Cognitive Behavioral Treatment of Panic Disorder

The original version of these slides was provided by Michael W. Otto, Ph.D. & Heather W. Murray, Ph.D., with support from NIMH Excellence in Training Award at the Center for Anxiety and Related Disorders at Boston University (R25 MH08478)

Use of this Slide Set

Presentation information is listed in the notes section below the slide (in PowerPoint normal viewing mode). A bibliography for this slide set is provided below in the note section for this slide. References are also provided in note sections for select subsequent slides

Panic Disorder

Diagnostic Considerations

DSM Panic Attacks:

Defined by 4 or more of the following 13 symptoms 11 Somatic Symptoms Increased heart rate Shortness of breath Chest pain Choking sensation Trembling Sweating Nausea Dizziness

Numbness/Tingling Hot flashes or chills Depersonalization

2 Cognitive Symptoms Fear of dying Fear of losing control

Panic Disorder
Recurrent unexpected panic attacks Criterion B Worry about future attacks Worry about the consequences of the attack (i.e., having a heart attack) Substantial behavioral changes in response to the attacks

Agoraphobia
Anxiety about being in situations related to perceived inability to escape or get help if a panic attack occurs Situations are avoided or endured with significant distress

Core Patterns in Panic Disorder

Fears of symptoms of anxiety (anxiety sensitivity)
Risk for onset of panic attacks Risk for biological provocation of panic Risk for panic disorder relapse
(McNally , 2002)

Common Catastrophic Thoughts in Panic Disorder

Fears of death or disability
Am I having a heart attack? I am having a stroke! I am going to suffocate!

Fears of losing control/insanity

I am going to lose control and scream I am having a nervous breakdown If I dont escape, I will go crazy

Fears of humiliation or embarrassment

People will think something is wrong with me They will think I am a lunatic I will faint and be embarrassed

Cognitive-Behavioral Model of Panic Disorder

Alarm Reaction

Stress Biological Diathesis

Rapid heart rate, heart palpitations Shortness of breath, smothering sensations Chest pain or discomfort, numbness or tingling
Catastrophic misinterpretations of symptoms

Increased anxiety and fear

Conditioned Fear of Somatic Sensations

Hypervigilance to symptoms Anticipatory anxiety Memory of past attacks

Case example
Abby, a 29 year old female, reports unexpected panic attacks and describes increased heart rate, lightheadedness, shortness of breath, and tingling sensations in her arms. When she experiences these episodes, she believes that she is going to faint; she describes fainting as both embarrassing and dangerous. She worries about having these episodes when in public places and places where getting help would be difficult. Because of her fear, she avoids going to public places alone and always carries her cell phone in case she needs to call for help.

Elements of Cognitive Behavior Therapy for Panic Disorder

Core Elements of CBT

Psychoeducation/ Informational intervention Cognitive interventions Interoceptive (internal) exposure In vivo exposure
Can be delivered in individual or group treatment formats

Information Interventions
May include handouts or patient manuals Distinguishes between symptoms, thoughts, and behaviors and introduces the cascade between these elements Introduces the notion and consequences of catastrophic thoughts Addresses the role of escape and avoidance in maintaining fear Helps the patient adopt an informed and active role in treatment

Cognitive Restructuring - General

Identify the nature of thoughts: they dont have to be true to affect emotions
Learn about common biases in thoughts

Treat thoughts as guesses or hypotheses about the world

Cognitive Restructuring - Specific

Increase awareness of thinking patterns
Over-estimating the probability of negative outcomes Assuming the consequence will be unmanageable

Monitor relationship between thinking and panic episodes Challenge thinking

Evaluating evidence for the thought Evaluating the cost of the feared outcome

Establish adaptive thinking patterns

Reality based thinking and not just positive thinking

Exposure Interventions
Provide rationale for confronting feared situations Establish a hierarchy of feared situations Provide accurate expectations Repeat exposure until fear diminishes Attend to the disconfirmation of fears (What was learned from the exposure?)

Interoceptive Exposures (exposures to internal sensations)

Rationale: Provide opportunities to examine negative predictions about internal sensations Provide opportunities to increasing tolerance to and acceptance of internal sensations though repeated exposure to sensations Method: Engage in systematic exercises that induce feared internal sensations (i.e., dizziness, increased heart rate).

Common Interoceptive Exposure Procedures

Headrolling 30 seconds - dizziness, disorientation Hyperventilation 1 minute - produces dizziness lightheadedness, numbness, tingling, hot flushes, visual distortion Stair running a few flights produces breathlessness, a pounding heart, heavy legs, trembling Full body tension 1 minute produces trembling, heavy muscles, numbness Chair spinning several times around produces strong dizziness, disorientation Mirror (or hand) staring 1 minute produces derealization

Panic Cycle Uh oh! What if: This gets worse? I lose control? This is a stroke? I have to control this!

