2: EMDR Therapy Protocol for Panic Disorders With or Without Agoraphobia
Introduction
Panic disorder, as stated in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association, 2013) is characterized by recurrent and unexpected panic attacks and by hyperarousal symptoms like palpitations, pounding heart, chest pain, sweating, trembling, or shaking. These symptoms can be experienced as catastrophic (“I am dying”) and mostly have a strong impact on daily life. When panic disorder is accompanied by severe avoidance of places or situations from which escape might be difficult or embarrassing, it is specified as “panic disorder with agoraphobia” (American Psychiatric Association, 2013).
EMDR Therapy and Panic Disorder With or Without Agoraphobia
Despite the well-examined effectiveness of Eye Movement Desensitization and Reprocessing (
From a theoretical perspective, there are several reasons why
The occurrence of panic attacks is likely to be totally unexpected; therefore, they are often experienced as distressing, causing a subjective response of fear or helplessness. Accordingly, panic attacks can be viewed as life-threatening experiences (McNally & Lukach, 1992; van Hagenaars, van Minnen, & Hoogduin, 2009).
Panic memories in panic disorder resemble traumatic memories in
PTSD in the sense that the person painfully reexperiences the traumatic incident in the form of recurrent and distressing recollections of the event, including intrusive images and flashbacks (van Hagenaars et al., 2009).Besides the panic attack itself being a threatening experience, there are indications that
PDA often develops after other stressful life events (Faravelli & Pallanti, 1989; Horesh, Amir, Kedem, Goldberger, & Kotler, 1997).
The same research group (Feske & Goldstein, 1997; Goldstein, de Beurs, Chambless, & Wilson, 2000; Goldstein & Feske, 1994) conducted almost all of the studies concerning the use of
The purpose of this chapter is to illustrate how
DSM-5 Criteria for Panic Disorder With and Without Agoraphobia
Before identifying suitable targets for
Panic attacks are recurrent and unexpected and include a surge that may range from intense discomfort to extreme fear cresting within minutes. They are accompanied by at least four or more of the following physiological symptoms: paresthesias (tingling sensations or numbness); sensations of heat or chills; experiences of dizziness, lightheadedness, unsteadiness or weakness; queasiness or abdominal upset; chest pain or distress; feeling of choking; unable to catch breath or feeling smothered; trembling or quaking; perspiring; and fast or irregular heartbeat. There are also intense cognitive distortions such as feelings of unreality (derealization) or being disconnected from oneself (depersonalization); fear of going crazy or losing control; and/or fear of dying.
In order to meet the criteria, a person must be either continuously worrying about having another panic attack or their consequences (such as losing control, having a nervous breakdown, etc.) or significantly changing behavior to avoid having another panic attack over the period of 1 month after the attack. If the symptoms can be ascribed to the physiological effects of a substance (such as a medication or drug abuse) or another medical condition (such as cardiac disorders or hyperthyroidism) or another mental disorder (such as social anxiety disorder or specific phobia), panic disorder is not diagnosed.
In contrast to DSM-IV-TR (American Psychiatric Association, 2000), where panic disorder is diagnosed with or without agoraphobia, the DSM-5 considers agoraphobia as an independent disorder. Therefore, agoraphobia is diagnosed irrespective of the presence of panic disorder. This diagnosis includes a separate DSM-5 code for agoraphobia. In case both disorders are present, both should be assigned. Agoraphobia is characterized by fear about situations related to being in enclosed or open spaces, being in line or in a crowd, being outside of the home alone or using public transport. These situations are difficult because in the event of panic symptomatology, the fear is that escape might be difficult and help might not be available is predominant leading to the avoidance of these situations or the need for the presence of another person. The fear or anxiety that is felt is out of proportion to the actual situation itself; this includes when another medical condition is occurring as well. This type of fear, anxiety, or avoidance lasts 6 months or more, impairs functioning in social, occupational or other areas of functioning and is not explained by other mental disorders.
Measurement
Standardized Clinical Interview
To determine whether a client suffers from panic disorder with or without agoraphobia, and its severity, a standardized clinical interview, such as the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 2002), should be administered. The answers to the questions reveal whether the client suffers from panic disorder and/or other anxiety disorders, like
Mobility Inventory
When a client is diagnosed with panic disorder with agoraphobia, the Mobility Inventory (Chambless, Caputo, Jasin, Gracely, & Williams, 1985) can be administered to determine the severity of the disorder. This inventory is a self-report questionnaire to measure the degree of agoraphobic avoidance across 27 situations. These situations are subdivided according to whether the client is encountering them with a trusted companion or alone.
Agoraphobic Cognitions Questionnaire
To identify the intensity of a client’s catastrophic cognitions when feeling anxious or tense, the Agoraphobic Cognitions Questionnaire (Chambless, Caputo, Bright, & Gallagher, 1985) can be used. This questionnaire has 14 catastrophic cognitions, divided into two subscales, which include anxiety about physical consequences and anxiety for social consequences.
