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Treatment of Adolescent Panic Disorder:

A Nonrandomized Comparison of
Intensive Versus Weekly CBT
a a
Rhea M. Chase PhD , Sarah W. Whitton PhD & Donna B. Pincus PhD
a

a
Center for Anxiety and Related Disorders, Boston University,
Boston, Massachusetts, USA
Published online: 06 Nov 2012.

To cite this article: Rhea M. Chase PhD , Sarah W. Whitton PhD & Donna B. Pincus PhD (2012)
Treatment of Adolescent Panic Disorder: A Nonrandomized Comparison of Intensive Versus Weekly
CBT, Child & Family Behavior Therapy, 34:4, 305-323, DOI: 10.1080/07317107.2012.732873

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 Child & Family Behavior Therapy, 34:305–323, 2012
Copyright © Taylor & Francis Group, LLC
ISSN: 0731-7107 print/1545-228X online
DOI: 10.1080/07317107.2012.732873

Treatment of Adolescent Panic Disorder:

A Nonrandomized Comparison of
Intensive Versus Weekly CBT

RHEA M. CHASE, PhD, SARAH W. WHITTON, PhD,

and DONNA B. PINCUS, PhD
Center for Anxiety and Related Disorders, Boston University, Boston,
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Massachusetts, USA

This study compared the relative efficacy of intensive versus weekly

panic control treatment (PCT) for adolescent panic disorder with
agoraphobia (PDA). Twenty-six adolescents participated in weekly
sessions and 25 received intensive treatment involving daily ses-
sions. Both groups demonstrated significant and comparable reduc-
tions in panic disorder severity and general anxiety symptoms,
which maintained over time. Participants receiving weekly treat-
ment showed significant decreases in depressive symptoms, whereas
those in the intensive program reported no change. Findings sup-
port the efficacy of the intensive approach for adolescent PDA, but
suggest that adolescents receiving intensive treatment may benefit
from a brief course of additional weekly sessions.

KEYWORDS adolescents, cognitive-behavioral therapy, intensive,

panic disorder, treatment

Panic Disorder (PD) is characterized by the presence of recurring, unex-

pected panic attacks, and persistent concern about another panic attack
(American Psychiatric Association [APA], 2000). Individuals presenting with
agoraphobia within the context of panic disorder (PDA) avoid certain places

Received 1 February 2011; revised 28 April 2011; accepted 1 May 2011.

Rhea M. Chase is now at Duke University Medical Center. Sarah W. Whitton is now at the
University of Cincinnati.
Address correspondence to Rhea M. Chase, PhD, Duke University Medical Center, Center
for Child and Family Health, 411 W. Chapel Hill Street, Suite 908, Durham, NC 27701, USA.
E-mail: rhea.chase@duke.edu

305
 306 R. M. Chase et al.

due to the fear of having a panic attack. Prevalence rates of panic disorder
suggest that it occurs in approximately 1% of the general population; how-
ever, prevalence studies in clinical samples have found estimates of up to
10% (Last & Strauss, 1989; Masi, Favilla, Mucci, & Millepiedi, 2000). The onset
of PD most commonly occurs in late adolescence (APA, 2000), although
studies have documented the presence of the disorder and panic-related
avoidance in younger samples (Doerfler, Connor, Volungis, & Toscano, 2007;
Masi et al., 2000). Comorbidity with both internalizing and externalizing dis-
orders is common; adolescents with PD often present with additional diag-
noses of separation anxiety disorder, generalized anxiety disorder, and
depression, as well as attention deficit hyperactivity disorder and opposi-
tional defiant disorder (Doerfler et al., 2007). PD has also been linked to an
increased risk for substance and alcohol abuse and dependence (Zimmermann
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et al., 2003). Overall, PDA is recognized as a debilitating anxiety disorder that

warrants early intervention.
Panic Control Treatment (PCT; Barlow & Craske, 2000) is a cognitive
behavioral program developed specifically for the treatment of PD. PCT pro-
vides psychoeducation regarding the interplay of physiological, cognitive,
and behavioral factors in the origin and maintenance of panic symptoms.
Treatment also addresses cognitive distortions that contribute to the experi-
ence of panic. The client is eventually exposed to feared physical sensations
until habituation occurs (Barlow & Craske, 2000). The efficacy of PCT for
adults has been established (White & Barlow, 2002) and PCT is superior to
progressive muscle relaxation and a wait-list control (Barlow, Craske, Cerny,
& Klosko, 1989; Craske, Brown, & Barlow, 1991), as well as treatment as
usual in a managed care setting (Addis et al., 2004).
Researchers have adapted the PCT protocol for an adolescent population
(PCT-A; Hoffman & Mattis, 2000). PCT-A maintains the key principles of the
adult protocol, with modifications to increase its developmental sensitivity,
such as more simple and concise language. PCT-A also includes situational
exposure to address agoraphobic avoidance (Hoffman & Mattis, 2000; Mattis
& Ollendick, 2002). Results from a randomized control trial revealed that
PCT-A improved panic severity, anxiety sensitivity, and depression relative to
control groups. Treatment gains maintained 3- and 6-months posttreatment
(Pincus, May, Whitton, Mattis, & Barlow, 2010).
Cognitive-behavioral therapy (CBT) programs such as PCT are consid-
ered the most effective treatment for panic disorder; however, 26 to 40%
percent of patients continue to demonstrate clinically significant symptoms
after a course of CBT (Barlow, 2002; Marcaurelle, Belanger, Marchand,
Katerelos, & Mainguy, 2005). Research is beginning to explore modifications
to traditional CBT programs to increase treatment effectiveness. For exam-
ple, sensation-focused intensive treatment (SFIT; Bitran, Morissette, Spiegel,
& Barlow, 2008) combines the principles of PCT with situational exposure to
create an intensive treatment program delivered over eight consecutive days.
 Intensive Versus Weekly CBT for Adolescent Panic 307