Relative Comfort Notice the sensation Do nothing to control it. Relax WITH the sensation

Learning Safety in Panic

Interoceptive exposure

Feared sensations become safe sensations

in the office with the therapist at home independent of the treatment context

Situational Exposures
Rationale:
Providing a new learning opportunity to examine negative predictions about feared outcomes Increasing tolerance to internal sensations in feared situations

Situational Exposure Guidelines

Prior to completing in-vivo exposures, create a fear hierarchy identifying feared and avoided situations Identify safety behaviors- actions taken to avoid, prevent, or manage a potential threat
Avoidance Checking (pulse, exits, hospitals) Carrying aids (rescue medications, cellular phones)

Application of CBT
An effective first-line treatment A replacement strategy for medication treatment (medication discontinuation) In combination with medication treatment
Treatment resistance Standard strategy

CBT for Panic Disorder

And it is acceptable, tolerable, and cost effective

Meta-Analytic Results of Panic Disorder Treatment Studies

CBT (IE+CR)

Effect Size (Cohens d)

CBT Non-SSRI Antidepressants

Benzodiazepines

SSRIs Antidepressants

Gould et al, 1995; Otto et al., 2001

CBT for Panic Disorder

In addition to core panic, anxiety, and avoidance outcomes, CBT has broader-based benefits, including: Improvements in quality of life Improvement in comorbid conditions

(e.g., Allen et al., 2010; Telch et al., 1995; Tsao et al., 1998)

Treatment Acceptability (dropout rates)

Percent Dropout

Treatment Acceptability
Refusal Rate in the Multicenter Panic Trial
35 30 25 34

Percent

20 15 10 5 0 1

CBT

Imipramine

Treatment
Hofmann SG, et al. Am J Psychiatry. 1998;155:43-47.

Strategies to Enhance CBT

Combination with standard pharmacotherapy (CBT plus antidepressants or benzodiazepines)
Some acute benefits Benefits lost with medication discontinuation

Novel combination treatment

Memory enhancers

Panic Disorder: Continuation Treatment

60
% Responders (40% PDSS)

50 40 30 20 10 0
Maintenance (ITT) 6 More Months
CBT + imipramine CBT + placebo CBT Imipramine Placebo

Barlow DH, et al. JAMA. 2000;283:2529-2536.

Panic Disorder: PostImipramine Discontinuation

60
% Responders (40% PDSS)

50 40 30 20 10 0
6 Months Treatment Discontinuation (ITT) (Imipramine over 1 to 2 weeks)

CBT + imipramine CBT + placebo CBT Imipramine Placebo

Barlow DH, et al. JAMA. 2000;283:2529-2536.

Panic Disorder: After 8 Weeks of Treatment

1.3 1.1 0.9 EXP + ALP EXP + PBO ALP + Relax

Effect Size 0.7 (CGI relative to PR)

0.5 0.3 0.1 -0.1

EXP = exposure treatment. ALP = alprazolam treatment. PBO = placebo treatment. Relax = relaxation treatment. Marks IM et al. Br J Psychiatry.1993;162:776-787.

Panic Disorder: Post Benzodiazepine Discontinuation (Week 18)

1.3 1.1 0.9 0.7 Effect Size (CGI relative to PR) 0.5 0.3 0.1 -0.1 -0.3 EXP + ALP EXP + PBO ALP + Relax

EXP = exposure treatment. ALP = alprazolam treatment. PBO = placebo treatment. Relax = relaxation treatment. Marks IM et al. Br J Psychiatry.1993;162:776-787.

The Solution
Apply (re-apply) CBT at the time of medication taper and thereafter Remember, it works for medication discontinuation with expansion of treatment gains
Treatment with benzodiazepines1,2 Treatment with SSRIs3,4
1Otto

MW et al. Psychopharmacol Bull. 1992;28:123-130. 2Spiegel DA et al. Am J Psychiatry. 1994;151:876-881. 3Schmidt NB et al. Behav Res Ther. 2002;40:67-73. 4Whittal ML et al. Behav Res Ther. 2001;39:939-945.

Greater success with a novel combination strategy

Combination of CBT with the putative memory enhancer, d-cycloserine 2 small treatment trials suggest that d-cycloserine helps consolidate therapeutic learning from exposure, helping speed treatment outcome
Similar benefits for d-cycloserine + exposure is seen for other anxiety disorders

Preventive Treatment
Target a putative risk factor for Panic Disorder (anxiety sensitivity) 5-hour prevention workshop:
Psychoeducation Cognitive restructuring Interoceptive exposure Instruction for in vivo exposure

Gardenswartz CA, Craske MG. Behav Ther. 2001;32:725-738.

Preventive Treatment
% Developing Panic Disorder
25 20

Wait List Workshop

15

13.6

10

1.8
0

121 Participants

Gardenswartz CA, Craske MG. Behav Ther. 2001;32:725-738.

Exporting Treatment: Benchmarking Research

CBT for panic disorder can be transported to a community setting and achieve effectiveness in accordance with expectations from clinical trials

Wade WA, et al. J Consult Clin Psychol. 1998;66:231-239.