Panic Disorder With or Without Agoraphobia Protocol Script Notes
Identifying Useful EMDR Therapy Targets
When identifying useful targets for
Panic Attack Memories
As mentioned earlier, panic attacks are likely to occur totally unexpectedly, and clients experience them as life threatening, causing a subjective response of fear or helplessness. Therefore, based on Shapiro’s Adaptive Information Processing (
Traumatic Memories
Besides the panic attack itself being a threatening experience, there are indications that panic disorder with or without agoraphobia often develops after other stressful life events (e.g., the loss of a loved one, a serious accident, or a divorce). These life events as such, most of the time, do not meet (full)
Agoraphobia Memories
Clients with panic disorder often develop agoraphobia. Since the agoraphobia develops after the start of the first and/or worst panic attack, it can be expected that, in the most ideal situation, the severity of the symptoms characterizing the agoraphobia (e.g., avoidance of a certain situation) will be reduced when the panic attack memories are completely processed. But, when the anticipatory anxiety for clients’ typical agoraphobic situations does not dissolve, it is important to determine the presence of other (disturbing) memories of past events that possibly keep the agoraphobic fears vivid.
In certain cases, clients who have been treated with
If the client’s flashforward has been fully processed and the Validity of Cognition (
Panic Disorder With or Without Agoraphobia Protocol Script
Currently, no official guideline is available for the treatment of panic disorder with or without agoraphobia using
Phase 1: Client History
Determine to what extent the client fulfills the DSM-5 criteria of a panic disorder with or without agoraphobia (American Psychiatric Association, 2013).
Identify the Targets
First Panic Attack/Stimulus Situation
Identify the first panic attack or stimulus situation.
Say, “Please describe your first panic attack that you remember.”
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Check whether this is indeed the first panic attack.
Say, “Is this indeed your first panic attack? I mean, are you absolutely sure you don’t remember having had a panic attack prior to this incident?”
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Worst Panic Attack/Most Representative Experience
Identify the worst panic attack or most representative experience.
Say, “Please describe the worst panic attack you remember.”
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Most Recent Panic Attack
Identify the most recent panic attack.
Say, “Please describe the most recent panic attack.”
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Identify Other Experiences Relevant to the Onset of the Panic Disorder
Identify other experiences relevant to the onset of the panic disorder.
Say, “What other past experiences might be important in relation to the onset of the panic disorder you have? Please describe.”
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Or say, “If the panic attacks started with a traumatic event, which one was that?”
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Or say, “Do the panic attacks remind you of another specific event?”
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Or say, “Do you remember having been exposed to any traumatic (other) event prior to the start of your first panic attack?”
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Introduce the Timeline
Introduce the timeline for the client’s panic and trauma experiences.
Say, “Let’s draw a timeline of your panic history and traumatic experiences until now. The horizontal line represents the time, and the vertical line the severity of the symptoms.”
Help the client draw the timeline on a piece of paper.
Expected Consequence/Catastrophe
Identify the expected consequence or catastrophe (e.g., physical consequences, like “I must have a brain tumor” and/or social consequences, like “I am going crazy”).
Say, “What are you afraid could happen when you get a panic attack?”
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If the client meets the criteria of agoraphobia, say the following:
Say, “What are you afraid could happen when you are confronted with or exposed to __________ (state the agoraphobic situation)?”
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Assess the Validity of Catastrophe
State the reality of the fear of exposure and assess the percentage of fear that a client feels if exposed to the agoraphobic situation using the VoC score.
Say, “Is it true you are saying that IF you would be exposed to __________ (state the agoraphobic situation) THEN you would __________ (state the catastrophe the client fears would happen)?”
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Say, “On a scale from 0% to 100%, where 0% means it is completely false and 100% means it is completely true, how true does this feel?”
0% | 10% | 20% | 30% | 40% | 50% | 60% | 70% | 80% | 90% | 100% |
(completely false) | (completely true) |
Treatment Goal
Determine an appropriate and feasible treatment goal(s).
Say, “Based on all that we have been talking about, let’s discuss our goal(s) for treatment. What is/are the goal/s and how will you know when you have reached your goal(s)?”
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Addictive Medications
Assess for any addictive medications.
Say, “Are you using benzodiazepines?”
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If yes, and client is using benzodiazepines, say the following:
Say, “Would you be willing to stop or to reduce your benzodiazepine consumption before starting
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Phase 2: Preparation Phase
Explanation of EMDR Therapy
Explain
Say, “When a negative and distressing event, like a panic attack, occurs, it seems to get locked in the nervous system with the original picture, sounds, thoughts, and feelings. The eye movements we use in
Teach Working Memory Taxation Techniques
Teach working memory-taxing methods for immediate anxiety management between sessions, such as the following:
Say, “Please describe out loud the content of the room with as much detail as you can.”
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The types of exercises that tax clients’ working memory include mental exercises such as counting backward from 1,000 by 7s, remembering a favorite walk in detail, and so on. For example, try the following:
Say, “Please count backward from 1,000 by 7s.”
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Or say, “In detail, tell me about a favorite walk that you took.”
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In the case of a child, distraction can be applied, for instance, by thinking of animals beginning with each letter of the alphabet in turn.
Say, “Think of an animal that begins with the letter A.”
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Say, “Great, now let’s continue finding the names of animals using the rest of the alphabet. What would the name of an animal be for the letter B?”
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Continue finding the names of the animals with the rest of the alphabet.
Say, “These exercises that we have been practicing may help you when you are dealing with anxiety-eliciting situations. It is really important for you to prepare yourself for possible discomfort between sessions by practicing these exercises. The more you practice, the better you will get at them.”
Phase 3: Assessment Phase
Past Memories. Target Selection
Select a target image (stationary picture) of the memory. (See Phase 1: Client History for the series of targets that have to be processed. It is recommended to start with the first and/or worst panic attack.)
