EMDR in the Treatment of Panic Disorder With Agoraphobia: A Case Description

Descriptive Case Study

The treatment took 17 sessions during which identified targets were reprocessed to SUD = 0, VoC = 7, clear body scan. Follow-up was done at intervals of 6 months, 1 year, and 5 years.

Treatment Course

Seventeen treatment sessions were provided. The history taking and preparation phases (Phases 1 and 2) extended across six sessions during which history was collected and preparation strategies were taught and practiced (Table 2). Reprocessing of past targets (Phase 3) began with the panic attack memories including background stressor, first panic attack, and recent panic attacks (Table 3). Reprocessing of past targets continued with the contributory childhood events, done across five sessions (Table 4). Reprocessing of current stimuli (present triggers including external and interoceptive cues) and final future templates are outlined in Table 5.

Initial Presentation

Pam (name changed to protect anonymity) presented for therapy in December 2010; she was then 30 years old and working as an interior designer. Her presenting complaints were sadness, lethargy, sleep disturbance, and physical sensations such as palpitations, tremors, sweating, chest pains, and dizziness, which hadn’t been explained by medical examinations. She experienced these physical sensations for the first time in October 2010 while traveling to work by public transport. She was terrified that she was having a heart attack and sought medical intervention. Doctors evaluated her blood pressure, electrocardiogram (ECG), and also ran a 2-D echogram. Her test reports were normal. Immediately after the first episode, she took off from work for a week and continued to experience similar physical sensations every couple of days. In the next couple of months, she began fearing experiencing these sensations while traveling. She put in an application to request medical leave, took a 3-month sabbatical from work and temporarily moved in with distant family. She sought therapy in December 2010.

Pretreatment Assessment and Diagnosis

Diagnosis and medication being initial considerations, the client was administered the Minnesota Multiphasic Personality Inventory (MMPI). The MMPI is a written psychological assessment used by mental health professionals to assist with the diagnosis of mental disorders and the selection of appropriate treatment methods. It provides clear, valid descriptions of people’s problems, symptoms, and characteristics in broadly accepted clinical language. On the MMPI, elevation of T scores above 70 is considered clinically significant. Pam’s MMPI test did not reveal any clinically significant elevations. Mild indications of somatization and social introversion were indicated. Pam was given a diagnosis of Axis-1 PDA. Pam’s symptoms met the DSM-IV-TR diagnostic criteria (APA, 2000). The Multimodal Life History Questionnaire (Lazarus & Lazarus, 1991) was also administered at intake. The questionnaire gathers information on areas such as personal and social history, modality analysis of presenting problems, interpersonal relationships, biological factors, and trauma history.

Client History

Pam is the eldest child in her family. She stated that her father was a chronic alcoholic. The earliest memory of his drinking was at age 9 years when her father came home in a drunken rage and became physically and verbally abusive with her mother, tried to tear off his clothes, and violently broke furniture in the house. Pam said she had to intervene to calm him down. She disclosed that this was the onset of her anxiety and that she became overprotective of her mother and two younger sisters, while trying to calm her father down during the drinking episodes. Another very disturbing memory was of being alone with her sister at home after her father left the house in a drunken rage. He then had an accident, and she called her father repeatedly through the night while trying to keep a brave front for her younger sister.

Pam stated that she soon lost interest in academics and developed high anxiety around earning money to manage her family. By 12th grade, her anxiety was very high and she did not write her exam at all. Later, she forged her marksheet to get a job and began working. She also continued keeping a watch on her fathers’ drinking believing that his alcohol consumption reduced to occasional social drinking because of her constant monitoring.

