This month’s psychology model is the CBT formulation for Panic, starring (you know who he is…) Marvel’s Avengers very own Tony Stark, aka Iron Man. Perhaps not the first name that comes to mind when we think of anxious characters, however it seems even the bravest of heroes can have moments of fear and panic to contend with…
The CBT Formulation Model for Panic
What is Panic?
Panic or panic attacks are a form of anxiety, characterised as a sudden distinct episode of discomfort and/or fear that is accompanied by:
(a) physical symptoms: heart palpitations, trembling, sensations or choking or shortness of breath, sweating, chest pain, nausea, dizziness, numbness, tingling, hot or cold flashes, light-headedness;
(b) cognitive symptoms: fear of losing control, fear of dying, wanting to escape the situation, as well as feelings of ‘going insane’, detachment or unreality.
Panic attacks often last up to 30 minutes, with peak anxiety being present for approximately 10 minutes. Attacks can at times seem to come from nowhere (“unexpected” attacks) or they can have a clear trigger and occur in the presence of specific feared environment (“situational” attacks). If people have persistent panic attacks, they can then worry about future attacks and/or the repercussions of these. People can also alter their behaviour as a result of anxieties around attacks, such as avoiding certain situations, which can then have a significant impact on day-to-day life.
What is the CBT model of Panic?
The CBT (Cognitive Behavioural Therapy) formulation model for panic is a Situational Formulation model. This means it focuses on the ‘here and now’ factors which maintain an individual’s panic or panic attacks, rather than the influence of past experiences. You can recap on the basic Situational CBT formulation model (or ‘hot crossed bun’) in this previous post. This basic situational model has been adapted to explain different types of presentations, however the fundamental principles remain the same. Situational CBT formulation models always centre around the main concept of exploring the links between thoughts, emotions, behaviours and physiological symptoms. This highlights maintaining factors and ‘vicious cycles’, which help to understand what keeps the problem going and highlights areas to be targeted to break these cycles and help to reduce difficulties.
The CBT formulation model for Panic was developed by Clark (1986). There have been various adaptations of this model since then, however the fundamental concepts are kept the same. The model and definitions used in this post are informed by Clark’s (1986) original model, as well as Westbrook, Kennerly and Kirk’s (2011) interpretation.
The CBT model of Panic:
- There is an external (environment) or internal (thought/image/sensation) trigger. An example of an external trigger could be going into a busy shop.
- This triggers a ‘perceived threat’ i.e. a prediction of something bad happening. For example, “I might get lost in this shop”.
- This leads to an emotional and cognitive response of anxiety/panic.
- This further brings on the physical symptoms of anxiety, described above.
- There is then a catastrophic interpretation of these bodily sensations, believing they indicative of impending mental or physical harm (e.g. stroke, heart attack, brain aneurysm).
- This then causes increased anxiety, leading to a vicious maintenance cycle of panic.
At times, the CBT model also considers how safety behaviours may also maintain someone’s anxiety and panic, contributing to these vicious cycles. Safety seeking behaviour can take many forms, although it is often avoidance, e.g. avoiding certain environments or situations. The aim of this behaviour is to reduce the likelihood of a feared catastrophe occurring, as well as avoid the actual feeling of anxiety or panic. This gives a short-term relief from anxiety and panic symptoms. This lack of catastrophe and presence of ‘safety’ is then attributed to the safety behaviour, reinforcing this as necessary to do to keep safe in the future. For example, “I avoided the shop, which meant I didn’t get lost and didn’t have a panic attack. I am safe because I didn’t go to the shop. It’s best to avoid shops in the future to stay safe.”
However, this is more problematic in the long-term. In avoiding situations, an individual’s anxious appraisals of that situation are never challenged. For example, someone may be worrying that they will get lost in a shop, have a panic attack, and then they will collapse. If they never go into this situation and experience something other than these negative predictions, their beliefs remain unchallenged and unchanged. This in turn means that their anxiety around these situations is maintained in the long-term.
Iron Man’s Formulation
As the Panic CBT model is a ‘Situational Formulation’, we will not be exploring Stark’s past (an interesting one for another post perhaps… for example, his panic attacks being part of a wider post-traumatic reaction to his near death experience in the worm hole during Loki’s assault on New York in the first Avengers film? Or perhaps just him being a case for a formulation on Narcissism? We could go on…).
This post will instead focus on this specific situation in Iron Man 3. Stark experiences a few moments of panic throughout the films and his ‘anxiety attacks’ become a theme throughout this story and his character development. For this formulation, we are focusing on the first time we see this in the film, in the scene in the video below. Here our hero demonstrates a textbook example of a Panic Attack, including common responses to the emotional and physical experiences associated with panic.
We can apply the CBT model of Panic to this situation:
In terms of safety behaviours, throughout the movie Stark engages in a number of strategies to try and manage these feelings of panic and anxiety. We could think of these as attempts to build protection around himself to keep him and others safe from perceived threats (he literally builds protective casings for himself in the form of his suits).
His safety behaviours are also attempts to avoid the feeling of fear. Stark’s avoidance strategies can be seen in a number of forms, for example, throwing himself into building his suits as a means of distracting himself from the anxiety and panic linked to his past experiences. He also tries to avoid any reminders of his past traumatic experiences, such as talking about these events. This seems to be in order to reduce the likelihood of him having another panic attack. This is all likely to have maintained his difficulties and increased his anxiety in the long run.
We do however see throughout the movie, Stark recognises these unhelpful safety strategies and in the end he starts to reduce these. This was seen vividly at the end of the movie when he destroys all the suits which he has been building and hiding behind.
As we can see, our Anxious Avenger has been on quite a journey battling with his experience of panic attacks and the impact this has on his life. The emotions and behaviours we see Tony Stark portray in this movie remind us that despite him being a “billionaire, genius, playboy, philanthropist” (and superhero), he is as human as the rest of us.
That’s all folks!
Thanks for reading! I’ll be back with another famous formation soon… but until then I would love for you to stay in touch!
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Which star of the silver screen would you like to see a formulation for in the future?
Let me know in the comments!
References and additional information:
- An introduction to Cognitive Behavioural Therapy: Skills and Applications, (2011) by David Westbrook, Helen Kennerley and Joan Kirk
- Treatment Plans and Intervention for Depression and Anxiety Disorders, (2011) by Leahy, Holland and McGinn.
- A Cognitive Approach to Panic, (1986), by David M. Clark
- Panic worksheet by Get Self Help
- Safety Behaviours by Get Self Help
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Disclaimer: All Marvel image and video rights belong to Disney. Game of Thrones image rights belong to HBO. Images and reference to the original movies are used in this blog post in the understanding that it falls under ‘fair use’. This is due to the images and reference to the films being used in the context of a commentary/critique of the original material for educational purposes. To my knowledge, the use of images in this post do not deny the owner of income and they are not being used in this context for monetary gain of the user.