Say, “You’ve just told me how this event is present in your mind. Now I’m asking you, at this moment, if you look at it right here and right now, what is the most disturbing picture of this memory? Look at it, as if it’s a film, and stop it, right at that second, so it becomes a picture. We are looking mostly for a picture with you in it. It’s not about what you found most disturbing at that time, but what is now, at this moment, the most disturbing picture to look at, including pictures that show what could have happened.”
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If it helps, you can also ask these questions:
Say, “So you’re looking at yourself from a distance?”
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Say, “What does this picture look like?”
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Negative Cognition
Obtain the
Say, “What words go best with the picture that express your negative belief about yourself now?”
Note: The
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Positive Cognition
Say, “When you bring up the picture of the incident, what would you like to believe about yourself now?”
Note: The
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Validity of Cognition
Say, “When you bring up the picture of the incident, how true do those words __________ (repeat the
1 | 2 | 3 | 4 | 5 | 6 | 7 |
(completely false) | (completely true) |
Identify emotion,
Emotions
Say, “When you bring up the picture (or incident) and those words __________ (state the
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Subjective Units of Disturbance
Say, “On a scale of 0 to 10, where 0 is no disturbance or neutral and 10 is the highest disturbance you can imagine, how disturbing does the picture (or incident) feel now?”
0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
(no disturbance) | (highest disturbance) |
Location of Body Sensation
Say, “Where do you feel it (the disturbance) in your body?”
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Phase 4: Desensitization Phase
Hold your hand in front of the patient’s eyes.
Say, “Look at my fingers (or fingertips).”
Say, “I want to ask you to be a spectator who is observing the things that are happening to you from the moment you start following my hand. Those things can be thoughts, feelings, images, emotions, physical reactions, or maybe other things. These can relate to the event itself, but also to other things that seem to have no relationship to the event itself. Just notice what comes up, without trying to influence it, and without asking yourself whether it’s going well or not. It’s important that you don’t try to hold onto the image that we will start with or keep it in mind all the time. The image is just the starting point of anything that can and may come up. Every once in a while we will go back to this image to check how disturbing it still is to look at. Keep in mind that is impossible to do anything wrong, as long as you just follow what’s there and what comes up.”
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Then say, “Bring up the picture and the words __________ (repeat the
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This protocol uses a different strategy to go back to the target than in the Standard
Say, “Please go back to the picture that we started with as it is now stored in your head. How disturbing is it now to look at the picture, on a scale from 0 to 10, where 0 is not disturbing at all, and 10 is as disturbing as it can get?”
0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
(no disturbance) | (highest disturbance) |
If the
Say, “What aspect of the picture is causing that disturbance/tension (you may name the number, e.g., ‘What is there in the picture that is causing the 4?’).”
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Or say, “What is there in the picture that is causing the __________ (state the
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Then say, “Concentrate on that aspect. OK, have you got it? Go with that.”
Repeat the “Back to target” procedure until
If
Say, “Are you absolutely sure that there isn’t a little bit of disturbance or tension somewhere? If so, try to let it affect you.”
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If necessary, continue the desensitization until the original picture feels completely neutral. Then continue with installation.
Phase 5: Installation Phase
Install the PC
Say, “How does __________ (repeat the
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Say, “Do the words __________ (repeat the
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If the client accepts the original PC, the clinician should ask for a
Say, “As you think of the incident, how do the words (the
1 | 2 | 3 | 4 | 5 | 6 | 7 |
(completely false) | (completely true) |
Say, “Think of the event and hold it together with the words __________ (repeat the
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Continue this procedure until the
Check the Response and the Symptoms Regarding the Previous Processing
If, after the previous steps, the client still suffers from symptoms such as panic attacks or agoraphobic fears that persist after all memories of all past events that could be identified as contributing to the current symptoms have been fully processed, the Flashforward Procedure (Logie & de Jongh, 2014; see Chapter 3 in this volume) should be applied. This procedure addresses clients’ irrational fears and anticipatory anxiety responses/triggers and is focused on the mental representation that represents the worst possible outcome of a confrontation with the object or situation that provokes the fear.
Check the Other Targets
See Phase 1: Client History and decide whether it is still necessary to reprocess these experiences (i.e.,
Say, “OK, let’s check the next target that is in your list __________ (state the next target). On a scale of 0 to 10, where 0 is no disturbance or neutral and 10 is the highest disturbance you can imagine, how disturbing does it feel now?”
0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
(no disturbance) | (highest disturbance) |
Phase 6: Body Scan
Say, “Close your eyes and keep in mind the experience (e.g., a panic attack) that you will have in the future. Then bring your attention to the different parts of your body, starting with your head and working downward. Any place you find any tension, tightness, or unusual sensation, tell me.”
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If any sensation is reported, introduce eye movements.
If it is a positive or comfortable sensation, a new set of eye movements is introduced to reinforce the positive sensation.
If a sensation of discomfort is reported, this is reprocessed until the discomfort subsides. Finally, the VoC has to be checked.
Say, “As you think of the incident, how do the words feel, from 1 being completely false to 7 being completely true?”
1 | 2 | 3 | 4 | 5 | 6 | 7 |
(completely false) | (completely true) |
Present Triggers. Flashforward
After all old memories that currently “fuel” the fear have been resolved, check whether the patient has an explicit disaster image about the future. What does the patient think will happen to him, in the worst case, if what is feared cannot be avoided?
