2.1 Cognitive theory of panic disorder
If you walk up a flight of stairs you might notice your heart rate going up. A common thought might be ‘Wow, I really need to get a bit fitter!’ A less common thought is to think that this means you are about to have a heart attack. The cognitive model of panic disorder suggests that it is this kind of ‘catastrophic interpretation’ (or terrible misinterpretation) of body sensations that is key to developing panic disorder.
The vicious cycle that develops is depicted in Figure 4. The sequence is that first there is some kind of stimulus – this could be something internal (like noticing a body sensation such as one’s heart beating fast) or external (like noticing that the shop you just walked into is very crowded). This stimulus is then interpreted as a sign something bad is going to happen (it is perceived as a threat). As a result a person feels anxious (apprehension) and because they are worried their body begins to have the normal physical reactions to anxiety or worry. The person notices these body sensations and then interprets these as ‘catastrophic’ – really dangerous. This creates an increased perception of threat which in turn increases the worry, which then kicks up the bodily response, and so on in a terrible spiral that results in a panic attack
Activity 4 A pathway to panic
Now you have learned about the model, try to map out how one stimulus (internal or external) might lead to a panic attack. Look at the box below and use the example to fill in your own response.
|Trigger stimulus (internal or external)||Internal stimulus: Being slightly breathless||Trigger:|
|Perceived threat||Thought: ‘Being breathless might mean something bad’||Perceived threat:|
|Body sensations||Body sensations: starting to pant, heart begins to beat faster, start to sweat and feel shaky||Body sensations:|
|Catastrophic (mis)interpretation||Thought: ‘I am struggling to breathe, I am going to suffocate’||Catastrophic (mis)interpretation:|
|Vicious cycle||The thought ‘I am struggling to breathe’ further increases the perceived threat, the worry and fear and the body sensations, leading to further catastropic (mis)interpretations – like ‘I am suffocating, I am going to die’.||Vicious cycle:|
The pathway to a panic attack that you plotted might be quite different that the example provided; this shows how the cognitive model of panic disorder works even when people have quite different experiences and thoughts during a panic attack.
Panic attacks out of the blue and while asleep
Earlier it was stated that a key aspect of panic disorder is that a person can experience panic attacks occurring as it were out of the blue or even in sleep. The cognitive model of panic disorder seeks to explain this in the following ways:
- Panic attacks where there is a clear trigger. Sometimes a panic attacks occurs after someone gets very frightened. For example, a person who is deathly afraid of spiders might have a panic attack after seeing a big one unexpectedly. In this case the panic attack – while a horrible experience – might not be unexpected.
- Panic attacks ‘out-of-the-blue’. Sometimes a panic attack happens, as far as the person is concerned, quite without warning. One idea here is that these panic attacks occur because a person experiences a bodily sensation that they associate with panic attacks and are scared of (such as being slightly breathless). This bodily sensation might be caused by something benign (maybe their heart is beating fast because they ran for a bus, or are excited). However the key point is that the person does not or cannot separate the ‘trigger’ of the bodily sensation from the actual panic attack. The result is that the person experiences the panic attack as coming out of the blue.
- Panic attacks during sleep . In the same way as waking unexpected panic attacks, it is thought that a thought or emotion or benign body sensation probably sets off the panic attack, however it is not the thought or emotion or body sensation that wakes the person, it is the panic attack. So from their perspective the panic attack comes without cause.
The cognitive model of panic disorder seeks to explain panic disorder in terms of catastrophic interpretation of the normal physical reaction to fear or worry. The next section explains more about this ‘normal’ fear response and how it is not itself something to be afraid of.