Symptom Induction And Deescalation
The cognitive-behavioral model of panic contends that, individuals' misinterpretations of bodily sensations play an integral role in the escalation of panic symptoms. Consequently, such misinterpretations can be responsible for maintaining the vicious panic cycle. During this period of vulnerability, individuals tend to overestimate perceived danger and to underestimate their capacity for coping. In symptom induction, clients are presented with a therapeutic exercise whereby they are instructed to follow the therapist in taking short successive breaths of air, inhaling and exhaling, for approximately two to three minutes. This procedure serves to reproduce the symptoms of panic by activating the autonomic nervous system and disrupting the balance of oxygen and carbon dioxide levels, sometimes causing hyperventilation as well. Symptom induction allows the therapist to obtain a direct report of the client's thought processes as the attack develops and to assist the client first-hand in controlling the attack through progressive breathing and thought restructuring. The goal here is to reproduce the type of situation that may precipitate an attack and then show the client that he or she can "turn on" as well as "turn off" the attacks. Once the symptoms have been induced, the therapist records the sequence of events that have occurred, paying particular attention to the specific symptoms, the automatic thoughts that occurred, and the resulting emotional reaction. Figure I provides an example of how to track the patient's panic sequence during an attack. In response to the initial symptom, spontaneous increase in heart rate, the automatic thought is overreactive in the sense that it is assumed that "something is wrong" or that the client "could faint." It is essential that all clients who are candidates for this technique receive medical clearance prior to the exercise in order to ensure that the technique is not contraindicated by an existing medical condition. The therapist can then begin to intervene with the deescalation techniques by collaboratively focusing with the client on the initial symptoms. A spontaneous increase in heart rate followed by the thought, "Something is wrong" or "I'm going to faint," translated into increased fear. By identifying the early onset of symptoms in the panic cycle, the therapist can aid patients in the deescalation of symptoms. This is done by having patients downplay the severity of the symptoms by altering their misinterpretations. For example, the individual in Figure 1 had developed a pattern of responding to increased heart rate by perceiving it as dangerous and a sure sign that "Something is wrong." In having clients restructure their thoughts, they are asked to consider an alternative response that may involve a less catastrophic implication. For instance, "Just because I have an increase in heart rate doesn't mean that this is necessarily dangerous or that something is wrong. It is perhaps just benign autonomic activity that will last for a limited time." This cognitive response is then supported by having the client log each attack and review the log for reassurance that since nothing dangerous has occurred in the past, it is unlikely to occur in the future. Patients are then taught controlled breathing in order to regulate their oxygen-intake level and reduce autonomic activity. The purpose of this type of restructuring is to lessen the likelihood that the individual's automatic thoughts are fueling the subsequent increase in symptoms and emotional reaction and to persuade them that their fear ("I might faint") is unsubstantiated. This point can be affirmed with cognitive correction via factual information (e.g., in order to faint, one must experience a decrease in blood pressure; blood pressure increases with increased heart rate and anxiety). In addition, this serves to improve the patient's perceived sense of bodily control which reduces the intensity of threat and danger. This type of thought correction is followed throughout the entire panic cycle and then reinforced by virtue of reexposure to symptoms through the use of the panic-induction exercise. It is the combination of the artificial induction of symptoms (e.g., purposely increasing heart rate), as well as the reinterpretation of these symptoms, (e.g., it will not hurt me), deescalation of the catastrophic thoughts, (e.g., this will not last forever), and eventual reduction of symptom severity, that makes the technique effective. In addition, follow-through on having clients expose themselves to real-life situations is also an important component of treatment so that the ability to generalize the techniques to a variety of situations can develop. This technique is usually well received by panic sufferers, particularly after they have overcome their initial apprehension about raising their autonomic activity level. With those clients who sometimes do not benefit from the intervention (e.g., they become too overwhelmed or are unable to increase their autonomic activity level), it is recommended that the same technique of cognitive restructuring be used without the symptom-induction exercise.
