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Compare and contrast the behavioural treatment of Panic Disorder (with agoraphobia) using exposure in vivo, with David Clark’s therapy treatment of panic. Evaluate critically the merits of each approach.
This essay will explore the similarities and differences between how panic disorder (with agoraphobia) is conceptualised and treated by a behavioural approach (xxx), using exposure in vivo, and David Clark’s CBT treatment approach (xxx).
This essay will outline the key features and symptoms of panic disorder as defined in the Diagnostic Statistical Manual version 5 (DSM). It will then briefly explore the rational and treatment steps of the two approaches before comparing and contrasting them in the conclusion.
Symptoms of Panic Disorder.
Panic disorder is an anxiety based disorder and was first codified in the DSM-III (xxx). In the DSM-V (xxx) the essential features of panic disorder are recurrent unexpected panic attacks, and after one of these attacks for the next month a persistent worry about having additional attacks or the implication of those attacks. The full diagnostic criteria can be seen in Appendix x
The panic attacks will include one of a number of common physical and/or psychological symptoms [see appendix X]. Due to the unexpected nature of the attacks and the persistent worry of having an attack, sufferers will often change behaviour to try to avoid panic attacks. This avoidance, which initially is about a certain place or situation, can gradually become more generalised over time to the point that some suffers will start to develop agoraphobia. This group will also report significant anticipatory anxiety surrounding availability of help or perceived social repercussions if they suffer a panic attack (farmer xx 222).
Behavioural Approach to treatment.
In behavioural therapy, and theory, primary emphasis is placed on the physical environment and an individual’s observable reaction to it (Baum, 2005 bb). But this is being challenged, from some behavioural perspective thinking and emotional responses are examples of behaviour subject to many of the same influences as the more observable behaviours (BB). In this model fears and behaviours, such as those that sufferers experience, are acquired through the process of classical conditioning and maintained through operant conditioning of avoiding behaviour (Mowrer, 1939, 1960).
When anxiety and discomfort levels peak the individuals will leave or avoid the situation, reducing discomfort. The avoidance acts as a operant behaviour that results in the reinforcement of behaviours that become more probable over time in the presence of the triggering stimuli.
Behavioural treatments focus on the cycle of learning that takes place and how avoidance helps to maintain anxiety (xxx). It involves systematic exposure to situations and stimuli that trigger the anxiety reaction. The rationale for this is that over time the patient will become habituated to the stimuli; the anxiety response gradually diminishes with repeated and prolonged exposure without the anticipated traumatic consequences (Wolpe, 1958, xxx f).
Exposure used to treat phobias and emotional problems has several key aspects to help the learning to take place. These are frequent, prolonged, repeated and without avoidance or safety seeking. A patient needs to repeat the exposure for learning to take place. Over repeated exposures the probability and frequency of a patient’s response will decline (xxx). Barlow et al (bb p271) have argued that helping patients engage in actions that are inconsistent with their current emotions are among the most important aspects for the treatment of anxiety disorders.
In Panic Disorder the behavioural theory treatment used is systematic exposure to the bodily sensations that a patient suffers during a panic attack, to allow habituation of these sensations, termed Interoceptive exposure (barlow xxxx).
Interoceptive exposure has been found to be most effective when strong sensations are invoked (White & Barlow xxxxf). Patients are encouraged to continue with the exposure as long as possible. Stopping or disengaging from the exposure prematurely risks strengthening avoidance behaviours.
When the Panic disorder also includes Agoraphobia in vivo exposure is added to the treatment plan. This involves exposing the patient to triggering stimuli in real life through a hierarchy of graded exposures developed in collaboration with the patient based upon levels of distress when confronted by the stimuli (xxx).
These theories pay little attention to how cognitions can influence behaviour, unlike the CBT and cognitive therapy models.
David Clark’s therapy treatment of panic
There are a number of different models which fall under the umbrella of CBT. David Clark’s model of Panic Disorder (xxx) with or without agoraphobia uses and extends Becks (xxx) original model.
In his original theory of emotional disorders Beck (xxx) stated that emotional disorders were maintained by cognitive distortions which lead to extreme emotions. These in turn lead to changes in behaviour.Â The root of these dysfunctional thoughts and styles of thinking will often be childhood formative experiences.