Say: “What we have to figure out now is what you fear will happen (will go wrong) when you are confronted with __________ (object or situation that is avoided). So basically, what catastrophe do you expect to happen, that prevents you from doing what you want or need to do? What is that ‘doom scenario’ or ‘worst nightmare’ that’s in your head?”
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Let the client create a still image of this disaster scenario and process this mental representation with the Standard
Future Template
For installing the future template, instruct the patient by asking her to imagine a future situation that—until now—has been avoided (or experienced with a lot of anxiety) and/or has been anticipated with extreme anxiety because of the fear of getting a panic attack. In this situation, the preferred behavior is expressed. When doing so, check for catastrophic aspects in the picture. If so, ask the patient to make a picture in her mind without these “disasters.”
Install the Future Template
Say, “OK, we have reprocessed all of the targets that we needed to do that were on your list. Now, let’s anticipate what will happen when you are faced with __________ (state the (agoraphobic) fear). What picture do you have in mind?”
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Say, “I would like you to imagine yourself coping effectively with __________ (state the fear trigger) in the future. Bring up this picture and say to yourself: ‘I can handle it’, and feel the sensations. OK, have you got it? Follow my fingers (or any other forms of
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Say, “Bring up the picture again. On a scale from 1 to 7, where 1 feels completely false and 7 feels completely true, to what extent do you think you can manage to really do it?”
1 | 2 | 3 | 4 | 5 | 6 | 7 |
(completely false) | (completely true) |
Install with sets of eye movements until a maximum level of VoC has been achieved.
If there is a block, meaning that even after 10 or more installations, the VoC is still below 7, there are more targets that have to be identified and addressed. The therapist should use the Standard
Say, “What would you need to feel confident in handling the situation?”
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Or say, “What is missing from your handling of this situation?”
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Use
Video Check (Future Template as Movie)
Say, “This time, I’d like you to imagine yourself stepping into the scene of a future confrontation with (the object or the situation for which the future template was meant; e.g., a confrontation with a dog). Close your eyes and play a movie of this happening, from the beginning until the end. Imagine yourself coping with any challenges that come your way. Notice what you are seeing, thinking, feeling, and experiencing in your body. While playing this movie, let me know if you hit any blocks. If you do, just open your eyes and let me know. If you don’t hit any blocks, let me know when you have viewed the whole movie.”
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If the client encounters a block and opens her eyes, this is a sign for the therapist to instruct the client as follows:
Say, “Say to yourself ‘I can handle it’ and follow my fingers (introduce a set of eye movements).”
To provide the clinician with an indication regarding the client’s self-efficacy, ask her to rate her response on a VoC scale from 1 to 7. This procedural step may give the clinician feedback on the extent to which the goals have been met.
Say, “As you think of the incident, how do the words (restate the PC) feel from 1 being completely false to 7 being completely true?”
1 | 2 | 3 | 4 | 5 | 6 | 7 |
(completely false) | (completely true) |
If the client is able to play the movie from start to finish with a sense of confidence and satisfaction, then the client is asked to play the movie once more from the beginning to the end,
Say, “OK, play the movie one more time from beginning to end and say to yourself, ‘I can handle it.’ Go with that.”
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In Vivo Confrontations
Prepare the client for in vivo confrontations.
Say, “Many clients with a panic disorder with agoraphobia appear to avoid certain activities for so long that they no longer know how to behave and how to feel secure in this situation. To be able to help further alleviate your fears and concerns, it is important that you learn to counter the negative belief that contributes to this sense of threat and anxiety. Therefore, you need to actually test the catastrophic expectations you have that fuel your anxiety in real life. I would like to ask you to gradually confront the (agoraphobic) situations that normally would provoke a fear response. It may seem odd, but if you have a positive experience and it appears that the catastrophe you fear does not occur, it helps you to further demonstrate—or to convince yourself—that your fear is unfounded.”
Say, “I want you to understand that nothing will happen against your will during the confrontation with the things that normally would evoke fear. The essence of this confrontation is that it is safe. Do you understand? Do you have any questions?”
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In Vivo Exposure
In vivo exposure is done to reduce avoidance and evoke mastery while observing that no real danger exists. It is essential that the therapist help the client pay attention to features of the (agoraphobic) situation that are positive or interesting while being exposed to it.
Say, “Please describe the most notable features of the situation. Are you noticing any interesting elements about __________ (state the situation)?”
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To identify negative thought content, say the following:
Say, “What are you thinking as you pay attention to __________ (state the situation)?”
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To cognitively reconstruct the situation, say the following:
Say, “How would someone who is not afraid of __________ (state the situation) view or evaluate this situation?”
If needed, give advice to help the client cope with both the situation and his own mental and body sensations.
Note: It is helpful to make variations with regard to the stimulus dimensions such as action, distance, and time.
Say, “Isn’t it interesting to notice that now that you are confronted with this __________ (state the situation) __________ (state the catastrophe the client normally would have feared to happen) does not occur?”
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Say, “Do you notice that your anxiety is not as physically harmful as you might have expected?”
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Say, “These emotional reactions will subside and fade over time. Therefore, it is important that you continue exposing yourself to the feared stimuli as long as you feel that you have achieved a certain degree of self-mastery. Please note that you are gradually learning to feel that you are capable of handling a certain level of anticipatory anxiety with confidence.”
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The therapist should make sure that confrontations are repeated so that the reduction in distress is fully consolidated before moving on. Check results by assessing the validity of catastrophe.
