Article summary by A cognitive approach to panic by Clark - 1986

It has long been accepted that panic attacks often occur in certain types of anxiety disorders. Panic attacks later became a separate subject of investigation, and Donald Klein is partly responsible for this. He showed that people with anxiety disorder with panic attacks respond to imipramine and people with anxiety disorder without panic attacks do not: the so-called pharmacological dissociation. The DSM-III then accepted this distinction by including "panic disorder" and "agoraphobia with panic" in the diagnoses.

A panic attack consists of a strong sense of fear or calamity that suddenly arises and is combined with many different physical characteristics. These can be: breathlessness, palpitations, chest pain, dizziness, tingling in feet and hands, feeling of suffocation, fainting, sweating, shaking and a feeling of unreality. The majority of people who suffer from panic attacks have a panic disorder or agoraphobia with panic. A panic disorder is only diagnosed if there have been at least three panic attacks in the last three weeks and these panic attacks do not only occur in certain anxious situations. Agoraphobia with panic is diagnosed when someone shows fear and avoidance of a certain type of situation and has a history of panic attacks.

Panic attacks can be triggered by various pharmacological and physiological agents such as caffeine, carbon dioxide and yohimbine. These drugs hardly cause panic attacks in people without a history of panic attacks, but do cause some sensations that are characteristic of a panic attack. This shows that certain biochemical changes have a panic-inducing effect and that people who are sensitive to these drugs therefore have a biochemical disorder. However, a psychological explanation has also been found for this phenomenon: the drugs do not have a direct panic-inducing effect, but only cause panic if the physical sensations are interpreted in a certain way. This is essential for the cognitive theory described in this article. It states that panic attacks are the result of catastrophic misinterpretations of certain bodily sensations. These are usually sensations such as dizziness and lack of breath (which normally occur with anxiety), but can also be other sensations. This misinterpretation means that the sensations are experienced as much worse than they are. The order of a panic attack is as follows. Various incentives can cause panic attacks. These can be external incentives, but are more often internal incentives. When these stimuli are perceived as a threat, fear arises, along with a number of physical sensations. If this sensation is seen as catastrophic, more fear arises. This creates more physical sensations, etc.

Some panic attacks are preceded by a period of heightened anxiety, some not and come "suddenly." In the first case there are two types of panic attacks. In the first type, the period of increased anxiety is caused by the expectation of an attack, for example in a busy place for someone with agoraphobia. In the second type, the period of increased anxiety is not caused by the expectation of an attack. In the case of panic attacks that appear to be sudden, the cause of an attack is usually the perception of a physical sensation caused by an emotion (anger, for example) or by a harmless event such as getting up, exercising, or drinking coffee. The sensation is then interpreted in a catastrophic way. Other sensations that can cause a panic attack include breath shortage due to movement or sensations that are normally not part of a panic attack. In addition, sensations that arise from the perception of mental processes can also contribute to the vicious circle of panic attacks (for example, the fear of going crazy if their minds get stuck). For some patients, the sensations and associated interpretations remain constant over time, for some, these change.

The literature supports the model on the following points:

• Essential components of panic anxiety. The thinking of patients with panic attacks is dominated by thoughts that cause a catastrophic interpretation of sensations, such as thoughts of death or illnesses.
• The order of events in a panic attack. Patients often mention a physical feeling as one of the first things they feel during a period of anxiety.
• The role of hyperventilation in panic attacks. The sensations associated with hyperventilation often resemble the sensations associated with a panic attack. In some patients, voluntary hyperventilation does indeed cause a "panic-like" feeling and hyperventilation occurs with panic attacks. Hyperventilation only leads to panic if the physical sensations are experienced as unpleasant and are interpreted in a catastrophic way.
• Panic can be caused by sodium lactate. Patients with panic attacks interpret the feeling caused by sodium lactate in a catastrophic way; 60-90% of patients get an attack when they are given sodium lactate.
• Effects of psychological treatment. The most used and successful treatments are behavioral and behavioral cognitive treatment. CO2 inhalation is an example of a treatment, because CO2 inhalation is very effective in inducing panic attacks. This allows the patients to "get used" to the feeling. Neither the behavioral cognitive treatment of Clark nor the behavioral treatment of Griez and van den Hout has been compared with other psychological treatments.

This makes it difficult to say anything about the cause of the effectiveness. In contrast to the treatment of panic disorders, there is a generally accepted treatment for agoraphobia with panic, namely in vivo exposure. The question is whether behavioral cognitive and behavioral treatments can add anything to this.

• The role of biological factors in panic. There are three ways in which biological factors influence the vicious circle of panic attacks. First, biological factors can influence the cause of an attack. Secondly, biological factors can influence the extent to which a threat brings about changes in physical sensations. Thirdly, biological factors can play a role in the extent to which sensations are interpreted in a catastrophic way.
• Effects of pharmacological treatment. Three drugs have been investigated, showing that propranolol is ineffective and diazepam is not effective in the long term. Imipramine appears to be effective, but is always offered in combination with gradual exposure to dreaded stimuli. It is therefore possible that imipramine has no direct effects.

Further evaluation of the model can follow if the following predictions are investigated:

• Patients with panic attacks interpret physical sensations more catastrophically than anxious patients and the control group.
• Pharmacological agents only cause a panic attack if the sensations are catastrophically interpreted and the effects of these agents can be blocked by manipulations.
• Treatments that do not change the tendency for catastrophic interpretation in patients are more likely to experience relapse than treatments that do.