Adult Treatment Planner
28: Panic/Agoraphobia
SNOMED Terms
- Agoraphobia without history of panic disorder
- Panic disorder with agoraphobia
- Panic disorder without agoraphobia
Goals
- Reduce the frequency, intensity, and duration of panic attacks.
- Reduce the fear that panic symptoms will recur without the ability to manage them.
- Reduce the fear of triggering panic and eliminate avoidance of activities and environments thought to
trigger panic.
- Increase comfort in freely leaving home and being in a public environment.
Behavioral Definitions
- Complains of unexpected, sudden, debilitating panic symptoms (e.g., shallow breathing, sweating, heart
racing or pounding, dizziness, depersonalization or derealization, trembling, chest tightness, fear of dying
or losing control, nausea) that have occurred repeatedly, resulting in persisting concern about having
additional attacks.
- Demonstrates marked avoidance of activities or environments due to fear of triggering intense panic
symptoms, resulting in interference with normal routine.
- Acknowledges a persistence of fear in spite of the recognition that the fear is unreasonable.
- Increasingly isolates self due to fear of traveling or leaving a "safe environment," such as home.
- Avoids public places or environments with large groups of people, such as malls or big stores.
- Displays no evidence of agoraphobia.
Diagnoses
- Panic Disorder Without Agoraphobia
- Panic Disorder With Agoraphobia
- Agoraphobia Without Panic Disorder
Objectives and Interventions
- Describe the history and nature of the panic symptoms.
- Assess the client's frequency, intensity, duration, and history of panic symptoms, fear, and
avoidance (e.g., The Anxiety Disorders Interview Schedule for the DSM-IV by DiNardo, Brown, and
Barlow).
- Assess the nature of any stimulus, thoughts, or situations that precipitate the client's panic (or
assign "Monitoring My Panic Attack Experiences" in Adult Psychotherapy Homework Planner, 2nd ed. by
Jongsma).
- Complete psychological tests designed to assess the depth of agoraphobia and anxiety sensitivity.
- Administer a fear survey to further assess the depth and breadth of agoraphobic responses (e.g., The
Mobility Inventory for Agoraphobia by Chambless, Caputo, and Gracely).
- Administer a measure of fear of anxiety symptoms to further assess its depth and breadth (e.g., The
Anxiety Sensitivity Index by Reiss, Peterson, and Gursky).
- Cooperate with an evaluation by a physician for psychotropic medication.
- Arrange for an evaluation for a prescription of psychotropic medications to alleviate the client's
symptoms.
- Monitor the client for prescription compliance, side effects, and overall effectiveness of the
medication; consult with the prescribing physician at regular intervals.
- Verbalize an accurate understanding of panic attacks and agoraphobia and their treatment.
- Discuss how panic attacks are "false alarms" of danger, not medically dangerous, not a sign of
weakness or craziness, common, but often lead to unnecessary avoidance.
- Assign the client to read psychoeducational chapters of books or treatment manuals on panic
disorders and agoraphobia (e.g., Mastery of Your Anxiety and Panic by Barlow and Craske; Don't
Panic: Taking Control of Anxiety Attacks by Wilson; Living with Fear by Marks).
- Verbalize an understanding of the rationale for treatment of panic.
- Discuss how exposure serves as an arena to desensitize learned fear, build confidence, and feel
safer by building a new history of success experiences.
- Implement calming and coping strategies to reduce overall anxiety and to manage panic symptoms.
- Teach the client progressive muscle relaxation as a daily exercise for general relaxation and train
him/her in the use of coping strategies (e.g., staying focused on behavioral goals, muscular
relaxation, evenly paced diaphragmatic breathing, positive self-talk) to manage symptom attacks.
- Teach the client to keep focus on external stimuli and behavioral responsibilities during panic
rather than being preoccupied with internal focus on physiological changes.
- Practice positive self-talk that builds confidence in the ability to endure anxiety symptoms without serious
consequences.
- Consistently reassure the client of no connection between panic symptoms and heart attack, loss of
control over behavior, or serious mental illness ("going crazy").