Say, “If you would encounter __________ (state the situation) again, on a scale from 0% to 100%, where 0% means it is completely false and 100% means it is completely true, how true does this feel that the situation is still catastrophic?”
0% | 10% | 20% | 30% | 40% | 50% | 60% | 70% | 80% | 90% | 100% |
(completely false) | (completely true) |
Phase 7: Positive Closure
At the end of every session, consolidate the changes and improvements that have occurred.
Say, “What is the most positive thing you have learned about yourself in the last hour with regard to __________ (state the incident or theme)?”
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If the cognitions are not already on the identity level, say the following:
Say, “What does this say about yourself as a person?”
Say, “Go with that.”
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Install with
Next, check the results by assessing the VoC.
Say, “If you would be exposed to __________ (state the situation), on a scale from 0% to 100% where 0% means it is completely false and 100% means it is completely true, how true does this (the
0% | 10% | 20% | 30% | 40% | 50% | 60% | 70% | 80% | 90% | 100% |
(completely false) | (completely true) |
Explain the expectations for the time in between sessions, which may include any contracts, diary keeping, and contact information.
Say, “Things may come up or they may not. If they do, great. Write it down and it can be a target for next time. If you get any new memories, dreams, or situations that disturb you, just take a good snapshot. It isn’t necessary to give a lot of detail. Just put down enough to remind you so we can target it next time. The same thing goes for any positive dreams or situations. If negative feelings do come up, try not to make them significant. Remember, it’s still just the old stuff. Just write it down for next time.”
Planning Self-Managed Homework Assignments
After the therapy has been concluded, the therapist makes it clear that it is important to keep practicing during daily life to ensure that the changes are maintained.
Say, “It is very important to keep practicing with exposing yourself to difficult situations during your daily life in order to maintain the changes that you have experienced.”
“Each time that you have a chance to see __________ (state the feared stimulus), it is an opportunity for you to practice these new skills that you now know how to do. So, the more that you encounter __________ (state the feared stimulus), the better you can get at __________ (state the goal). Your brain learns to do new behaviors by practicing.”
Phase 8: Reevaluation
Say, “Make sure to write down your responses when you are practicing your new skills. Sometimes, even with the skills, you might find that you reexperience your fear (e.g., a panic attack). I want to tell you that this can happen sometimes, and it is not unusual. What you can do at that time is to note what has led up to the feeling, what is going on around you, and what you did to help yourself handle the situation. Jot down some notes about what happened as soon as you can so that you won’t forget what happened and then bring them to the next session so that we can figure it out.”
Evaluate whatever has not been completed.
Say, “As you think back on the target that we were working on last time, on a scale of 0 to 10, where 0 is no disturbance or neutral and 10 is the highest disturbance you can imagine, how disturbing does it feel now?”
0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
(no disturbance) | (highest disturbance) |
If the disturbance level has increased, these disturbances must be targeted or otherwise addressed.
The therapist should assess the necessity of teaching the client additional self-control and perhaps relaxation techniques or other relevant exercises that could further enhance his ability to confront the former anxiety-provoking situation in real life.
Say, “So, what other resources do you think might be helpful in assisting you to deal with this situation?”
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Repeated rehearsal and reinforcement for success should be emphasized. To encourage hope and foster engagement in treatment, it is crucial that therapy sessions and homework assignments furnish experiences of success that clients can attribute to themselves.
Say, “I can see that through all of the work you did between sessions that you are really working hard (reinforce what the client has done that has been successful).”
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Summary
The purpose of this chapter is to illustrate how
Therefore, this chapter showed how
References
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- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
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- Faravelli, C., & Pallanti, S. (1989). Recent life events and panic disorder. American Journal of Psychiatry, 146, 622–626.
- Feske, U., & Goldstein, A. J. (1997). Eye movement desensitization and reprocessing treatment for panic disorder: A controlled outcome and partial dismantling study. Journal of Consulting and Clinical Psychology, 65, 1026–1035.
- First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (2002). Structured clinical interview for DSM-IV-TR axis I disorders, research version, client edition. (SCID-I/P). New York, NY: Biometrics Research, New York State Psychiatric Institute.
- Goldstein, A. J., de Beurs, B. E. Chambless, D. L., & Wilson, K. A. (2000). EMDR for panic disorder with agoraphobia: Comparison with waiting list and credible attention-placebo control conditions. Journal of Consulting and Clinical Psychology, 68, 947–956.
- Goldstein, A. J., & Feske, U. (1994). Eye movement desensitization and reprocessing for panic disorder: A case series. Journal of Anxiety Disorders, 8(4), 351–362.
- Horesh, N., Amir, M., Kedem, P., Goldberger, Y., & Kotler, M. (1997). Life events in childhood, adolescence and adulthood and the relationship to panic disorder. Acta Psychiatrica Scandinavica, 96, 373–378.
- Logie, R., & de Jongh, A. (2014). The “Flashforward procedure”: Confronting the catastrophe. Journal of EMDR Practice and Research, 8(1), 25–32.
- Luber, M.(Ed.). (2009). Eye movement desensitization and reprocessing (
EMDR ) scripted protocols: Special populations. New York, NY: Springer. - Luber, M.(Ed.). (2012). Eye movement desensitization and reprocessing (
EMDR ) scripted protocols with summary sheets: Special populations. New York, NY: Springer. - McNally, R. J., & Lukach, B. M. (1992). Are panic attacks traumatic stressors? American Journal of Psychiatry, 149, 824–826.
- Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York, NY: Guilford Press.
