A reanalysis of Clarks theory of panic disorder within the Spaars framework

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David Clark's theoretical work on panic has been extremely influential, especially within the clinical domain, and any analysis of panic phenomena within SPAARS would have much in common with Clark's ideas. Enshrined within the SPAARS approach is the proposal (see Chapters 2 and 5) that emotions consist of an event, an interpretation, an appraisal, physiological arousal, an action potential, conscious awareness (and behaviour). We can see that these components are clearly delineated within Clark's model: bodily sensations are the proximal event; catastrophic misinterpretations are the interpretation; and there is an implicit assumption that these interpretations will be appraised in a fear-related way leading to the physiological activation of fear-related bodily systems. Furthermore, Clark argues that the catastrophic misinterpretations of bodily sensations need not be conscious, and we have made this suggestion in Chapter 5 with respect to all emotion-related interpretations. In addition, Clark argues that the pathway from bodily sensation to emotion generation can become relatively automatic and, hence, outside the individual's control; this suggestion is loudly echoed by the proposed second route to emotion generation, the generation of emotion via the associative level of meaning within the SPAARS model (Power & Dalgleish, 1999).

So what might the SPAARS framework offer in addition to Clark's work? We propose that the greater theoretical power provided by a multi-level approach can perhaps go some way to answering the criticisms of Clark's work mentioned above. The key to this improvement lies in the associative generation of fear within SPAARS, in addition to the effortful conscious appraisal route to panic. Such laying down of associative links, we have suggested, is a function of the repeated activation of the pathway between bodily sensation via interpretation to appraisal of threat at the schematic model level (see Figure 6.5). However, this establishment of associative links can take two different forms within panic disorder. First, it is possible that the

ANALOGICAL LEVEL Bodily sensations

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ASSOC LE\

IATIVE (EL

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LEVEL e.g., "I am feeling dizzy and I will faint"

PROPOSITIONAL

LEVEL e.g., "I am feeling dizzy and I will faint"

PRODUCTS OF PANIC!

Figure 6.5 Automatic routes to panic in SPAARS (1 = propositional misinterpretation route; 2 = direct analogical route).

interpretation of a bodily sensation (for example, "I am feeling dizzy and that means I am likely to faint") could come to instigate the generation of fear via the associative level of representation. Alternatively, it is possible that the bodily sensation itself, in the absence of any interpretation of its putative consequences, could come to instigate the emotion of fear via the associative level of meaning within SPAARS as an example of interoceptive conditioning (Razran, 1961) mentioned earlier (see Figure 6.5).

With this state of affairs, the individual is likely to experience some panic attacks which seem to arise out of a clear awareness of bodily sensations and a clear awareness of catastrophic misinterpretations of those sensations (schematic model route). Other panic attacks, however, would seemingly come "out of the blue" or may even arise during sleep; thus, Uhde (2000) reported that 65% of individuals who suffer from panic disorder based on panic attacks while awake also experience panic attacks that wake them out of their sleep. In these cases it is possible that the individual is catastrophically misinterpreting bodily sensations, but that these interpretations are unavailable or inaccessible to conscious awareness (cf. Clark). One might then expect that, within the therapeutic context, such interpretations would become more and more accessible and become more and more under the individual's control (Power & Dalgleish, 1999). Alternatively, it is possible that no interpretations are being made and that the panic attack is being generated via the associative level of meaning as a result of the onset of bodily sensations. In these situations, it seems unlikely that the individual would be able to report any misinterpretations of the bodily sensations even within the therapeutic milieu.

Let us return, then, to the two points raised by McNally (1990) as possible problems with Clark's approach. McNally suggested, first, that "it remains a mystery why some individuals require such rigorous demonstrations [that is behavioural experiments within cognitive therapy] for them to abandon their pathological beliefs" (p. 407). Second, McNally raised the concern that, if interpretations of imminent disaster are always extant in the onset of panic symptoms, it would seem unlikely that the client would never be able to bring these interpretations into conscious awareness. With respect to the first point, it is inherent in the SPAARS approach that the associative generation of emotions is a relatively inflexible and uncontrollable process. Thus, in a situation in which the emotion of fear is generated via the associative level by a catastrophic misinterpretation, then although the individual may be fully aware of the interpretation that is being made, it would be very difficult to interrupt or control the generation of emotion which is a result of that interpretation. In this analysis, some individuals will "recover" from panic disorder following a few well-chosen words from their therapist because for them, panic is entirely schematically driven. Others will require more intensive therapeutic work to overcome associatively driven panic. With respect to McNally's second point, within SPAARS it is possible, as we have said, for the generation of fear to occur with no concurrent catastrophic interpretations; consequently, it would be expected that for some individuals, access to catastrophic misinterpretations prior to the onset of panic would not be possible (cf. Rachman et al., 1988; Roth et al., 2005). Finally, it is important to note that, although an explicit specification of two routes to emotion clarifies some of the issues associated with panic, it seems likely that for most sufferers, panic disorder is driven by a combination of both routes.

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