Pam married at age 26 years and at the outset barred her husband from any drinking and strictly forbade alcohol to be brought home. Her husband while complying with her demands, also engaged in social drinking, and this led to frequent verbal quarrels. Her husband would also often be unreachable on the phone, and Pam reported severe anxiety when her calls to him went unanswered. On one occasion (which was the precipitating event to the panic attacks), her husband arrived home at midnight from an official gathering, extremely drunk. Scared of a fight with his wife, he fell asleep in the basement of their apartment building. Pam reported spending a distressing night trying to reach her husband, calling him several times an hour. Early the next morning, he was discovered by the building security who helped her carry him back home. This event reminded Pam so much of her childhood that she had an emotional breakdown resulting in a loud verbal fight. Their relationship went into a downward spiral thereafter and Pam reported that they had verbal fights almost every day. In subsequent months, Pam reported experiencing mild chest pains frequently. She stopped initiating work projects. She also began avoiding socializing with friends and workmates, and her only outings were restricted to a monthly family gathering. A few months later, she reported having her first panic attack.

Case Conceptualization

Pam’s anxiety was conceptualized with the AIP model (Shapiro, 2001) as originating with the distressing childhood experiences with her alcoholic father and triggered by current events with her husband. Leed’s (2009, 2012) model plan for treating PDA was the basis for treatment planning (see Table 1).

Psychoeducation

Pam’s immediate worry, as with many patients diagnosed with PD, was the health risks these attacks posed. She was also not fully convinced about the need for psychological intervention and believed that her symptoms were definitely physical. Psychoeducation on panic and anxiety, the triune brain model, the nervous system, sympathetic arousal, and the panic cycle helped her recognize that although she was experiencing very extreme and distressing physiological symptoms, these experiences actually posed no threat to physical health. Worries of people with anxiety disorders are usually dismissed with “it’s all in your head”; a strong therapeutic alliance is therefore based on validation of fears along with offering a scientific rationale for the patient’s symptoms.

Daily Diary

Pam was asked to keep a daily diary to monitor her panic attacks. The diary had two sections: The first section was a daily anxiety chart that tracked anxiety across a 12-hour period. This was done using a graphical representation with timings on the Y axis—8 a.m., noon, 4 p.m., 8 p.m., and midnight. The X axis measured the level of anxiety from 0 to 10. The peak points (anxiety above 5) on the daily anxiety chart were noted. The second part to the diary involved maintaining a thought log which described her reaction to the disturbing event(s) during those peak points. An example of this was “8 p.m.: Anxiety level (8). Thought log ‘Calling husband to ask when he was coming back home, got no response to my calls and messages. Sent him many texts, he sent back a text saying ‘I’m fed up.’ I was anxious and angry with his behavior.’” In-session analysis of the diary indicated that panic attacks were being triggered by arguments with husband or when thinking about moving back in with him.

Self-Control Strategies

Pam was also taught self-control strategies such as square breathing, diaphragmatic breathing, and sensory focusing. Leeds (2009) explains that such anxiety management methods reduce the frequency and severity of the panic attacks but do not eliminate panic attacks or the fear of further panic attacks. EMDR therapy uses breathing retraining as a preparatory tool to help clients manage the intense affect originating from the autonomic nervous system during the panic attacks. Clients are educated that these are preparatory processes to stabilize them and that EMDR reprocessing of past panic attacks as well as contributory childhood events is the more direct intervention toward reducing panic attacks.

Providing Information About EMDR and Adaptive Information Processing Model

Phase 2 preparation also included explaining the AIP model and standard EMDR protocol. Explanation of the AIP model gave Pam insight about contributory childhood experiences, and we arrived at a structured treatment plan beginning with the recent panic attacks and going back to past targets with similar experiences.

Calm (Safe) Place Exercise

Pam was also introduced to the “Calm (Safe) place exercise,” a mechanism used during the preparation phase for self-regulation. Pam accessed a place that she associated with calmness—the Lotus temple in Delhi. She was asked to bring up an image of the place and eye movements were used to enhance the positive feelings. She mentioned feeling “no tension in the mind and absolute calmness” at the end of the exercise.