- ten Broeke, E., & de Jongh, A. (2009). Praktijkboek EMDR: casusconceptualisatie en specifieke patiëntejagroepen. Amsterdam, The Netherlands: Pearson.
- van Hagenaars, M. A., van Minnen, A., & Hoogduin, K. A. (2009). Reliving and disorganization in posttraumatic stress disorder and panic disorder memories. The Journal of Nervous Mental Disease, 197, 627–630.
2A
Summary Sheet: EMDR Therapy Protocol for Panic Disorders With or Without Agoraphobia
Summary Sheet By Marilyn Luber
Name: _________________________________________ Diagnosis: ________________
☑ Check when task is completed, response has changed, or to indicate symptoms or diagnosis.
Note: This material is meant as a checklist for your response. Please keep in mind that it is only a reminder of different tasks that may or may not apply to your client.
Introduction
EMDR Therapy and Panic Disorder With or Without Agoraphobia
Why eye movement desensitization and reprocessing (
Can be viewed as life-threatening experience
Resemble traumatic memories in posttraumatic stress disorder (
PTSD ) including recurrent and distressing recollections of the event, intrusive images, and flashbacksDevelops after stressful life event
DSM-5 Criteria for Panic Disorder With or Without Agoraphobia
Panic Attacks
Panic attacks are recurrent and unexpected and include a surge that may range from intense discomfort to extreme fear cresting within minutes. They are accompanied by at least four or more of the following physiological symptoms:
paresthesias (tingling sensations or numbness);
sensations of heat or chills;
experiences of dizziness, lightheaded, unsteadiness, or weakness;
queasiness or abdominal upset;
chest pain or distress; feeling of choking;
unable to catch breath or feeling smothered; trembling, or quaking;
perspiring;
fast or irregular heartbeat;
intense cognitive distortions such as feelings of unreality (derealization) or being disconnected from oneself (depersonalization);
fear of going crazy or losing control;
and/or fear of dying.
In order to meet the criteria, a person must be either continuously worrying about having another panic attack or their consequences (such as losing control, having a nervous breakdown, etc.) or significantly changing behavior to avoid having another panic attack over the period of 1 month after the attack. If the symptoms can be ascribed to the physiological effects of a substance (such as a medication or drug abuse) or another medical condition (such as cardiac disorders or hyperthyroidism) or another mental disorder (such as social anxiety disorder or specific phobia), panic disorder is not diagnosed.
Agoraphobia
Agoraphobia is characterized by fear about situations related to being in enclosed or open spaces, being in line or in a crowd, being outside of the home alone or using public transport. These situations are difficult because in the event of panic symptomatology, the fear is that escape might be difficult and help might not be available is predominant leading to the avoidance of these situations or the need for the presence of another person. The fear or anxiety that is felt is out of proportion to the actual situation itself, this includes when another medical condition is occurring as well. This type of fear, anxiety, or avoidance lasts 6 months or more, impairs functioning in social, occupational, or other areas of functioning and is not explained by other mental disorders.
Measurement
Standardized Clinical Interview
Mobility Inventory
Agoraphobic Cognitions Questionnaire
Panic Disorder With or Without Agoraphobia Protocol Script Notes
Identifying Useful EMDR Therapy Targets: Any Experience That “Fuels” the Current Pathology
Panic-Attack Memories (Unexpected, Experiences as Life Threatening, Subjective Response of Fear or Helplessness)
Target: First, worst, and most recent panic attack memory
Traumatic Memories
Process underlying traumatic memories/life events.
Flashforward: If still not sufficient because client is avoiding activities even without panic attacks and does not know how to feel secure, check the most feared catastrophic future event/flashforward.
Check to see if client can deal with agoraphobic situations.
If not, use in vivo exposure.
Agoraphobic Memories
Usually decrease after panic attack memories have been completely processed.
Panic Disorder With or Without Agoraphobia Protocol Script
Phase 1: Client History
Diagnosis: __________________________________________________
__________________________________________________________________________
Identify the Targets
First Panic Attack/Stimulus Situation
Target/Memory/Image: __________________________________________________
__________________________________________________________________________
Worst Panic Attack/Most Representative Experience
Target/Memory/Image: __________________________________________________
__________________________________________________________________________
Most Recent Panic Attack
Target/Memory/Image: __________________________________________________
__________________________________________________________________________
Identify Other Experiences Relevant to the Onset of the Panic Disorder
Relevant past experiences related to the onset of the panic disorder ___________________________________
__________________________________________________________________________
__________________________________________________________________________
Panic attack started with traumatic event _____________________________________________
__________________________________________________________________________
__________________________________________________________________________
Panic attacks remind client of another specific event ____________________________________
__________________________________________________________________________
__________________________________________________________________________
Exposed to any traumatic event prior to the start of the first panic attack ______________________________
__________________________________________________________________________
__________________________________________________________________________
Introduce the Timeline
“Let’s draw a timeline of your panic history and traumatic experiences until now. The horizontal line represents the time, and the vertical line the severity of the symptoms.”
Expected Consequence/Catastrophe
Identify the expected consequence/catastrophe if you get a panic attack: ______________________________
__________________________________________________________________________
__________________________________________________________________________
Identify the expected consequence/catastrophe if confronted with or exposed to the agoraphobic situation:
__________________________________________________________________________
__________________________________________________________________________
Assess the VoC
“Is it true you are saying that IF you would be exposed to __________ (state the agoraphobic situation) THEN you would __________ (state the catastrophe the client fears would happen)? __________”
“How true does it feel (0–100%)?”
