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) .

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 .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 don’t escape.


smothering sensations Chest pain or discomfort.Cognitive-Behavioral Model of Panic Disorder Alarm Reaction Stress Biological Diathesis Rapid heart rate. 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 . heart palpitations Shortness of breath.

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

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 .

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 . thoughts.Information Interventions • May include handouts or patient manuals • Distinguishes between symptoms.

General • Identify the nature of thoughts: they don’t have to be true to affect emotions • Learn about common biases in thoughts • Treat thoughts as “guesses” or “hypotheses” about the world .Cognitive Restructuring .

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?”) .

dizziness.e.. increased heart rate). .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.

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

•Relax WITH the sensation .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.

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 .

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

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 .

Otto et al. 1995.. 2001 .Meta-Analytic Results of Panic Disorder Treatment Studies CBT (IE+CR) Effect Size (Cohen’s d) CBT Non-SSRI Antidepressants Benzodiazepines SSRIs Antidepressants Gould et al.

1995. 1998) ..CBT for Panic Disorder In addition to core panic. and avoidance outcomes. 2010. Tsao et al. Telch et al. including: • Improvements in quality of life • Improvement in comorbid conditions (e.. anxiety..g. CBT has broader-based benefits. Allen et al..


Treatment Acceptability (dropout rates) Percent Dropout .

et al.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. . 1998.155:43-47. Am J Psychiatry.

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 .

2000.283:2529-2536. JAMA. et al.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. .

Panic Disorder: Post–Imipramine 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. JAMA. 2000. . et al.283:2529-2536.

3 0.3 1.7 (CGI relative to PR) 0.5 0.1 0. PBO = placebo treatment. Br J Psychiatry.162:776-787.Panic Disorder: After 8 Weeks of Treatment 1. . Marks IM et al. Relax = relaxation treatment.1 -0.1993.9 EXP + ALP EXP + PBO ALP + Relax Effect Size 0.1 EXP = exposure treatment. ALP = alprazolam treatment.

ALP = alprazolam treatment.9 0. Relax = relaxation treatment.Panic Disorder: Post Benzodiazepine Discontinuation (Week 18) 1.1 -0.3 1.3 0.1993.1 0.7 Effect Size (CGI relative to PR) 0.3 EXP + ALP EXP + PBO ALP + Relax EXP = exposure treatment.5 0. Br J Psychiatry.162:776-787. Marks IM et al. . PBO = placebo treatment.1 -0.

Behav Res Ther. 1992. Behav Res Ther.The Solution • Apply (re-apply) CBT at the time of medication taper and thereafter • Remember.151:876-881. 4Whittal ML et al.2 – Treatment with SSRIs3. Am J Psychiatry. 2002. Psychopharmacol Bull. 1994.40:67-73.28:123-130. . it works for medication discontinuation with expansion of treatment gains – Treatment with benzodiazepines1. 2001. 2Spiegel DA et al.4 1Otto MW et al. 3Schmidt NB et al.39:939-945.

Greater success with a novel combination strategy • Combination of CBT with the putative memory enhancer. helping speed treatment outcome • Similar benefits for d-cycloserine + exposure is seen for other anxiety disorders . d-cycloserine • 2 small treatment trials suggest that d-cycloserine helps consolidate therapeutic learning from exposure.

Craske MG.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. 2001.32:725-738. Behav Ther. .

.8 0 121 Participants Gardenswartz CA. Behav Ther.Preventive Treatment % Developing Panic Disorder 25 20 Wait List Workshop 15 13.32:725-738. Craske MG.6 10 5 1. 2001.

J Consult Clin Psychol. .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.66:231-239. 1998.

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