临床与咨询心理学导论 20 - Cognitive-Behavioral (CBT)

L20 Cognitive-Behavioral Therapy (CBT): Treatment for Panic Disorder 

参考文献/图片来源：Pomerantz, A. (2013). Clinical psychology: science, practice, and culture (3rd ed.). Thousand Oaks, CA: SAGE Publications.

20.1 Cognitive-Behavioral Approaches

• Places emphasis on both behavioral and cognitive techniques

• Includes features of both:

- Time-limited

- Structured

- Focused on the present

- Focused on problems

• Treatments developed for many mental health problems with a strong evidence base

Cognitive-Behavioral Therapy (CBT)

• Evaluated in RCTs for many different disorders with remarkable findings

• Review of 16 meta-analyses (Butler et al., 2006):

- Large effect sizes (d ≥ 0.8) for:

• Major Depressive Disorder

• Generalized Anxiety Disorder

• Panic Disorder with Agoraphobia

• Panic Disorder without Agoraphobia

• Posttraumatic Stress Disorder

• Social Anxiety Disorder

- Superior to antidepressants in the treatment of Major Depressive Disorder in adults

20.2 DSm-5 Criteria for Panic Disorder

Panic Attacks

• An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four or more of the following symptoms occur. The abrupt surge can occur from a calm state or an anxious state:

- Palpitations, pounding heart, accelerated heart rate

- Sweating

- Trembling or shaking

- Shortness of breath

- Choking sensation

- Chest pain or discomfort

- Nausea or abdominal distress

- Feeling dizzy, unsteady, lightheaded, or faint

- Chills or heat sensations

- Numbness or tingling sensations

- Fear of losing control

- Fear of dying

- Derealization (feelings of unreality) or depersonalization (detached from oneself)

• Recurrent, unexpected panic attacks

• At least 1 attack has been followed by 1 month (or more) of one or both of the following:

- Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack)

- Significant maladaptive change in behavior related to the attacks (e.g., avoidance unfamiliar situations)

• The panic attacks are not the direct result of substance use or a medical condition and are not restricted to the symptoms of another mental disorder (e.g., specific phobia, PTSD).

20.3 Cycle of Panic

20.4 Key Components of CBT for Panic Disorder

Components of CBT for Panic Disorder

• Education & Monitoring

- Introduction

- Negative Cycles of Panic

- Learning to Record Panic and Anxiet

- Panic Attacks are Not Harmful

• Breathing Skills

• Thinking Skills

• Exposure - Facing Physical Symptoms & Feared Activities

Rationale for Recording Panic & Anxiety

• Recording panic attacks and anxiety helps clients:

- Feel more in control by being able to identify when/where panic attacks are likely to occur

- Identify specific ways in which they experience anxiety (i.e., physical feelings, thoughts about them, and behaviors)

- Judge your level of panic and anxiety more accurately

- Evaluate the success of your attempts to change

The Anxiety-Breathing Link

• Over-breathing (i.e., chronic hyperventilation)

- Indicators: Feeling short of breath, feeling like suffocating, chest pain/pressure, frequent yawning, sighing

• Diaphragmatic Breathing

- Breath via diaphragm not via chest

- Smooth inhale and exhale

- Normal amount of air

- Meditative component:

• Count as breath in

• “Relax” as breath out

• Focus on breath

“Thinking Skills”

• Challenging relationships between Thoughts ⇔ Emotions

• Identifying negative thoughts

• Evaluating odds of a feared negative event

• Challenging negative beliefs/perspective

Exposure Activities

• Create hierarchy of feared sensations and situations

• Situational Exposure

        - Facing a feared situation (e.g., going to a store, driving on a bridge) and learning something from it

        - Steps in exposure typically include:

    • Identify specific worries/fears in the situation

    • Establish best conditions to disconfirm worries/fears

    • Envision ways to manage the fear in the moment

        - Using breathing skills and thinking skills

        -   Recognizing probabilities

    • Evaluate what was learned

    • Interoceptive Exposure

        - Facing feared sensations within the body (e.g., racing heart, trouble breathing, chest pain)

        - Specific activities done in session