Resource Development and Installation

The resource development and installation (RDI; Korn & Leeds, 2002) protocol was also used to install resources. RDI is used in the preparation phase of EMDR therapy; it has ego strengthening benefits and prepares clients for EMDR reprocessing. The client can be asked to access three types of inner resources—mastery, relational, or symbolic—that represents a needed capacity and is associated with positive affect. With Pam, RDI was initially used to develop and install calming symbolic resources (image of Buddha). At this point, she could not access mastery resources (memories of positive experiences), but as she gained further confidence, we worked on accessing mastery resources to handle challenging situations. She identified needing qualities such as “trust in self” and “hope” especially during stressful times such as husband’s unavailability or seeing him drinking at social events. Such incidents left her feeling hopeless and out of control. Positive memories around these resources included managing complex work assignments under pressure (trust in self) and times when her father had listened to her and not had alcohol (hope). We then used slow and short sets of eye movements (6–8 passes) to install these resources. Developing mastery resources modulated the intense affect around daily life disturbance and reduced Pam’s physical agitation (see Table 2).

By the 6th session, Pam could better manage affect between sessions, and we discussed moving to Phases 3–8 of EMDR treatment, which included desensitization and reprocessing of target memories. The following factors supported this clinical decision:

Sessions 7 and 8

The first memory to be reprocessed—which we recognized as the background stressor to the first panic attack—was the event of finding husband drunk and passed out in the apartment basement. Her initial NC was “I cannot trust.” The SUD for this memory fell from 10 to 0 and the PC “I can trust” was installed to a VoC of 7. We also developed future templates using the same PC where she imagined herself managing an upcoming family gathering where her husband would most likely have a couple of drinks. “I will say yes if he asks for permission, won’t feel very bothered and will just enjoy the party.” This target took two 90-minute sessions to complete.

Session 9

A reevaluation of symptoms at the beginning of Session 9 showed visible changes. She reported reduction in mood swings, improved sleep, and feeling an overall sense of calmness. Her anger toward her husband reduced, anxiety diminished, and she did not feel the need to constantly call her husband to check his whereabouts.

We then targeted the first panic attack which had occurred while traveling to work on a train. This was also reported as the worst panic attack. Her NC was “I can’t handle it” and SUD was a 6. The reprocessing in Sessions 7 and 8 had brought up connections where she recognized that fights with her husband had precipitated the attacks and that there was nothing really wrong with her physically (her biggest fear was that she had some medical illness). We then installed the PC “I can handle it,” and it reached a VoC of 7. We also installed some future templates around using the train to go back to work (she had avoided trains and other forms of local city transport since the panic attacks started). We also developed some self-control strategies she could try if the panic attacks occurred while traveling.

Session 10

A reevaluation of symptoms at the beginning of Session 10 showed calmness and reduction of anxiety. In this session, we targeted more recent panic attacks and chose the most disturbing of these which was being at home alone during the week after the first panic attack. Image was of her sitting alone at home, experiencing a panic attack. Her NC was “I’m not in control.” The SUD for this event was a 3. At the end of the session, SUD dropped to 0; her PC for this target was “I can learn to manage/handle (these attacks)” which was installed to a VoC of 7.

Session 11

When Pam returned to therapy after the 3-week break, she reported more stability and less anxiety. She stated that her panic attacks had diminished in frequency and intensity. Pam also reported meeting friends on weekends, and she also participated actively in two family celebrations. But she still had notable disturbance around her husband’s drinking and would experience a sense of anger and disappointment at herself for giving him permission to drink or not stopping him in time. In earlier sessions, Pam and I had discussed targeting her childhood experiences using EMDR which we had hypothesized as the basis of the current fear and panic attacks. We decided that now may be the time to approach this material. There was some anxiety, and we spent part of this session doing preparatory work around her feelings about addressing these memories. RDI was used where she developed inner resources of calmness and soothing.

