribute to avoidance of activities and situations associated with somatic sensations and cues. The avoidance then becomes negatively reinforced, since the individual believes that an attack has been averted owing to escape or avoidance.

According to the anxiety sensitivity theory, this is characterised by a belief that, beyond any immediate physical discomfort, anxiety and its associated symptoms may cause deleterious physical, psychological or social consequences. Anxiety sensitivity differs from interoceptive conditioning in that the former does not refer to a conditioned response pattern to physical sensations, but to the individual’s belief that the anxiety symptoms are harmful; thus conditioning is not necessary for anxiety sensitivity. Anxiety sensitivity is also distinguished from catastrophic misinterpretations of anxiety.

Although individuals with PD may be inclined to make such misinterpretations, they may be fully aware of the causes of their sensations, and still hold an inherent belief that the sensations alone are dangerous. One of the most common measures of anxiety sensitivity is the Anxiety Sensitivity Index. Anxiety sensitivity has been found to be normally distributed in the population; individuals with PD and agoraphobia have been found to score higher than individuals with other anxiety disorders, who in turn score higher than normal controls.

Anxiety sensitivity is thought to put an individual at increased risk of developing anxiety disorders in general and PD with agoraphobia in particular. In conclusion, it can be said that theoretical models of panic, from biological, psychological and, ultimately, integrative perspective, will be far more complex than the focused linear models currently undergoing evaluation. It seems likely that both biological and psychological vulnerabilities may be non-specific, and that the development of specific panic and anxiety disorders may involve a variety of experiences at different developmental stages to activate these non-specific diatheses. Future theory building should emphasise an integrated approach, considering such stages.

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