Intensive programs typically involve a time-limited treatment course

with daily sessions for a concentrated period of time. The intensive approach
offers many potential advantages over weekly sessions. Daily sessions may
lead to more rapid symptom reduction as compared to weekly treatment
approaches, and some evidence suggests that intensive programs may be
helpful in treatment-resistant patients (Storch, Geffken, Adkins, Murphy, &
Goodman, 2007). Perhaps one of the most attractive advantages of the
intensive approach is increased access to quality treatment services. Although
CBT programs are recognized as the treatment of choice for PD and PDA,
few individuals can access this type of treatment. Less than 10% of panic
disorder patients receive CBT. Pharmacotherapy is the most common
treatment reported, and few patients participating in psychotherapy receive
CBT specifically (Stein et al., 2004). An intensive approach may allow patients
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with limited access to CBT providers to temporarily re-locate to receive

services at a specialty clinic.
Thus, the field is increasingly recognizing the potential merits of inten-
sive CBT programs. Research comparing intensive versus weekly formats of
exposure and response prevention (ERP) treatment of obsessive compulsive
disorder (OCD) revealed similar improvements in OCD symptoms and global
improvement scores across formats (Storch et al., 2008). Additionally, the two
groups did not differ in remission rates. Notably, in this nonrandomized
study, patients were allowed to choose intensive versus weekly treatment.
Significantly more patients in the intensive program traveled significant dis-
tances (60 miles or greater) to receive treatment. The authors conclude that
the intensive format may be a particularly attractive option for patients with-
out local access to CBT (Storch et al., 2008).
Some research supports the intensive approach to treating adults with
PD, through uncontrolled studies demonstrating improvement in panic
symptoms from pretreatment to posttreatment (Bitran et al., 2008; Deacon,
2007). A recent case study also supports the use of the intensive format with
the adolescent population (Angelosante, Pincus, Whitton, Cheron, & Pian,
2009). However, no research has directly compared the intensive and weekly
approaches in the treatment of panic symptoms. Additionally, the efficacy of
the intensive format has yet to be examined with larger samples of adoles-
cents. This seems an important area of study, given that the disorder often
begins in the teenage years (APA, 2000) and typically causes adolescents to
miss out on activities important to their development across school, athletic,
and social domains. A more intensive, briefer treatment might help adoles-
cents return to participation in these activities more quickly, lessening risks
for poor outcomes such as poor academic performance and grade retention.
In addition, evaluation of the intensive treatment for individuals whose PD
presents with agoraphobia seems important. Agoraphobic severity is nega-
tively correlated with treatment outcome (Ramnero & Ost, 2004) and has
thus been recognized as a crucial treatment target (Bitran et al., 2008). The
 308 R. M. Chase et al.

intensive approach may be particularly helpful in addressing agoraphobic

symptoms because it includes extended sessions (6–8 hours each) dedicated
to exposure exercises that allow sufficient time to conduct therapist-assisted
exposures in real-life situations that the client has been avoiding.
This study provides a comparison of weekly and intensive approaches
in the treatment of adolescent panic disorder. The treatment groups were
involved in two separate studies of PCT-A. Adolescents receiving weekly
PCT-A were involved in an efficacy trial of PCT-A in the treatment of adoles-
cent panic disorder, and participated in eleven sessions of PCT-A delivered
over 12 weeks. The intensive treatment group was drawn from an ongoing
study of PCT-A delivered in six extended sessions over eight consecutive
days. Given the paucity of existing data on intensive treatment for PD, the
current study was largely exploratory and sought to examine potential differ-
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ences in treatment outcome across the two treatment formats. Specifically,

we compared clinical severity of panic symptoms, as well as more general
anxiety and internalizing symptoms, from pretreatment to posttreatment, in
the two treatment groups.