We began with the memory at age 9 years when her father came home in a drunken rage and began breaking household furniture. Image was of him breaking a cupboard and screaming. The NC was “I cannot show my emotions,” and the initial PC was “I can let it out and show my emotions.” During desensitizing, Pam was able to connect with body sensations of panic (heart racing and shortness of breath), which closely resembled the panic she felt recently while traveling and when she had fights with her husband. We had to regulate the emotions using various distancing strategies. At session end, this memory was not completely reprocessed.

Session 12

By the next session, Pam reported a major panic attack while she was at work, and she had to call her husband to help her get back home. She also had various somatic complaints of head heaviness, headaches, and backaches. We paused targeting of memories to work with the emerging disturbance and went back to Phase 2 (preparation and stabilization). For this session, we worked with some self-control strategies to manage intense panic attacks and other self-soothing skills. We practiced square breathing in session along with diaphragmatic breathing. She did future rehearsal with using anxiety management skills if she got a panic attack at work. Her husband accompanied her for this session and also discussed how he could support her if there was an intense panic attack.

Session 13

Pam said that she felt sufficiently stable and that she recognized the direct link between the panic sensations and body sensations when we had worked with the childhood memory. We returned to the same target memory (father in drunken rage). Several cognitive interweaves had to be used as there was blocked processing. Cognitive interweaves are statements or questions that is offered to the client by the clinician in response to a blockage in the processing or to facilitate relevant connections, optimize generalization effects, help the client with affect regulation, address defensive responses, and maintain dual awareness (Hensley, 2009, 2016). She seemed especially to be “looping” around the information that she should have taken on more responsibility for her mother and sisters and in getting her father to stop drinking. She was asked questions so she could differentiate between standards for an adult and standards for a child. For example, “Whose role was it to manage your father when he was drunk” or “How old were you when this [incident] happened.” Processing then progressed as she recognized that her mother should have taken on more responsibility and since she didn’t, Pam had no choice but to behave “grown-up” and step in. Positive associations emerged as she recognized “I had no choice then, but I have a choice now” and felt that although she had lost her childhood, she has choices now to live her life the way she wants. PC of “I have choices now” was installed. The PC reached a VoC of 7, and she could also visualize herself being more assertive at work with her boss and juniors to whom she felt she could delegate work more confidently.

Sessions 14 and 15

At the beginning of the next session, Pam reported feeling more confident especially at her workplace. We targeted the other past memories which also involved parent–child role reversal as well as the one about forging her marksheet when she failed her exam. Cognitive interweaves and stabilization skills were used when required. The gains were visible. As per Pam’s self-report, panic attacks dropped to negligible. She travelled freely across the city using various forms of public transport. She was able to mingle with people. She also moved back in with her husband and was able to handle the isolation she had earlier felt in her far-flung home by planning get-togethers with friends.

Session 16

For people presenting with PD, present triggers include both (a) external cues such as places, people, smells, and/or sounds, which may be perceived as threat cues or associated with rising anxiety, and (b) interoceptive cues such as body sensations and anxiety-provoking thoughts. The first 30 minutes of the session targeted external cues including husband’s social drinking, father’s current occasional drinking, and husband not answering calls. These triggers had already reduced in intensity but still maintained their emotional effects because of conditioning (Leeds, 2009, 2012). These reprocessed spontaneously in this session and required focusing on body sensations to reduce disturbance.

The next 60 minutes were spent on targeting interoceptive cues experienced while traveling by train. At this point in the treatment, Pam was no longer experiencing severe panic attacks and only occasionally had brief thoughts of fear. Nevertheless, interoceptive cues such as shortness of breath, chest pains, and palpitations were targeted with the hypothesis that these can reoccur. These cues were reprocessed with her worst fear, which was having these panic sensations while traveling by train or when she was at work. We set up the standard protocol for both targets around physical sensations when (a) traveling by train and (b) at work. NC for both targets was “I cannot manage/handle,” and the SUD was 2. Again, she could successfully reprocess these targets to SUD = 0, VoC = 7. PC was “I am in control and can manage.”