These experiences help to form the core of our psychological being and are referred to as core beliefs, although other terms have been used previously (phlip p9). These help individuals to define themselves in relation to self, self in relation to others, other people and the world.
Above the level of thinking that core beliefs represent are ‘rules for living’. These are general rules about how we live our lives that rise up from, and protect, the core beliefs; they are directly related to have we act and behave to ourselves, others and the world. Beck (1979) states that if we are unable to meet the demands of these rules we become vulnerable to anxiety and depression. Growing from the rules for living are automatic thoughts that are used to appraise situations and events (beck 1979), in a clinical setting the automatic thoughts that have high levels of negative feelings, negative automatic thoughts (NATs), will draw the most interest.
In this model anxiety is a subjective response to fear, it is a cognitive, emotional, physiological and behavioural response that happens when we interrupt events or circumstances to be uncertain, uncontrollable, beyond our ability to cope and highly dangerous to our wellbeing (Beck et al 2011 below in doc).
Clark’s model of Panic disorder (xx) has overlapping features with Becks generic model of anxiety (well). In this model the panic attacks are triggered by normal somatic sensations that are misinterpretations as dangerous or catastrophic (xxx), illustrated in his viscous cycle diagram [appendix xxx], and these are the focus of the NATs.
Once these attacks have occurred there are regarded as 3 primary factors that help to maintain the problem. These are
1) Selective attention to bodily events; by focusing on something you amplify it in your awareness (Gendlin 1981 hyp-p18) which can lead to lower thresholds for sensations and subjectively increase the intensity of them.
2) In-situation safety behaviours; safety behaviours don’t allow for the patient to test their hypothesis about the outcome of these bodily sensations. These behaviours can make catastrophe more believable due to the directly exacerbating symptoms e.g. Over breathing due to a fear of fainting can then trigger dizziness.
3) Avoidance (xxxx wells pp101). This helps to maintain the disorder as it restricts the opportunity to learn that anxiety does not lead to catastrophe.
David Clark’s treatment plan (xxx) attempts to address these factors, helping the patient to develop new learning and alternative viewpoint. A brief summary of Clark’s treatment plan can be seen in [Appendix xxx].
Research has shown Clark’s treatment plan to have an empirical grounding, that it is an effective treatment (xxxx). It attempts to address thinking styles and provide the patient with new evidence which will often challenge their assumptions.
Looking at these two approaches it could appear that Clark’s model (xxxx) integrates in the behavioural elements of exposure. This suggests that there is a commonality between the two.
Both follow similar use of introceptive exposure and in vivo exposure steps. The key difference between the two is the theoretical reasoning for using exposure.
From a behavioural perspective exposure is about habituation (xxx) and from the CBT perspective it is about providing new evidence in which to test current understanding and hypotheses. This new information helps to feed a cycle of learning [appendix xx]
The potency of using exposure to treat panic disorder has been shown to have empirical support by a number studies (xxxx xxxx xxx xxxx xxxx) and it has been said of Cognitive therapy that “without the actual exposure, all the preliminary briefing would be useless” (Panic: Psychological Perspectives By S. Rachman, Jack D. Maser p199). It has been suggested that the exposure is the driving force behind the success of CBT model in treating panic (bb p273).
Exposure treatments unsupported with other interventions are highly effective in treating behaviour involved in maintaining anxiety, but how well it is eliminated the anxiety can be questioned (Bouton, 2004). The habituation that occurs can be focused on defined triggers. If the context of the trigger changes after habituation the panic can reoccur (other essayxxxx). It can be argued that if the distance, either chronological or psychologically, between the original trigger and modified trigger is too large then learned generalisation, an aspect of learning theory, would not take place (Richard shepard).
Studies have raised queries about the success of only using exposure (xxx). Although exposure is theoretically central to treatment Mitte (2005) (bb p273) has found that the combined packages of CBT is better at improving the quality of life compared with only behavioural interventions.
From my personal perspective a Clark’s approach seems more in tune with how people really inhabit the world. As Clark comments ‘At the very heart of the CT model is the view that the human mind is not a passive receptacle of environmental and biological influences and sensations, but rather that individuals are actively involved in constructing their reality’ Clark(1995 p156 100 key points p3)
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