METHOD

Participants
Participants were 51 adolescents (35 females, 16 males) between the ages of
11 and 18 (M = 15.26, SD = 1.53) with a principal diagnosis of PDA. The
majority (98%) were Caucasian, with one participant of Hispanic descent.
The average income was high (M = $112,044, SD = $97,317), although there
was significant variability in annual income (range = $12,500–$500,000). To
compare the weekly versus intensive formats, participants were drawn from
two intervention studies, both of which involved the implementation of PCT
treatment specifically with adolescents. A brief description of each study is
provided below. Each study recruited from consecutively referred adoles-
cents presenting to a specialty anxiety disorders clinic who met eligibility
criteria. The two studies involved virtually identical inclusion and exclusion
criteria, although the intensive program involved a slightly broader age
range.
Inclusion criteria necessitated that the adolescent receive a principal
diagnosis of panic disorder with or without agoraphobia during an initial
diagnostic assessment using the Anxiety Disorders Interview Schedule for
the DSM-IV, Child Version (Silverman & Albano, 1997). Although agoraphobic
avoidance was not required for study inclusion, all adolescents in the current
study were diagnosed with PDA. Adolescents receiving psychotropic
medication were required to have been stabilized on this medication for at
least one month for anti-anxiety medications and three months for
 Intensive Versus Weekly CBT for Adolescent Panic 309

anti-depressant medications prior to study entry. Exclusion criteria included

diagnosis of schizophrenia or other psychotic disorder, pervasive
developmental disorder, organic brain syndrome, mental retardation, or
current suicidal ideation.

Panic Control Treatment for Adolescents (PCT-A)

One subset of participants (n = 26) was drawn from a study examining the
efficacy of a developmental modification of panic control treatment for an
adolescent sample (PCT-A; Pincus et al., 2010). Twenty-six adolescents
between the ages of 14 and 17 were enrolled in the study from April 1999
through April 2003 after being referred to a research clinic specializing in the
treatment of anxiety and associated conditions. Main outcome data from this
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study have been published previously (Pincus et al., 2010).

Adolescent Intensive Program (AIP)

The second group of participants was drawn from an ongoing study examin-
ing the efficacy of PCT for adolescents delivered in an intensive, 8-day format
(Angelosante et al., 2009). For the current study, we selected the first 25
adolescents between the ages of 12 and 18 who were enrolled in the larger
study beginning in October of 2005 after seeking treatment at a research
clinic specializing in the treatment of anxiety and associated conditions.

Measures
ANXIETY DISORDERS INTERVIEW SCHEDULE FOR THE DSM-IV, CHILD
AND PARENT VERSIONS (ADIS-IV-C/P)

The ADIS-IV-C/P (Silverman & Albano, 1997) is a developmental modifica-

tion of the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV;
Brown, DiNardo, & Barlow, 1994) that includes both a child and a parent
interview. This semi-structured diagnostic interview allows the diagnosis of
DSM-IV anxiety disorders, mood disorders, and externalizing disorders of
childhood, and also provides screening questions for selected other disor-
ders (e.g., psychotic disorders, eating disorders, and somatization disorders).
The interviewer assigns a clinical severity rating (CSR) on a 0–8 scale for all
diagnoses. A CSR of 4 or above is considered clinical, while a CSR less than
4 is considered subclinical. The ADIS-IV-C/P has good interrater reliability
(r = .98 for the parent interview and r = .93 for the child interview; Silverman
& Nelles, 1988) and good retest reliability (e.g., k = .76 for the parent inter-
view; Silverman & Eisen, 1992; Silverman, Saavedra, & Pina, 2001). The
instrument is sensitive to treatment effects in studies of youth with anxiety
disorders (Kendall et al., 1997).
 310 R. M. Chase et al.

MULTIDIMENSIONAL ANXIETY SCALE FOR CHILDREN (MASC)

The MASC(March, 1997) is a 39-item questionnaire assessing various anxiety
dimensions in children. On the MASC, children rate how often anxiety-
related statements (e.g., “I get dizzy or faint,” “I worry about other people
laughing at me”) is true for him or her on a 0–3 scale (0 = never true about
me, 3 = often true about me). The MASC total score measures overall anxiety
level and has shown robust psychometric properties in clinical, epidemio-
logical, and treatment studies. Three-week test-retest reliability for the MASC
is .79 in clinical samples and .88 in school-based samples (March, 1997).

CHILDHOOD ANXIETY SENSITIVITY INDEX (CASI)

The CASI (Silverman, Fleisig, Rabian, & Peterson, 1991) is a developmental
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modification of the Anxiety Sensitivity Index (Reiss, Peterson, Gursky, &

McNally, 1986) designed to measure anxiety sensitivity in children and ado-
lescents. Children rate the severity of their response to anxiety and fear (e.g.,
“it scares me when my heart beats fast”) by endorsing “none” (1), “some” (2),
or “a lot” (3) in response to each item. The total anxiety sensitivity score is
defined as the sum of the child’s endorsements, and ranges from 18 to 54.
The CASI has been reported to have sound psychometric properties, with
adequate test-retest reliability of .79 in a clinical sample and good internal
consistency (α = .87) both clinical and nonclinical samples (Silverman et al.,
1991).