- Use modeling and behavioral rehearsal to train the client in positive self-talk that reassures
him/her of the ability to endure anxiety symptoms without serious consequences.
- Identify, challenge, and replace biased, fearful self-talk with reality-based, positive self-talk.
- Explore the client's schema and self-talk that mediate his/her fear response, challenge the biases;
assist him/her in replacing the distorted messages with self-talk that does not overestimate the
likelihood of catastrophic outcomes nor underestimate the ability to cope with panic symptoms.
- Assign the client a homework exercise in which he/she identifies fearful self-talk and creates
reality-based alternatives (or assign "Journal and Replace Self-Defeating Thoughts" in Adult
Psychotherapy Homework Planner, 2nd ed. by Jongsma); review and reinforce success, providing
corrective feedback for failure (see 10 Simple Solutions to Panic by Antony and McCabe; Mastery of
Your Anxiety and Panic by Barlow and Craske).
- Undergo gradual repeated exposure to feared physical sensations until they are no longer frightening to
experience.
- Teach the client a sensation exposure technique in which he/she generates feared physical sensations
through exercise (e.g., breathes rapidly until slightly lightheaded, spins in chair briefly until
slightly dizzy), then uses coping strategies (e.g., staying focused on behavioral goals, muscular
relaxation, evenly paced diaphragmatic breathing, positive self-talk) to calm himself/herself down;
repeat exercise until anxiety wanes (see 10 Simple Solutions to Panic by Antony and McCabe; Mastery
of Your Anxiety and Panic - Therapist Guide by Craske, Barlow, and Meadows).
- Assign the client a homework exercise in which he/she does sensation exposures and records (e.g.,
Mastery of Your Anxiety and Panic by Barlow and Craske; 10 Simple Solutions to Panic by Antony and
McCabe); review and reinforce success, providing corrective feedback for failure.
- Undergo gradual repeated exposure to feared or avoided situations in which a symptom attack and its negative
consequences are feared.
- Direct and assist the client in construction of a hierarchy of anxiety-producing situations
associated with the phobic response.
- Select initial exposures that have a high likelihood of being a successful experience for the
client; develop a plan for managing the symptoms and rehearse the plan in imagination.
- Assign the client a homework exercise in which he/she does situational exposures and records
responses (e.g., "Gradually Reducing Your Phobic Fear" in Adult Psychotherapy Homework Planner, 2nd
ed. by Jongsma; Mastery of Your Anxiety and Panic by Barlow and Craske; 10 Simple Solutions to Panic
by Antony and McCabe); review and reinforce success, providing corrective feedback for failure.
- Implement relapse prevention strategies for managing possible future anxiety symptoms.
- Discuss with the client the distinction between a lapse and relapse, associating a lapse with an
initial and reversible return of symptoms, fear, or urges to avoid and relapse with the decision to
return to fearful and avoidant patterns.
- Identify and rehearse with the client the management of future situations or circumstances in which
lapses could occur.
- Instruct the client to routinely use strategies learned in therapy (e.g., cognitive restructuring,
exposure), building them into his/her life as much as possible.
- Develop a "coping card" on which coping strategies and other important information (e.g., "Pace your
breathing," "Focus on the task at hand," "You can manage it," and "It will go away") are written for
the client's later use.
- Verbalize the costs and benefits of remaining fearful and avoidant.
- Probe for the presence of secondary gain that reinforces the client's panic symptoms through escape
or avoidance mechanisms; challenge the client to remain in feared situations and to use coping
skills to endure.
- Verbalize the separate realities of the irrationally feared object or situation and the emotionally painful
experience from the past that has been evoked by the phobic stimulus.
- Clarify and differentiate between the client's current irrational fear and past emotional pain.
- Encourage the client's sharing of feelings associated with past traumas through active listening,
positive regard, and questioning.
- Commit self to not allowing panic symptoms to take control of life and lead to a consistent avoidance of
normal responsibilities.
- Support the client in following through with work, family, and social activities rather than
escaping or avoiding them to focus on panic.
- Return for a follow-up session to track progress, reinforce gains, and problem-solve barriers.
- Schedule a "booster session" for the client for 1 to 3 months after therapy ends.
Index