Paradoxical intention, originally developed by Frankl, is much like symptom induction in that it involves a behavioral prescription for clients to perform responses that seem incompatible with the goal for which they are seeking help. The specific difference, however, is that in paradoxical intention, patients are asked to exaggerate their anticipations rather than behaviorally induce the symptoms by deliberately hyperventilating. For example, individuals who experience panic attacks and fear that they may die suddenly or become "overwhelmed" would be instructed to "go ahead and let themselves die" or do whatever they fear they might do. After several attempts, they often discover that they are unable to achieve the feared response, and their anxiety then diminishes. At this point, many patients are able to perceive the ridiculous or irrational aspect of their apprehensions, which is an awareness strongly encouraged by the therapist. They are then instructed to repeat this same procedure in selected settings at graded levels of panic-evoking situations until they experience few or no symptoms. This technique also differs from symptom induction and deescalation in that there is no deescalation of symptoms and no instruction in the use of controlled breathing as an anxiety-reducing agent. In fact, it poses the opposite approach to the patient with the reliance on the paradoxical focus itself as the trigger in reducing anxiety. Paradoxical intention may be recommended for individuals who experience relaxation-induced anxiety, for which many of the more traditional anxiety-reducing techniques are less effective. Such side effects as tingling, numbness, dizziness, paradoxical increases in tension, increased heart rate, and other untoward reactions have been reported with relaxation-based treatment. Relaxation techniques may at times even evoke seizure activity or traumatic memories, which may undermine the intention of the treatment. Paradoxical intention would also be recommended in patients who appear resistant to techniques that involve actual symptom induction, as well as patients with a history of cardiovascular disorders. Even though paradoxical intention encourages the symptoms to worsen, there is no direct induction of symptoms (e.g., overbreathing); thus, the likelihood of cardiovascular stress is reduced. It is, therefore, suggested as an alternative treatment when induction is contraindicated and when an expedient intervention is required as is the case with crisis situations. Symptom induction, deescalation, breathing retraining and paradoxical intention are all nonpharmacologic techniques that may be applied for rapid amelioration of panic symptoms in emergency and crises situations. In combination with exposure and/or pharmacological interventions, these techniques may prove to be the most efficacious
Eye-Movement Desensitization And Reprocessing
Shapiro and Forrest propose a new method that has shown benefit in the treatment of traumatic memories and has recently been explored as a second-line intervention in panic disorder. This approach is referred to as Eye Movement Desensitization and Reprocessing (EMDR). Shapiro reports initially developing EMDR while working with some 70 people over the course of about six months, with refinements added over the past 10 years. Consequently, a standard procedure that evolved alleviated patients' complaints. Since the primary focus of EMDR was on reducing anxiety, this has become Shapiro's targeted population. It was fairly recently that Goldstein and Feske reported on the use of EMDR in the treatment of panic disorder. They initially selected seven panic-disordered subjects who were patients at anxiety-disorder clinics. The patients were treated with EMDR for memories of past and anticipated panic attacks and other anxiety-evoking memories of personal reference. Standardized report inventories and behavioral monitoring instruments were employed to measure changes with treatment. After only five sessions of EMDR, subjects reported a considerable decrease in the frequency of panic attacks, fear of experiencing a panic attack, general anxiety, fear of body sensations, depression, and other measures of pathology. These results sparked the authors' further investigation of the effectiveness of EMDR for panic. In a subsequent study, the same authors randomly assigned 43 outpatients diagnosed with panic disorder to six sessions of EMDR. A control group was assigned to the same treatment, but with the omission of the eye movement and with a waiting list. Posttest comparisons showed EMDR to be more effective in alleviating panic and panic-related symptoms than the waiting-list procedure. Compared with the same treatment without the eye movement, EMDR led to a greater improvement on two of five primary outcome measures at posttest. EMDR's advantages had dissipated three months after treatment. Consequently, this study fails to support the eye-movement component of the treatment of panic disorder. Subsequent studies involving randomized controlled trials also suggest that EMDR should not be the first-line treatment for panic, but may be used as an alternative treatment.
Table I. Questions for Crisis Intervention
1. Have you recently adjusted, discontinued or changed any medications either prescription or nonprescription?
2. Have you experienced any recent illness, deaths, change in relationship, job, financial situation in the past 6 months?
3. Have you recently experienced child birth, surgery or change in menstrual pattern?
4. Has anyone in your immediate family or family of origin experienced similar symptoms such as these?
5. Have you recently commenced or discontinued any use of tobacco, drug or alcohol?
6. Do you have any history of medical disorders, such as hypoglycemia, cardiac abnormalities, seizure disorder, etc.?
7. Do you have any history of experiencing these types of symptoms in the past?
8. Are you currently using stimulant/diet drugs, such as crank, speed, cocaine, crack, etc.?
- Dattilio FM; Crisis intervention techniques for panic disorder. American Journal Of Psychotherapy, 2001, Vol. 55, Issue 3
Reflection Exercise #7
The preceding section contained information about specific techniques for addressing panic in crisis intervention. Write three
case study examples regarding how you might use the content of this section in
Online Continuing Education QUESTION 21
What are three suggested techniques for addressing panic during crisis intervention? Record the letter of the correct answer the .