Clark's elegantly simple model of panic owes much to the ideas of Beck (e.g., 1976) which are discussed in detail in Chapter 4. According to Clark's (1986, 1996) model of panic "catastrophic misinterpretations of certain bodily sensations" (1986, p. 461) are a necessary condition for the production of a panic attack. Thus, a panic attack may originate from the misinterpretation that an increase in heart rate is a signal for an impending heart attack, or that the onset of feeling slightly dizzy or flushed is a sign that the individual is about to faint. Although such bodily sensations are symptoms of fear, and consequently Clark's model can be thought of as an extension of the fear of fear hypothesis, such sensations are not uniquely associated with fear. So, for example, heart palpitations may result from excessive caffeine intake or exercise rather than from an interpretation or appraisal related to threat. The point, then, is that Clark's model is about the catastrophic misinterpretation of bodily sensations whatever their cause; that is, it does not restrict itself to a fear of fear analysis.
The specific sequence of events that Clark suggests occur in a panic attack is illustrated in Figure 6.4. So, as can be seen from the figure, panickers are spiralling down a vicious circle—the more afraid they become, the more intense the feared bodily sensations, and thus the greater the fear, and so on. According to Clark, two further processes contribute to the maintenance of panic disorder once the individual has developed the tendency to misinterpret bodily sensations catastrophically. First, panickers become hypervigilant and repeatedly scan the body for evidence of bodily sensations that might be signals of impending catastrophe. This hypervigilance leads them to notice sensations of which many other people would be unaware and these sensations are taken as further evidence of the presence of some serious physical or mental disorder. Second, panickers develop a series of avoidance strategies. Clark (1989) cites the example of a patient who was preoccupied with the idea that he had some form of cardiac disease; he thus began to avoid exercise or sex whenever he noticed palpitations. Such avoidance, he believed, helped to prevent the onset of cardiac arrest. However, as Clark points out, because the patient did not actually have cardiac disease, the effect of the avoidance was to prevent him from learning that the palpitations he was experiencing were innocuous.
In line with Clark's ideas, panic patients report thoughts of imminent catastrophe which accompany their panic attacks (e.g., Ottaviani & Beck, 1987). Furthermore, these thoughts most usually occur following detection of identifiable bodily sensations (e.g., Clark et al., 1997; Hibbert, 1984). According to Clark (1988), the catastrophic misinterpretation of bodily sensations need not be accessible to awareness: "in patients who experience recurrent attacks, catastrophic misinterpretations may be so fast and automatic that patients may not always be aware of the interpretive process" (p. 76). This provides a possible explanation for panic attacks that either begin when the subject is asleep or which come "out of the blue".
There have been a number of critiques of Clark's work (see Roth, Wilhelm, & Pettit, 2005, for an overview). Seligman (1988), for example, questioned the persistence of panic attacks that were the result of misinterpretations by the subjects that they were becoming insane or about to have a heart attack. Such individuals, Seligman
CATASTROPHIC MISINTERPRETATION (e.g., "I'm having a heart attack")
FEAR AND ANXIETY
Figure 6.4 Clark's cognitive model of panic (based on Clark, 1986).
argued, would be immediately presented with information that illustrates that the instigating bodily sensations did not lead to catastrophe. To accommodate this problem, Seligman suggested that panic may be a response to certain biologically "prepared" bodily sensations (Seligman, 1971). However, as we have already noted, Clark does not need to resort to such theoretical gymnastics in order to explain the maintenance of panic attacks in the face of seemingly contradictory information, because patients routinely avoid situations that might arouse fear and so never test out whether the predicted catastrophes have any basis in reality. Indeed, within the cognitive therapeutic approach to panic, behavioural experiments carried out by the client involve putting aside these avoidance strategies in order to allow the hypothesis that a catastrophe will occur to be refuted (e.g., Clark & Beck, 1988). However, as McNally (1990) points out, "it still remains a mystery why some individuals require such rigorous demonstrations for them to abandon their pathological beliefs, whereas others are immediately convinced that their symptoms are harmless when provided corrective information by their family physician" (p. 407). We shall consider this comment by McNally when we look at the analysis of panic within SPAARS.
A second criticism of Clark's cognitive model of panic revolves around the issue of whether all panic attacks are proceeded by catastrophic misinterpretations, together with the suggestion that the theory may be unfalsifiable (Roth et al., 2005). As Teasdale (1988) has argued, just because a catastrophic misinterpretation of a bodily sensation can lead to a panic attack, it does not mean that all spontaneously occurring panic attacks are the result of catastrophic misinterpretations. A number of studies have shown that panic patients insist that they do not catastrophically misinterpret bodily sensations, and Rachman, Lopatka, and Levitt (1988) reported that in their study 27% of panic attacks were not preceded by a catastrophic thought. However, as we have stated, Clark has submitted that such catastrophic interpretations need not be conscious and it is perfectly consistent with his arguments that the individual would be unaware of, and thus unable to report, any precipitating catastrophic cognitions. McNally (1990) rejects this counter-argument on intuitive grounds: "It seems implausible that thoughts of imminent disaster do not at some point enter consciousness either during or immediately after an attack. If patients think, however momentarily, that they are having a heart attack it seems they would remember having had this thought" (p. 407). Intuition, though, is a dangerous ally when it comes to theoretical refutation; this seems compounded by McNally's confusion of the term interpretation with the idea of a thought. Again, these issues are discussed in more detail when we come to consider panic disorder within the SPAARS framework.
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