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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)
Panic Disorder
Diagnostic Considerations
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
Rapid heart rate, heart palpitations Shortness of breath, smothering sensations Chest pain or discomfort, numbness or tingling
Catastrophic misinterpretations of symptoms
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.
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
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?)
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
Situational Exposures
Rationale:
Providing a new learning opportunity to examine negative predictions about feared outcomes Increasing tolerance to internal sensations in feared situations
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
Benzodiazepines
SSRIs Antidepressants
(e.g., Allen et al., 2010; Telch et al., 1995; Tsao et al., 1998)
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.
50 40 30 20 10 0
Maintenance (ITT) 6 More Months
CBT + imipramine CBT + placebo CBT Imipramine Placebo
50 40 30 20 10 0
6 Months Treatment Discontinuation (ITT) (Imipramine over 1 to 2 weeks)
EXP = exposure treatment. ALP = alprazolam treatment. PBO = placebo treatment. Relax = relaxation treatment. Marks IM et al. Br J Psychiatry.1993;162:776-787.
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.
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
Preventive Treatment
% Developing Panic Disorder
25 20
15
13.6
10
1.8
0
121 Participants