CHILDREN’S DEPRESSION INVENTORY (CDI)

The CDI (Kovacs, 1992) is a widely used self-report inventory assessing
depressive symptoms in children and adolescents. It contains 27 items con-
sisting of three statements which are graded in severity (0 to 2). The subject
is asked to endorse the statement which best describes his/her thoughts and
feelings during the past 2 weeks. A total score ranging from 0 to 54 is derived
by summing the severity ratings of the endorsed statements. Adequate inter-
nal consistency and test-retest reliability have been reported for this instru-
ment (Smucker, Craighead, Craighead, & Green, 1986).

PROCEDURE

Assessment Procedure
Following the informed consent process, families in both studies participated
in a pretreatment assessment that included completion of the ADIS-IV,
MASC, CASI, and CDI. The presence and severity of PD were determined by
the interviewing clinician based on child and parent report during the
 Intensive Versus Weekly CBT for Adolescent Panic 311

ADIS-IV. Interviewers were doctoral-level clinical psychologists and

advanced doctoral students in clinical psychology who had met ADIS-IV-
C/P training criteria, which includes observing three interviews,
collaboratively administering three interviewers with a trained clinician, and
conducting supervised assessments until reaching reliability (i.e., agreement
on clinical diagnoses and severity ratings on three of five consecutive
assessments). These measures were repeated at posttreatment, 3-month,
and 6-month follow-up assessments. The full ADIS-IV-C/P was used during
the initial diagnostic assessment, and a shorter version, the Mini-ADIS-IV-
C/P, which focused on the interim period since the previous assessment,
was used during posttreatment/wait-list and follow-up assessments.
Interviewers were blind to treatment condition.
Data from both PCT-A and AIP were drawn from randomized clinical
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trials examining the efficacy of PCT for adolescents in weekly and intensive
formats, respectively, in comparison to wait-list controls. Thus, participants
from each study were randomized to either an immediate treatment or a
wait-list control condition. Half of the adolescents (n = 13) in PCT-A were
randomly assigned to receive immediate treatment, while 13 were assigned
to a wait-list control group and received the intervention 8 weeks after
assignment. Approximately two thirds of the adolescents (n = 17) drawn
from the AIP study were randomly assigned to receive immediate intensive
treatment while eight were assigned to a wait-list control group and asked to
wait 6 weeks before receiving the intervention. Both treatment conditions
were conducted by doctoral-level clinical psychologists or advanced doc-
toral students who were supervised by clinical psychologists. For the present
study, pretreatment data were used from the time of study enrollment for all
participants, and posttreatment data from the point at which participants had
completed the intervention. We did not include postwait-list data in the pres-
ent analyses because the purpose was not to prove the efficacy of PCT-A,
but rather, to examine the relative efficacies of the weekly versus intensive
approaches.

Weekly PCT-A Treatment Procedure

Panic Control Treatment for Adolescents (Hoffman & Mattis, 2000) is a devel-
opmental modification of Panic Control Treatment (Barlow & Craske, 2000), an
empirically supported treatment for adults with panic disorder. PCT-A includes
11 sessions delivered over 12 weeks and targets three aspects of panic disorder
symptoms: anxiety-related cognitions, the hyperventilatory response, and con-
ditioned reactions to physical sensations. Treatment components are highly
similar to traditional PCT for adults; however, the PCT-A protocol includes
modifications to adapt treatment for an adolescent sample. Specifically, the
language was simplified to increase developmental sensitivity. Many concrete
examples were added to promote the adolescent’s comprehension of
 312 R. M. Chase et al.

treatment material, including both verbal and visual examples. Treatment also
included handouts specifically designed for adolescents. The program also
included parent involvement; parents were provided with psychoeducation
about panic disorder and appropriate responses to their adolescent’s panic.
For each session in which the adolescent was introduced to a new treatment
component (i.e., psychoeducation, cognitive restructuring, interoceptive expo-
sure, and situational exposure), the parent was invited in at the end of session
while the adolescent reviewed treatment concepts.
Initial sessions focused on psychoeducation about the nature of anxiety,
and the factors that contribute to the development of panic disorder and the
maintenance of panic symptoms. Adolescents learned to identify negative
thoughts that can contribute to and intensify panic sensations and counter
these thoughts with cognitive restructuring techniques. Adolescents also
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learned relaxation techniques to reduce the frequency and intensity of

physical sensations that trigger and maintain panic. Later treatment sessions
involved interoceptive exposure exercises, which are designed to desensitize
the individual to the physiological symptoms associated with panic attacks.
These exercises involve purposely eliciting panic sensations, but in a
controlled and systematic way, to learn the sensations are harmless and will
eventually subside. Participants also developed a fear and avoidance
hierarchy which included agoraphobic situations. Exposure exercises were
assigned as homework throughout treatment in order to encourage
adolescents to approach these situations.

