Experiential Cognitive Therapy for the Treatment of Panic Disorder With Agoraphobia: Definition of a Clinical Protocol

THROUGH THE DEVELOPMENT of epidemiologic studies we are able to say that 3.5% of the general population suffer from panic disorder1 with serious personal and social repercussions, such as depression, substance abuse, and suicidal tendencies.2 According to the DSM-IV,3 the essential feature of panic disorder (PD) is the occurrence of panic attacks. A panic attack is a sudden onset period of intense fear or discomfort associated with at least four symptoms that include: palpitations, breathlessness, dizziness, trembling, a feeling of choking, nausea, de-realization, chest pain, and paresthesias. The panic is characterized by a cluster of physical and cognitive symptoms, which occurs unexpectedly and recurrently, such as pervasive apprehension about panic attacks; persistent worry about future attacks; worry about the perceived physical, social, or mental consequences of attacks; or major changes in behavior in response to attacks. PD is often associated with circumscribed phobic disorders such as specific phobias, social phobias, and especially with agoraphobia.4,5 Agoraphobia is described separately from PD in the DSM-IV to highlight the occurrence of agoraphobic avoidance in individuals with or without a history of panic disorder.3 Agoraphobia consists of a group of fears of public places such as going outside, using public transportation, and being in public places (i.e., supermarkets, theaters, churches, football stadiums) that causes serious interference in daily life. Other fears may spring from this core phobia (such as going through tunnels, using lifts, and crossing bridges) as well as other internal fears, such as excessive worry about physical sensations (palpitations, vertigo, and dizziness) or an intense fear of panic attacks, including fear of social interaction. The results of these psychopathological symptoms are that the patient tends to avoid the feared situation and, from then on, this avoidance carries over into other situations. Indeed, avoidance of public places in order to reduce fear or panic became the main cause of incapacity in patients, who, in more serious cases, are confined to their homes.6,7 The recognition of PD as a specific syndrome was introduced by Klein.8,9 He disclosed that patients with recurrent panic attacks responded to imipramine but not benzodiazapines, and vice versa for anxious patients without recurrent panic attacks. His studies were particularly influential in establishing PD as a separate diagnostic entity. In the aetiopathology of PD, Barlow10 describes the initial panic attack as a misfiring of the “fear system” under stressful life circumstances in physiologically vulnerable individu-