Fear of Fear

Clinical trials have demonstrated the efficacy of cognitive-behavioral treatment (CBT) for panic disorder but the mechanism responsible for the improvement are lacking. The reduction of fear of fear (FOF), or the tendency to respond fearfully to benign bodily sensations, is believed to underlie the improvement resulting from CBT. Research has provided evidence consistent with the FOF hypothesis. Descriptive studies consistently show that panic disorder patients score significantly higher on self-report measures tapping fear of bodily sensations. Those who score high on measures tapping FOF display heightened emotional responding to challenge compared with those who score low on these same FOF measures (M. Brown, Smits, Powers, & Telch, 2003; Eke & McNally, 1996; Holloway & McNally, 1987; McNally & Eke, 1996; Rapee & Medoro, 1994; Telch et al., 2003). Findings from several prospective studies suggest that people score big on the Anxiety Sensititivity Index (ASI) are at greater risk for developing occurring panic attacks (Schmidt, Lerew, & Jackson, 1997;p Shmidt, Lerew, & Joiner, 1998).

Specific procedural components contained in contemporary CBT manuals for panic disorder include education about the nature and physiology of panic and anxiety, breathing retraining designed to assist patients in learning to control hyperventilation, cognitive restructuring aimed at teaching patients to identify and correct faulty threat perceptions that contribute to their panic and anxiety, interoceptive exposure aimed at reducing patents' fear of harmless bodily sensations associated with physiological activation, and fading of maladaptive defensive behaviors such as avoidance of external situations (Barlow, Craske, Cerny, & Klosko, 1989; Clark et al., 1994; Telch et al., 199).

On the basis of contemporary psychological theories of panic disorder, several findings implicate change in FOF as a mediator of treatment outcome. CBT results in significant reductions on measures broadly tapping FOF (Bouchard et al., 1996; Clark et al., 1997, Poulton & Andrews, 1996). Modifying patients; catastrophic misinterpretations of bodily sensations result in significant reductions in panic (Taylor, 2000). A clinical trial comparing cognitive therapy with guided mastery therapy for panic disorder, changes in catastrophic cognitions predicted differential change in panic disorder symptoms.

Of the 130 participants ( 99 women and 31 men), 40 were randomly assigned to a waitlist condition, and 90 participants received treatment previously described by Telch (Telch et al., 1993, 1995). This multicomponent group CBT treatment consists of four major treatment components: education and corrective information concerning the nature, causes, and maintenance of anxiety and panic; cognitive therapy techniques helping patient identify, examine, and challenge faulty beliefs of danger and harm associated with panic, anxiety, and phobic avoidance; training in methods of slow diaphragmatic breathing to help patients eliminate hyperventilation symptoms and reduce physiological arousal; interoceptive exposure exercises designed to reduce patients' fear of somatic sensations through repeated exposure to various activities; and self-directed exposure to patients; feared situation designed to reduce agoraphobic avoidance.

Treatment conststed of twelve 2 hour structured sessions conducted over and 8 week period. Sessions were conducted twice weekly for the first 4 weeks and once each week for the remaining 4 weeks. Patients were required to tape-record each session. Assessment of clinical status and FOF occurred pretreatment and then again post treatment. For the Texas Panic Attack Record Form, participants were provided with daily panic diary forms. Patients had to record the