Intensive Treatment Procedure

The intensive treatment program included virtually all of the treatment
components of the original PCT-A program, but delivered them in six
consecutive extended-length sessions over an 8-day period. Additionally, the
intensive approach involved therapist-assisted situational exposure exercises
to more fully address agoraphobic avoidance. Also of note, diaphragmatic
breathing was not a significant focus of treatment. Although these types of
relaxation exercises can be helpful in managing anxiety and reducing overall
physiological arousal, their use is actually counter-indicated during
interoceptive and situational exposure. During exposure exercises, the
adolescent should not attempt to lessen their anxiety symptoms, but rather,
experience them fully and learn that they will subside, even without any
distraction or relaxation techniques. Therefore, diaphragmatic breathing was
not taught during this program, especially since the therapist would be
engaging the adolescent in a range of different exposure exercises. Again,
parents were provided with psychoeducation about panic and were actively
involved in planning situational exposures outside the therapy session.
Treatment Days 1, 2, and 3 ranged from 90 to 120 min and were devoted
to psychoeducation about anxiety and the nature of panic, identification and
 Intensive Versus Weekly CBT for Adolescent Panic 313

cognitive restructuring of negative thoughts, and intereoceptive exposure,

respectively. Treatment Days 4 and 5 lasted 6–7 hours and involved continued
interoceptive exposure and massed, therapist-assisted situational exposure
exercises. At the end of Treatment Day 5, the therapist and the adolescent
planned situational exposure exercises for the next 2 days, which the
adolescent would complete outside of therapy. Treatment Day 8 was devoted
to review of the patient’s progress and the skills learned in treatment and
prevention of relapse. The therapist and the adolescent also discussed the
weeks and months ahead, and set a plan to approach any remaining
agoraphobic situations. Although Treatment Day 8 was the last formal
session, the therapist conducted brief weekly phone sessions for 4 weeks
following the last treatment session. These phone contacts allowed the
therapist to support the adolescent’s use of treatment skills and address any
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barriers to continued progress. Participants completed the posttreatment

assessment after this 4-week period of maintenance therapy.

RESULTS

Preliminary Analyses
To assess pretreatment differences between the two groups, weekly treatment
(WT) vs. intensive treatment (IT), on gender and ethnicity, chi-square (χ2)
analyses were conducted. The two groups did not differ on either variable; for
gender, χ2(1) = 0.49, p = .49, and for ethnicity, χ2(1) = 1.06, p = .30. Independent
samples t tests were used to assess pretreatment differences between groups
on the demographic variables of age and family income, as well as baseline
levels of the four outcome variables (see Table 1). The groups differed only on

TABLE 1 Pretreatment Descriptive Statistics for Groups Receiving Weekly Versus Intensive
Treatment

Variable Treatment N M SD t

Age Weekly 26 15.72 1.09 2.33*

Intensive 25 14.78 1.78
Panic CSR Weekly 26 5.50 0.81 −2.83**
Intensive 25 6.16 0.85
MASC Weekly 25 58.76 21.22 −0.04
Intensive 24 58.96 15.66
CASI Weekly 23 38.00 7.36 1.68
Intensive 23 34.78 4.45
CDI Weekly 24 13.29 7.86 0.49
Intensive 24 12.21 7.51

Note. CSR = Clinical Severity Rating; MASC = Multidimensional Anxiety Scale;

CASI = Child Anxiety Sensitivity Index; CDI = Child Depression Inventory.
*p < .05. **p < .01.
 314 R. M. Chase et al.

age and CSR. As expected given the different age requirements for participation
in the two treatment studies, participants who received WT were on average
older than those who received IT. At pretreatment, CSR scores were higher in
the group that received IT than in the group that received WT.
The majority (78%) of participants completed treatment and the post-
treatment assessment. In the WT group, one participant dropped out during
the wait-list period, prior to the first session. Twenty-two of the 25 partici-
pants who initiated treatment (88%) completed all 11 treatment sessions.
Two participants dropped out midtreatment (one after 6 and one after 8
sessions) but provided at least some posttreatment data and one participant
dropped out after one session and provided no further data. One participant
dropped from the follow-up period and provided no further data and five
participants provided partial data during follow-up. In the IT condition, one
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participant dropped out after the first treatment session and provided no
further data. Twenty-four of the 25 participants who initiated treatment (96%)
completed all eight treatment sessions. One participant did not provide any
data at posttreatment, and six participants provided partial data at the post-
treatment assessment. Six participants dropped from the follow-up period
and provided no further data and one participant provided partial data. We
used an intent-to-treat strategy to address missing data, to ensure that dif-
ferential withdrawal from treatment or follow-up between the two groups
would not influence results (e.g., Lachin, 2000). Participants who withdrew
early or who were missing data at a single assessment point were retained in
our analyses by carrying forward their last observation to substitute for their
missing data at posttreatment or follow-up assessments.