Treatment Goal
Goal(s): _____________________________________________________
__________________________________________________________________________
__________________________________________________________________________
How you know when goal is reached: ______________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Addictive Medications
Benzodiazepines ◻ Yes ◻ No
Stop benzodiazepines before
EMDR ◻ Yes ◻ No
Phase 2: Preparation
Explanation of EMDR Therapy
“When a negative and distressing event, like a panic attack, occurs, it seems to get locked in the nervous system with the original picture, sounds, thoughts, and feelings. The eye movements we use in
Teach Working Memory Taxation Techniques for Anxiety Management
Orientation—(describe room in detail)
Counting—(count backward from 1,000 by 7s)
Details of walk
Name animals (A to Z)
Phase 3: Assessment
Past Memories
Target Selection
“You’ve just told me how this event is present in your mind. Now I’m asking you, at this moment, if you look at it right here and right now, what is the most disturbing picture of this memory?
Look at it, as if it’s a film, and stop it, right at that second, so it becomes a picture. We are looking mostly for a picture with you in it. It’s not about what you found most disturbing at that time, but what is now, at this moment, the most disturbing picture to look at, including pictures that show what could have happened.”
Note:
First Panic Attack/Stimulus Situation
Target/Memory/Image: ____________________________________________________
__________________________________________________________________________
NC: ___________________________________________________________
PC: ___________________________________________________________
VoC: ___________________ /7
Emotions: ____________________________________________________
Sensation: ___________________________________________________
Worst Panic Attack/Most Representative Experience
Target/Memory/Image: __________________________________________________
__________________________________________________________________________
NC: ___________________________________________________________
PC: ___________________________________________________________
VoC: ___________________ /7
Emotions: ____________________________________________________
Sensation: ___________________________________________________
Most Recent Panic Attack
Target/Memory/Image: __________________________________________________
__________________________________________________________________________
NC: ___________________________________________________________
PC: ___________________________________________________________
VoC: ___________________ /7
Emotions: ___________________________________________________
Sensation: ___________________________________________________
Identify Other Experiences Relevant to the Onset of the Panic Disorder
Target/Memory/Image: __________________________________________________
__________________________________________________________________________
NC: ___________________________________________________________
PC: ___________________________________________________________
VoC: ___________________ /7
Emotions: ____________________________________________________
Sensation: ____________________________________________________
Phase 4: Desensitization
“Look at my fingers/fingertips. I want to ask you to be a spectator who is observing the things that are happening to you from the moment you start following my hand. Those things can be thoughts, feelings, images, emotions, physical reactions, or maybe other things. These can relate to the event itself, but also to other things that seem to have no relationship to the event itself. Just notice what comes up, without trying to influence it, and without asking yourself whether it’s going well or not. It’s important that you don’t try to hold onto the image that we will start with or keep it in mind all the time. The image is just the starting point of anything that can and may come up. Every once in a while we will go back to this image to check how disturbing it still is to look at. Keep in mind that is impossible to do anything wrong, as long as you just follow what’s there and what comes up. Bring up the picture and the words _____________________________________ (repeat the
Dutch strategy for going back to target:
“Please go back to the picture that we started with as it is now stored in your head. How disturbing is it now to look at the picture, on a scale from 0 to 10, where 0 is not disturbing at all, and 10 is as disturbing as it can get?”
Introduce according to
If
If
Phase 5: Installation
PC: ◻ Completed
New PC (if new one is better): _____________________________________________________
VoC: ___________________ /7
Incident +
Check the other targets to see if it is still necessary to reprocess these experiences.
Other Targets | Age | SUD | SUD Post |
1. _________________________________ | __________ | ______ /10 | ______ /10 |
2. _________________________________ | __________ | ______ /10 | ______ /10 |
3. _________________________________ | __________ | ______ /10 | ______ /10 |
4. _________________________________ | __________ | ______ /10 | ______ /10 |
5. _________________________________ | __________ | ______ /10 | ______ /10 |
Check the Response and the Symptoms Regarding the Previous Processing
If symptoms persist after processing these identified targets, use the Flashforward Procedure that addresses clients’ irrational fears and anticipatory anxiety responses/triggers and is focused on the mental representation that represents the worst possible outcome of a confrontation with the object or situation that provokes the fear. See below.
Check the Other Targets
“OK, let’s check the next target that is in your list __________ (state the next target). On a scale of 0 to 10, where 0 is no disturbance or neutral and 10 is the highest disturbance you can imagine, how disturbing does it feel now?” __________ /10
Phase 6: Body Scan
“Close your eyes and keep in mind the experience (e.g., a panic attack) that you will have in the future. Then bring your attention to the different parts of your body, starting with your head and working downward. Any place you find any tension, tightness, or unusual sensation, tell me.”
If positive, add
If negative/discomfort, reprocess until discomfort subsides.
Check VoC: ________________________/10
Present Triggers
Flashforward
“What we have to figure out now is what you fear will happen (will go wrong) when you are confronted with _________________ (object or situation that is avoided). So basically, what catastrophe do you expect to happen that prevents you from doing what you want or need to do? What is that ‘doom scenario’ or ‘worst nightmare’ that’s in your head?”