Session 17

The future template had been incorporated into the treatment plan alongside the reprocessing. This was to use the anxiety reduction gains made from reprocessing of targets and incorporate them into current areas of avoidance. Leeds mentions use of the “positive template” during this phase of therapy in which the patient imagines approaching formerly anxiety-provoking internal cues and being in formerly avoided locations (Leeds, 2009, 2010b). Pam was asked to imagine approaching fearful situations such as the local train, going back to work, setting limits with her husband, and moving back to her isolated home. We then worked on the remainder of avoidance and other areas of conflict in her life. We used the future template (Shapiro, 2001) to address challenging life situations such as disagreements with her husband, having guests over at home where drinks would be part of the occasion, meeting people in social contexts, and not taking overresponsibility at home or at work.

Target Sequencing

Sequencing targets in a manner that allows for initially reprocessing background stressors, followed by the first, worst, and most recent panic attacks and finally targeting of childhood contributory events allows a chain of associations to emerge spontaneously, thus permeating the entire memory network. This method of target sequencing is also particularly helpful when clients initially do not see the past–present link. Pam, like many clients, was initially doubtful about the link between her current symptoms and her past history of growing up with an alcoholic father. Careful target sequencing was required where the past was targeted only after Pam had made gains in the form of reduction of panic symptoms. By this time, she had adequate affect tolerance to approach more painful childhood memories, and during reprocessing of the first childhood contributory event (father in a drunken rage), she could connect the body sensations she was feeling while reprocessing the memory to the physiological arousal she experienced during panic attacks and during fights with her husband. This was possible because of careful “pruning” of associations (Leeds, 2009, 2012) which allowed her brain to absorb material and organize information based on her readiness.

Future Template

In Pam’s case, the future template was used throughout the treatment plan (Sessions 8, 9, 12, 13, and 17). The future template can be viewed as a “positive template” that is an expansion of the installation phase (Shapiro, 2001). In effect, the absence of disturbance measured on the SUD scale (0) along with strengthening of the positive belief measured on the VoC scale (up to a 7) can be further reinforced within the same session by exploring how the client might perceive, feel, act, and believe in future similar situations. It is probable that sessions which incorporated such a future template aided in immediate anxiety reduction, increased self-belief, and allowed Pam to approach previously avoided people/place and situations. “Imagining positive outcomes seems to assist the learning process” (Shapiro, 2001, p. 213). Pam was also able to approach the situations discussed during future template work and report positive changes by the next session (e.g., managing her husband’s drinking at a social event, train travel, delegating work). Reduction of such avoidance probably allowed the new learning to start integrating rapidly into an overall positive schema and emerging sense of self. At the end of treatment, Pam was not just free from panic attacks and agoraphobia but had also developed a healthier worldview. She could take appropriate adult responsibility and learn to delegate without micromanaging. She developed an adult understanding about alcohol consumption and learnt to differentiate social drinking from addiction.

Future-Related Work

The value of using future-related work as part of the three-pronged protocol interwoven within the treatment framework for PDA also needs further exploration. The treatment plan for Pam incorporated the future template while reprocessing past experiences (first prong) and present triggers (second prong). This process may be similar to the “flash forward procedure” proposed by Logie and de Jongh (2014), which addresses a client’s irrational fears that persist after the core memories of past events appear to have been fully processed. The flash forward has been proposed as part of the second prong of the EMDR three-pronged approach because “even though the client’s focus is on the future, the fears are experienced in the present, triggered by anticipatory thoughts, and so they are considered current fears suitable for processing in the second prong” (Logie & de Jongh, 2014, p. 26). Clients diagnosed with PDA and other anxiety disorders often “live in the future” anticipating catastrophic outcomes for future events. Therefore, the flash forward procedure may be the “missing link” between targeting memories in the past (first prong) and the future template (third prong). The authors de Jongh and Logie propose that only when the future anticipatory anxiety in the present has been reprocessed can the installation of a PC in relation to a future scenario with a positive outcome (future template) occur effectively. Further research employing such future templates can be valuable in PDA treatment.