Primary Analyses
Group means and standard deviations on the four outcome variables at each
time point for the intent-to-treat sample are presented in Table 2. Group dif-
ferences on each outcome variable were examined using a repeated measures
analysis of variance (ANOVA) with study type (weekly vs. intensive) included
as a between subjects factor and time (pretreatment, posttreatment, 3-month
follow-up, 6-month follow-up) included as a four-level within subject factor.
To aid interpretation of findings, results are also presented pictorially in
Figure 1. To further evaluate the clinical significance of treatment effects in
each group, effect sizes (Cohen’s d) were calculated for pretreatment to post-
treatment differences. Original means and standard deviations rather than the
paired t values were used to calculate Cohen’s d, to avoid inflated effect sizes
estimates resulting from the correlated pretreatment and posttreatment scores
(cf. Dunlap, Cortina, Vaslow, & Burke, 1996).
For the CSR, there was a significant within-subject main effect of time,
F(3, 147) = 78.19, p < .001, and no group × time interaction effect, F(3,
147) = 1.33, p > .27, indicating that CSR scores decreased over time and that
 Intensive Versus Weekly CBT for Adolescent Panic 315

TABLE 2 Means and Standard Deviations of Outcome Measures Across Time

Variable Treatment Pretreatment Posttreatment 3 Month 6 Month

Panic CSR Weekly 5.50 (0.81) 3.27 (1.56) 2.46 (1.92) 2.58 (1.79)
Intensive 6.16 (0.85) 3.08 (1.91) 3.00 (2.06) 3.08 (2.22)
MASC Weekly 58.76 (21.22) 46.69 (19.89) 46.31 (19.68) 40.88 (15.85)
Intensive 58.96 (15.66) 53.00 (15.46) 51.24 (16.90) 49.96 (17.43)
CASI Weekly 38.00 (7.36) 30.65 (7.49) 30.81 (6.30) 28.19 (7.18)
Intensive 34.78 (4.45) 33.28 (4.89) 32.04 (7.76) 32.08 (7.01)
CDI Weekly 13.29 (7.86) 9.46 (7.04) 9.38 (7.15) 8.27 (7.34)
Intensive 12.21 (7.51) 12.52 (8.30) 11.28 (7.85) 10.52 (8.33)

Note. CSR = Clinical Severity Rating; MASC = Multidimensional Anxiety Scale;

CASI = Child Anxiety Sensitivity Index; CDI = Child Depression Inventory; standard deviations appear in
parentheses.
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both treatments were associated with equal reductions in CSR over time.
Paired t tests revealed a slightly different pattern of change between the two
groups. In the WT group, CSR scores decreased from pretreatment to post-
treatment, t(25) = 7.70, p < .001; and continued to decrease from posttreat-
ment to 3-month follow-up, t(25) = 3.04, p < .01; but did not change from
3-month to 6-month follow-up, t(25) = −0.48, p > .63. In the IT group, CSR
scores decreased from pretreatment to posttreatment, t(24) = 7.87, p < .001;

FIGURE 1 Scores at pretreatment and posttreatment and 3- and 6-month follow-up for each
of the outcome measures for the weekly treatment (WT) and intensive treatment (IT) groups.
 316 R. M. Chase et al.

and did not change from posttreatment to 3-month follow-up, t(24) = 0.35,
p > .73; or from 3-month to 6-month follow-up, t(24) = −0.22, p > .82. Both
treatments yielded very large treatment effect sizes at posttreatment (Cohen’s
d = 2.7 for WT and 3.6 for IT).
For the MASC, there was a main effect of time, F(3, 141) = 9.93, p < .001;
and no group × time interaction effect, F(3, 141) = 0.82, p > .48, indicating
that MASC scores decreased over time and that there were no differences
between treatment groups in the reductions in MASC over time. Follow-up
comparisons indicated that in both groups, MASC scores declined from pre-
treatment to posttreatment, t(24) = 3.94, p < .001 for WT and t(23) = 2.31,
p < .05 for IT; and then did not change further (all ts < 1.2, ps > .27), indicat-
ing that treatment gains were maintained through 6 months of follow-up.
Effect sizes for pretreatment to posttreatment differences were in the medium
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range for both treatment types (Cohen’s d = 0.58 for WT and 0.40 for IT).

Secondary Analyses
For the CASI, there was a main effect of time, F(3, 132) = 12.73, p < .001; and
a significant group × time interaction effect, F(3, 129) = 4.89, p < .01. This
indicates that CASI scores decreased more in the weekly treatment group
than in the intensive treatment group. Follow-up paired t tests revealed that
in both groups, CASI scores declined significantly from pretreatment to post-
treatment, t(22) = 4.71, p < .001 for WT and t(22) = 2.45, p < .05 for IT; and
then did not change further (all ts < 1.6, ps > .10), indicating that treatment
gains in both groups were maintained through 6 months of follow-up.
However, these gains were greater in those receiving weekly versus intensive
treatment; the pretreatment to posttreatment effect size was large in the WT
group (Cohen’s d = 1.02) and small in the IT group (Cohen’s d = 0.34).
For the CDI, there was a main effect of time, F(3, 138) = 6.88, p < .001;
and a significant group × time interaction effect, F(3, 138) = 2.69, p < .05. This
indicates that CDI scores decreased more in the weekly treatment group
than in the intensive treatment group. Planned comparisons using paired t
tests revealed that CDI scores decreased from pretreatment to posttreatment
in the weekly treatment group, t(23) = 3.45, p < .01, Cohen’s d = 0.50 (medium
effect); but not in the intensive treatment group, t(23) = 0.28, p > .50. In nei-
ther group was there any significant change in CDI scores during the follow-
up period, indicating maintenance of treatment gains in the WT group and
no posttreatment gains in the IT group (all ts < 1.8, ps > .05).

DISCUSSION

The present study was the first, to our knowledge, to directly compare the
efficacy of intensive versus weekly PCT treatment for adolescents. Results
suggest that weekly and intensive approaches led to similar improvements in
 Intensive Versus Weekly CBT for Adolescent Panic 317

panic severity and anxiety symptoms. Adolescents in the weekly and inten-
sive treatment programs exhibited significant and comparable reductions in
panic disorder severity, as well as overall anxiety symptoms. However, ado-
lescents in the weekly treatment program demonstrated greater reductions in
anxiety sensitivity and depressive symptoms than adolescents receiving
intensive treatment. These findings add to the limited body of research com-
paring intensive versus weekly CBT in the treatment of child anxiety
disorders.

Panic and Anxiety Symptom Reduction at Posttreatment

Results revealed that both groups exhibited significant decreases in panic
disorder severity, as measured by the Clinical Severity Rating scale (CSR)
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from the ADIS-IV. Adolescents from both treatment groups also demon-
strated significant improvements in overall anxiety symptoms as measured
by the MASC. The lack of time by group interaction on each of these two
measures suggests no difference in the amount of change between the two
groups. Thus, the relative efficacy of intensive treatment for adolescent panic
disorder compared to the standard weekly treatment format was supported.
This is a timely finding in light of the recent growing interest in the intensive
CBT approach within the field. While the intensive format offers many poten-
tial advantages, including rapid reduction in panic-related impairment and
increased access to effective treatment, it has previously been unknown
whether an intensive approach would be as effective as a traditional weekly
approach. It was possible that the intensive approach might not allow suffi-
cient time for patients to comprehend and apply therapy skills or that the
massed exposure exercises, without weeks of alliance building between
therapist and adolescent beforehand, might evoke greater resistance to expo-
sure exercises, thereby diminishing treatment effects. However, the current
findings provide evidence that the intensive approach is equally effective in
reducing panic severity and general anxiety symptoms in teens with PDA,
mitigating those concerns and providing support for the acceptability and
efficacy of the intensive approach.

Panic and Anxiety Symptom Reduction at Follow-Up

Another critical issue when evaluating the intensive approach involves the
maintenance of treatment gains. As mentioned above, the intensive format
requires rapid learning and encoding of a multitude of new skills and infor-
mation. This raises the possibility that the intensive approach, even if it is
associated with comparable treatment effects immediately following therapy,
might not lead to sustained improvements in client functioning over time.
The current results suggest that, in fact, the durability of treatment effects
was comparable between the intensive and weekly approaches. Both groups
continued to report nonclinical levels of panic disorder symptoms at 3-month
 318 R. M. Chase et al.

and 6-month follow-ups. Similarly, overall anxiety levels and anxiety sensitiv-
ity in both groups remained stable across the 6 months following treatment.
It is interesting that the results did suggest a slightly different pattern of
reduction in panic symptom severity between groups, in which those who
received weekly PCT-A treatment, but not those participating in the intensive
treatment, continued to demonstrate decreases in the severity of their panic
disorder symptoms in the 3 months following active treatment. However, the
clinical significance of this finding is questionable, given that both groups
continued to demonstrate nonclinical levels of panic throughout the follow-
up period and did not differ significantly in their panic severity at any point
after treatment. Future longitudinal studies with larger samples may be help-
ful to understanding whether the intensive format of CBT is associated with
a different trajectory of symptom improvement than is traditional weekly
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CBT. If such studies do suggest that the weekly format leads to continued
gains posttreatment, but that the intensive format does not, it might be advis-
able to follow intensive treatments with a short period of weekly sessions to
ensure similar treatment gains.

Treatment Effects on Secondary Symptoms

In contrast to the comparable improvements in panic severity and anxiety
symptoms in the two treatment conditions, the intensive format was associ-
ated with smaller reductions in anxiety sensitivity than was the weekly treat-
ment. This finding suggests that the intensive format is not as effective as is
weekly treatment in reducing anxiety sensitivity. To be clear, adolescents
who received the intensive treatment did demonstrate significant improve-
ment in anxiety sensitivity at posttreatment, and maintained these gains
across 6 months of follow-up. However, adolescents who received weekly
treatment showed greater improvement. Anxiety sensitivity refers to the
belief that the physical sensations associated with anxiety are harmful. The
construct is conceptualized as a more stable trait that may predate the devel-
opment of PD (Reiss et al., 1986; Schmidt, Lerew, & Jackson, 1997). Anxiety
sensitivity may, therefore, require more time to modify in treatment, as it
relates to overall perception and personal beliefs regarding anxiety symp-
toms. Adolescents receiving intensive treatment may continue to experience
some fear surrounding their panic symptoms, but results suggest that this
fear no longer leads to significant avoidance.
One of the most interesting and unexpected findings from this study
was that, in contrast to the weekly treatment, the intensive treatment was not
associated with improvement in adolescents’ depressive symptoms. Although
no participants in either group had a principle mood disorder and average
pretreatment depressive symptoms were not at clinically significant levels in
either group, depressive symptoms are often elevated in individuals with PD
and may exacerbate functional impairment by fostering social withdrawal
and reducing motivation and energy to engage in daily activities. It is,
 Intensive Versus Weekly CBT for Adolescent Panic 319

therefore, noteworthy that the weekly approach appears to have a positive

effect on adolescents’ depressive symptoms, which decreased during active
treatment and remained low throughout follow-up, but that depressive
symptom levels showed no change in the intensive treatment group. It is
unclear why this difference exists. Depressive symptoms were not directly
targeted in either treatment, but it is possible that skills taught in PCT-A to
reduce panic and anxiety were generalized to help reduce clients’ depressive
symptoms to a greater extent in the weekly than the intensive treatment.
Although anxiety and depression are frequently comorbid, with some
overlapping features, they are ultimately distinct disorders, with unique treat-
ment targets (Kendall, Kortlander, Chansky, & Brady, 1992). Adaptations are
necessary to tailor CBT anxiety treatment to address comorbid depressive
symptoms (Hudson, Krain, & Kendall, 2001). Therapists in the weekly treat-
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ment program may have had more chance to become aware of their clients’
depressive symptoms, as well as the cognitions and behavioral patterns con-
tributing to those symptoms, and had more time to make the necessary
adaptations to the CBT skills to target the clients’ depressive symptoms.
Alternately, participants in the weekly program may have simply had greater
opportunity to experience gradual reduction in depressive symptoms as
their anxiety improved, leading to reductions in social isolation and increased
involvement in positive activities (i.e., behavioral activation). However, the
fact that reductions in depressive symptoms were not observed in the 6
months following intensive treatment argues against this explanation. In
sum, these results raise important questions regarding the effectiveness of
intensive treatment for panic disorder in addressing comorbid psychological
disorders. The intensive format may allow less time to address symptoms of
co-occurring disorders, either formally within treatment sessions, or naturally
as patients enjoy the positive sequalae of reduced anxiety levels. Therefore,
PCT-A delivered in an intensive format may need to be conceptualized as a
targeted intervention with high specificity that addresses panic and anxiety
symptoms in a short period of time. Comorbid disorders or symptoms may
need to be addressed in follow-up therapy sessions, depending on their
severity and related impairment.

Limitations
To allow comparison of the weekly versus intensive treatment programs, par-
ticipants were drawn from two different research studies. Participants were not
randomized into intensive versus weekly treatment programs, and adolescents
in the intensive program exhibited more severe PD as compared to those in
the weekly program. Differences in the samples may have introduced variabil-
ity in the results. The clinical presentation of these two samples was highly
similar, and study inclusion and exclusion criteria were virtually identical, but
differences also existed in each study’s design. The weekly program offered
active treatment over 12 weeks, compared to 6 weeks in the intensive approach.
 320 R. M. Chase et al.

This difference in therapeutic contact may have affected the results, particu-
larly the findings relating to anxiety sensitivity and depressive symptoms.
Missing data may also have affected results, although the intent-to-treat strat-
egy is a conservative method that would minimize rather than inflate treatment
effects. The study also involved a relatively small and primarily Caucasian
sample of adolescents from a fairly high socioeconomic status highlighting the
need for replication with larger and more diverse samples.

Future Directions and Conclusions

To the best of our knowledge, this is the first study to support the relative
efficacy of the intensive approach specifically for adolescent panic disorder.
The feasibility and acceptability of the intensive approach seems particularly
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relevant for this population given the significant impairment associated with
PD during the teenage years. Panic disorder in children often contributes to
significant academic difficulties and even school refusal, as well as avoidance
of social activities and isolation from peers. The consequences of these
impairments can be particularly devastating in adolescence, as academic and
social demands increase and the adolescent begins to transition into adult-
hood. Thus, the intensive approach may offer a particular advantage for this
population, as it offers rapid symptom relief and addresses avoidance associ-
ated with panic symptoms, allowing teens to return more quickly to the
activities that are important for their development. The current results sug-
gest that the intensive format is just as effective as traditional weekly CBT for
panic disorder in adolescents in reducing their panic severity and general
anxiety symptoms. Future research should continue to explore the feasibility
of intensive approaches with child anxiety populations, and the factors that
indicate use of intensive versus weekly programs. These findings indicate
that, while just as effective in addressing symptoms of panic, the intensive
treatment is not as effective as traditional weekly treatment in reducing sec-
ondary anxiety sensitivity (i.e., physiological reactivity to the sensations of
panic) or depressive symptoms. Specifically, a randomized clinical trial with
a larger sample is needed to further support the intensive approach with this
population. Current results suggest that intensive PCT treatment is a promis-
ing approach that may offer rapid symptom relief for adolescents with PD.

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