Use this as a target for processing with the Standard
Target/Memory/Image: __________________________________________________
__________________________________________________________________________
NC: I am powerless (in relation to the disaster image)
PC: I can handle it (the image)
VoC: __________________________________/7
Emotions: ____________________________________________________
Sensation: _____________________________________________________
Future Template
Installation of the Future Template (Image)
Image of coping effectively with/or in the fear trigger in the future: ____________________________________________
__________________________________________________________________________
Sensations: ___________________________________________________
+
VoC (able to handle the situation): __________ /7
Install until VoC = 7.
If VoC continues to be > 7, there are more targets to be identified and addressed using the Standard
Blocks/Anxieties/Fears in future scene: _______________________________________________________________
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
Do BLS. If they do not resolve, ask for other qualities needed to handle the situation or what is missing.
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
Use BLS. If blocks are not resolved, identify unprocessed material and process with Standard
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
Target/Memory/Image: __________________________________________________
__________________________________________________________________________
NC: ___________________________________________________________
PC: ___________________________________________________________
VoC: ___________________ /7
Emotions: ____________________________________________________
Sensation: _____________________________________________________
Video Check (Future Template as Movie)
Say, “This time, I’d like you to imagine yourself stepping into the future. Close your eyes and play a movie from the beginning until the end. Imagine yourself coping with any challenges that come your way. Notice what you are seeing, thinking, feeling, and experiencing in your body. While playing this movie, let me know if you hit any blocks. If you do, just open your eyes and let me know. If you don’t hit any blocks, let me know when you have viewed the whole movie.”
If block(s), say, “I can handle it,” and BLS. Repeat until client can go through the whole movie entirely without distress.
VoC: ___________________ /7
If client can play movie from beginning to end with confidence and satisfaction, play the movie one more time from beginning to end +
In Vivo Confrontations
“Many clients with a panic disorder with agoraphobia appear to avoid certain activities for so long that they no longer know how to behave and how to feel secure in this situation. To be able to help further alleviate your fears and concerns, it is important that you learn to counter the negative belief that contributes to this sense of threat and anxiety. Therefore, you need to actually test the catastrophic expectations you have that fuel your anxiety in real life. I would like to ask you to gradually confront the (agoraphobic) situations that normally would provoke a fear response. It may seem odd, but if you have a positive experience and it appears that the catastrophe you fear does not occur, it helps you to further demonstrate—or to convince yourself—that your fear is unfounded.”
“I want you to understand that nothing will happen against your will during the confrontation with the things that normally would evoke fear. The essence of this confrontation is that it is safe. Do you understand? Do you have any questions?”
Client agrees to in vivo exposure: ◻ Yes ◻ No
In Vivo Exposure
This is done to reduce avoidance and evoke mastery while observing that no real danger exists.
Pay attention to features of the phobic object or situation that are positive or interesting while being exposed to it:
Description of most notable features of the situation: __________________________________________________________
__________________________________________________________________________
Negative-thoughts thinking during in vivo exposure: ___________________________________________________________
__________________________________________________________________________
Thoughts someone who is not afraid would think in the situation: ______________________________________________
__________________________________________________________________________
It is helpful to make variations with regard to the stimulus dimensions “action,” “distance,” and “time.”
“Isn’t it interesting to notice that now that you are confronted with this __________ (state the object or situation) __________ (state the catastrophe the client normally would have feared to happen) does not occur?
◻ Yes ◻ No
“Do you notice that your anxiety is not as physically harmful as you might have expected?”
◻ Yes ◻ No
Importance of practice: “These emotional reactions will subside and fade over time. Therefore, it is important that you continue exposing yourself to the feared stimuli as long as you feel that you have achieved a certain degree of self-mastery. Please note that you are gradually learning to feel that you are capable of handling a certain level of anticipatory anxiety with confidence.”
Check with VoC (0–100%): __________
Phase 7: Positive Closure
Most positive thing learned: ________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
+ BLS
Check with
Explain expectations between sessions:
“Things may come up or they may not. If they do, great. Write it down and it can be a target for next time. If you get any new memories, dreams, or situations that disturb you, just take a good snapshot. It isn’t necessary to give a lot of detail. Just put down enough to remind you so we can target it next time. The same thing goes for any positive dreams or situations. If negative feelings do come up, try not to make them significant. Remember, it’s still just the old stuff. Just write it down for next time.”
Planning Self-Managed Homework Assignments
“It is very important to keep practicing with exposing yourself to difficult situations during your daily life in order to maintain the changes that you have experienced.”
“Each time that you have a chance to see __________ (state the feared stimulus), it is an opportunity for you to practice these new skills that you now know how to do. So, the more you encounter __________ (state the feared stimulus), the better you can get at __________ (state the goal). Your brain learns to do new behaviors by practicing.
Phase 8: Reevaluation
“Make sure to write down your responses when you are practicing your new skills. Sometimes, even with the skills, you might find that you reexperience your fear (e.g., a panic attack). I want to tell you that this can happen sometimes, and it is not unusual. What you can do at that time is to note what has led up to the feeling, what is going on around you, and what you did to help yourself handle the situation. Jot down some notes about what happened as soon as you can so that you won’t forget what happened and then bring them to the next session so that we can figure it out.”
New material: ______________________________________________________________
__________________________________________________________________________
If disturbance level increased, target it.
New resources needed: ◻ Yes ◻ No
__________________________________________________________________________
__________________________________________________________________________
Emphasize the need for rehearsal and reinforcement ◻ Yes ◻ No
Give praise for accomplishments ◻ Yes ◻ No
Reprocessed necessary targets ◻ Completed
Reference
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC.