Manualized Treatment of Panic Disorder in a Medical Setting: Two Illustrative Case Studies

People who experience panic attacks (PAs) typically present to medical settings, concerned that their symptoms signify a life-threatening condition. Despite the efficacy of cognitive-behavioral therapy (CBT) for panic disorder (PD), medical practitioners seldom provide this type of treatment. Physicians may lack the time or expertise to impart such behavioral medicine interventions, while patients may find group or individual CBT too costly even when available. Researchers have begun investigating manualized CBT as a cost-effective alternative when traditional forms of this intervention are prohibited. This article describes two case studies in which women presenting to a medical clinic with PD were treated with 6 weeks of manualized CBT after pharmacotherapy was unsuccessful or unpalatable. Both patients exhibited reductions in panic and depressive symptomatology over baseline levels, along with increases in self-efficacy regarding their ability to manage future PAs. Improvements were maintained over 12 months, supporting continued use of manualized CBT as a supplement or alternative to pharmacological methods of treating PD in the medical setting.     

Efficacy of CBT for benzodiazepine discontinuation in patients with panic disorder: Further evaluation

Despite its acute efficacy for the treatment of panic disorder, benzodiazepines (BZs) are associated with a withdrawal syndrome that closely mimics anxiety sensations, leading to difficulty with treatment discontinuation and often disorder relapse. An exposure-based cognitive-behavioral treatment for BZ discontinuation, Panic Control Treatment for BZ Discontinuation (CBT) targets the fear of these sensations and has demonstrated efficacy in preventing disorder relapse and facilitating successful BZ discontinuation among patients with panic disorder. In this randomized controlled trial, CBT was compared to taper alone and a taper plus a relaxation condition to control for the effect of therapist contact and support among 47 patients with panic disorder seeking taper from BZs. Based on the primary outcome of successful discontinuation of BZ use, results indicate that adjunctive CBT provided additive benefits above both taper alone and taper plus relaxation, with consistently medium and large effect sizes over time that reached significance at the six month follow-up evaluation. The efficacy of CBT relative to either of the other taper conditions reflected very large and significant effect sizes at that time. These findings suggest that CBT provides specific efficacy for the successful discontinuation from BZs, even when controlling for therapist contact and relaxation training.     

A pilot study of two-day cognitive-behavioral therapy for panic disorder

The present study investigated the short-term efficacy of brief, intensive cognitive-behavioral therapy (CBT) for panic disorder (PD). The treatment involved 9h of therapist contact over two consecutive days and was developed for the purpose of delivering CBT for PD to a largely rural patient population that must travel long distances to find a treatment provider. Ten patients who elected to participate in brief, intensive CBT instead of weekly CBT were recruited from routine clinical practice in a hospital-based anxiety disorders clinic. Patients were not excluded based on the presence of agoraphobia, diagnostic comorbidity, concurrent use of PRN benzodiazepine medications, or previous nonresponse to psychotherapy for PD. Assessments conducted at pre-treatment and 1-month follow-up revealed large, clinically significant reductions in PD symptoms, anxiety sensitivity, body vigilance, and anxiety and depressive symptoms. Most patients (60%) were panic-free after treatment and evidenced normative levels of symptomatology at follow-up. The present study suggests that brief, intensive treatment may be an effective means of delivering CBT for PD.     

Cognitive-behavior therapy for discontinuation of SSRI treatment of panic disorder: a case series

In this report we describe the outcome of eight outpatients with panic disorder and agoraphobia who discontinued their treatment with a selective serotonin reuptake inhibitor (SSRI) in the context of a structured, group program of cognitive-behavior therapy. All patients successfully discontinued their SSRI medication while demonstrating clinical improvement. These results were maintained at 3-month follow-up. This case series suggests that manualized CBT for discontinuation of benzodiazepine treatment for panic disorder may be successfully applied to SSRI discontinuation as well.     

Effects of group experiential cognitive therapy for the treatment of panic disorder with agoraphobia.

A treatment protocol, called experiential cognitive therapy (ExCT), was developed. It integrated traditional cognitive behavior therapy (CBT) with virtual reality exposure for the treatment of panic disorder with agoraphobia (PDA). The objective of this study was to test the efficacy of short-term (four sessions) ExCT compared with a traditional 12-session panic control program (PCP) for the treatment of PDA. Forty patients diagnosed as having PDA by the diagnostic criteria of DSM-IV were randomly assigned to ExCT and PCP groups of 20 patients each. The treatment effects were measured with self-report questionnaires, including the BDI, STAI, ASI, PBQ, ACQ, and BSQ. The authors also assessed high end-state functioning (HES), including the success rate of stopping or reducing medication at post-treatment and 6-month follow-up. In all ratings, both ExCT and PCP groups showed significant improvement post-treatment compared with pre-treatment scores. There were no significant differences between the two treatment groups in HES and medication discontinuation at post-treatment, but there was a significant difference in medication discontinuation at 6-month follow-up. These results suggested that although short-term effectiveness of ExCT might be comparable to the effectiveness of PCP, long-term effectiveness of ExCT might be relatively inferior to the effectiveness of PCP.     

Cognitive behavioral therapy for panic disorder and comorbidity: more of the same or less of more?

This study compared the effects of a higher dose of cognitive behavioral therapy (CBT) for panic disorder versus CBT for panic disorder combined with "straying" to CBT for comorbid disorders in individuals with a principal diagnosis of panic disorder with or without agoraphobia. Sixty-five participants were randomly assigned to one of two treatment conditions, either CBT focused solely upon panic disorder and agoraphobia or CBT that simultaneously addressed panic disorder and agoraphobia and, to a lesser degree, the most severe comorbid condition. Results indicated a significant reduction in panic disorder severity and a decline in severity of comorbid diagnoses across both treatment conditions. However, individuals receiving CBT focused only on panic disorder were more likely to meet high end-state functioning at post-treatment, even in intent-to-treat analyses, and report zero panic attacks at the 1-year follow-up, although this effect was not retained in intent-to-treat analyses. At follow-up, CBT focused only on panic disorder yielded more substantial improvement in the most severe baseline comorbid condition, although not in intent-to-treat analyses, and a greater proportion of individuals in this treatment condition were rated as having no comorbid diagnoses, even in intent-to-treat analyses. These findings raise the possibility that remaining focused on CBT for panic disorder may be more beneficial for both principal and comorbid diagnoses than combining CBT for panic disorder with 'straying' to CBT for comorbid disorders.     

Mechanisms of change in cognitive behaviour therapy for panic disorder: The role of panic self-efficacy and catastrophic misinterpretations

The efficacy of cognitive behavioural therapy (CBT) for panic disorder with or without agoraphobia (PD) is well-established; however, little is known about the underlying change processes of clinical improvement during therapy. According to cognitive theories, CBT for PD primarily works by changing catastrophic misinterpretations of bodily symptoms and panic attacks. However, panic self-efficacy, i.e. the perceived ability to cope with panic attacks, has also been suggested as an important change mechanism in CBT for PD. The aim of the study was to investigate if change in catastrophic misinterpretations and panic self-efficacy mediated change in the level of anxiety during the course of thirteen sessions of group CBT for PD. Forty-five participants completed weekly self-report measures of the possible cognitive mediators and the level of anxiety throughout therapy. The results indicated that within-person change in panic self-efficacy in one session, but not in catastrophic misinterpretations, predicted within-person level of anxiety symptoms the following week. However, in a reversed analysis, prior change in level of anxiety symptoms also predicted change in panic self-efficacy the following session. These results support panic self-efficacy as a mediator of change in CBT for PD, although a reciprocal causal relationship between panic self-efficacy and level of anxiety seems to be implied.     

Mechanisms of change in cognitive behavioral therapy for panic disorder: The unique effects of self-efficacy and anxiety sensitivity

The present study examined temporal dependencies of change of panic symptoms and two promising mechanisms of change (self-efficacy and anxiety sensitivity) during an 11-session course of cognitive-behavior therapy (CBT) for Panic Disorder (PD). 361 individuals with a principal diagnosis of PD completed measures of self-efficacy, anxiety sensitivity, and PD symptoms at each session during treatment. Effect size analyses indicated that the greatest changes in anxiety sensitivity occurred early in treatment, whereas the greatest changes in self-efficacy occurred later in treatment. Results of parallel process latent growth curve models indicated that changes in self-efficacy and anxiety sensitivity across treatment uniquely predicted changes in PD symptoms. Bivariate and multivariate latent difference score models indicated, as expected, that changes in anxiety sensitivity and self-efficacy temporally preceded changes in panic symptoms, and that intraindividual changes in anxiety sensitivity and self-efficacy independently predicted subsequent intraindividual changes in panic symptoms. These results provide strong evidence that changes in self-efficacy and anxiety sensitivity during CBT influence subsequent changes in panic symptoms, and that self-efficacy and anxiety sensitivity may therefore be two distinct mechanisms of change of CBT for PD that have their greatest impact at different stages of treatment.     

Impact of cognitive-behavioral therapy for panic disorder on comorbidity: a controlled investigation

This study examined the effects of cognitive-behavioral therapy (CBT) for principal panic disorder with or without agoraphobia, on comorbidity in 30 individuals (16 female). To test the hypothesis that improvements in co-existing conditions were not due to spontaneous fluctuations across time, patients receiving immediate CBT were compared to those assigned to wait list (n = 11). Results indicated clinician-rated severity of comorbid specific phobia declined significantly following immediate CBT compared to no change after wait list. The number of patients without comorbidity of any severity increased after immediate CBT, with no such increase following wait list. However, the groups did not differ in the frequency of additional diagnoses or overall severity of comorbidity. In the total sample, results indicated reductions in comorbidity by 9-month follow-up, with marked declines in the severity of comorbid generalized anxiety disorder (GAD), social and specific phobia. Our findings suggest that targeted CBT for panic disorder has beneficial effects on comorbidity over the longer term and that some of its immediate effects exceed those due to the passage of time alone.     

Emotion Regulation Strategies in Cognitive Behavioral Therapy for Panic Disorder

Emotion regulation (ER) has been incorporated into many models of psychopathology, but it has not been examined directly in cognitive behavioral therapy (CBT) for panic disorder with agoraphobia (PD/A). In this study, a preliminary model of ER in CBT for PD/A is proposed based on existing theories, and several propositions of the model are tested. We hypothesized that increases in cognitive reappraisal would precede decreases in biased cognitions, decreases in expressive suppression would follow decreases in biased cognitions, and a reduction in symptom severity would follow decreases in expressive suppression. Twenty-nine patients who received CBT for PD/A completed weekly self-report measures of symptom severity, anxiety sensitivity, reappraisal and expressive suppression. In addition, patients were compared to a matched normal sample. Cross-lagged analyses partially supported the hypotheses. Reappraisal did not change until late stages of therapy and was generally not associated with treatment outcome. Suppression decreased significantly and exhibited a reciprocal relationship with biased cognitions. Symptom reduction followed decreases in suppression as hypothesized. However, patients did not differ in ER from matched controls at either pre- or posttreatment. Results suggest the important distinction between reappraisal and appraisal, and stress the role of session-by-session decreases in suppression as a predictor of symptom reduction.     

Antidepressant Medication: Is It a Viable and Valuable Adjunct to Cognitive-Behavioral Therapy for School Refusal?

Cognitive-behavioral therapy (CBT) is an evidence-based treatment for school refusal. However, some youth do not respond to CBT. The serious risks associated with school nonattendance call for novel approaches to help those who do not respond to CBT. Because school refusal is commonly associated with anxiety disorders, and the combination of CBT and antidepressant medication enhances outcomes in the treatment of anxiety disorders, combined treatment may be effective for school refusal. This narrative review evaluates the current evidence base for adding antidepressant treatment to CBT for school refusal. Six randomized controlled trials (RCTs), two open trials, six case studies/series, and one observational study were identified and reviewed. There is support for combined CBT and imipramine, but this medication is not typically used due to the risk of concerning side effects. Two recent RCTs failed to provide evidence for the superiority of combined CBT and fluoxetine. Further research in this area is required because the extant studies have a number of methodological limitations. Recommendations are provided for clinicians who consider prescribing antidepressant medication or referring for adjunctive antidepressant treatment for school refusal.     

One-year follow-up of pharmacotherapy-resistant patients with panic disorder treated with cognitive-behavior therapy: Outcome and predictors of remission

Non-response to pharmacotherapy for panic disorder (PD) is a well-documented problem. However, little information exists to guide next-step strategies for these non-responders. In addition to pharmacologic augmentation strategies, several studies support the efficacy of cognitive-behavior therapy (CBT) for these patients, although data on long-term outcomes has been lacking. In this study, we provide one-year outcomes on a sample of 63 patients who completed group CBT for PD after failing to respond adequately to previous pharmacotherapy. Sustained significant benefit was found for all dimensional outcome scores, and nearly two-thirds of the sample met remission criteria. This occurred with reductions in medication use over the follow-up period. Negative predictors of remission status included comorbid dysthymia, social phobia, and generalized anxiety disorder. These results provide additional evidence for the efficacy of CBT for medication non-responders with PD.     

Cognitive-behavioral therapy for panic disorder: a review of treatment elements,strategies, and outcomes

This article provides an overview of cognitive-behavioral therapy (CBT) for panic disorder. CBT is currently considered a first-line treatment for panic disorder. It offers benefit after short-term intervention, typically consisting of 12-15 sessions conducted in either an individual or a group format. The treatment focuses on the elimination of the patterns that underlie and perpetuate the disorder. Through CBT, patients learn about the nature of the disorder and acquire a set of strategies that counter the fears of panic attacks themselves, and break the recurring cycle of anticipatory anxiety, panic, and agoraphobic avoidance. The collaborative format of treatment, and a focus on elimination of core fears may be factors in enhancing longer-term outcome. In this article, we review the efficacy of CBT as a first-line treatment, a strategy for medication nonresponders, a replacement strategy for patients who wish to discontinue pharmacotherapy, and a potential preventive strategy for at-risk individuals. We also discuss some of the complex issues involved with combination-treatment strategies.     

Should We Treat Depression with drugs or psychological interventions? A Reply to Ioannidis

We reply to the Ioannidis's paper "Effectiveness of antidepressants; an evidence based myth constructed from a thousand controlled trials." We disagree that antidepressants have no greater efficacy than placebo. We present the efficacy from hundreds of trials in terms of the percentage of patients with a substantial clinical response (a 50% improvement or more symptomatic reduction). This meta-analysis finds that 42-70% of depressed patients improve with drug and 21%-39% improve with placebo. The response benefit of antidepressant treatment is 33%-11% greater than placebo. Ioannidis argues that it would be vanishingly smaller because systematic biasing in these clinical trials would reduce the drug-placebo difference to zero. Ioannidis' argument that antidepressants have no benefit is eroded by his failures of logic because he does not present any evidence that there are a large number of studies where placebo is substantially more effective than drug. (To reduce to zero, one would also have to show that some of the unpublished studies find placebo better than drug and have substantial systematic or methodological bias). We also present the empirical evidence showing that these methodological concerns generally have the opposite effect of what Ioannidis argues, supporting our contention that the measured efficacy of antidepressants likely underestimates true efficacy. Our most important criticism is Ioannidis’ basic underlying argument about antidepressants that if the existing evidence is imperfect and methods can be criticized, then this proves that antidepressant are not efficacious. He presents no credible evidence that antidepressants have zero effect size. Valid arguments can point out difficulties with the data but do not prove that a given drug had no efficacy. Indeed better evidence might prove it was more efficacious that originally found. We find no empirical or ethical reason why psychiatrists should not try to help depressed patients with drugs and/or with psychotherapeutic/behavioral treatments given evidence of efficacy even though our treatment knowledge has limitations. The immense suffering of patients with major depression leads to ethical, moral, professional and legal obligations to treat patients with the best available tools at our disposal, while diligently and actively monitoring for adverse effects and actively revising treatment components as necessary.     

Belief disconfirmation versus habituation approaches to situational exposure in panic disorder with agoraphobia: a pilot study

Exposure therapy and cognitive behaviour therapy (CBT) are both effective in the treatment of panic disorder with agoraphobia. Cognitive theories suggest that the way in which exposure to avoided situations is implemented in either treatment may be crucial. In particular, it is suggested that clinical improvement will be greatest if opportunities for disconfirmation of feared catastrophes are maximized. In a small pilot study, 16 patients with panic disorder and (moderate or severe) agoraphobia were randomly allocated to either habituation based exposure therapy (HBET) or exposure planned as a belief disconfirmation strategy and accompanied by dropping of safety-seeking behaviours. Both treatments were brief (total of 3.25 h of exposure) and were similar in terms of expectancy of change. Patients in the CBT condition showed significantly greater improvements in self-report measures of anxiety, panic and situational avoidance. They also completed significantly more steps in a standardized behavioural walk, during which they experienced significantly less anxiety. The controlled effect sizes for CBT were substantial (range 1.7-2.7), which suggests it may be a particularly efficient way of managing therapeutic exposure to feared situations in panic disorder with agoraphobia. Further research is needed to clarify the mechanism of change involved.     

Evidenzbasierte Psychotherapie der Panikst?rung mit und ohne Agoraphobie

From the evidence reported in the recent guidelines [Heinrichs et al. (2009) Evidenzbasierte Leitlinie zur Psychotherapie der Panikst?rung mit und ohne Agoraphobie. Hogrefe, G?ttingen] the following conclusions can be drawn with respect to the treatment of panic disorder with or without agoraphobia, as well as for agoraphobia without panic disorder:

1. Every psychotherapy should be preceded by suitable diagnostics and a case formulation.
2. The effectiveness of every psychotherapy should be evaluated with well established measures.
3. For the treatment of panic disorder without agoraphobia, cognitive behavioral treatment (CBT) and applied relaxation have been shown to be effective (evidence grade 1).
4. For panic disorder with agoraphobia, CBT, combination treatment (CBT plus medication), as well as panic-focused psychodynamic psychotherapy in the outpatient setting have shown short-term effectiveness (evidence grade 1). Longer lasting effects have been documented for CBT (evidence grade 1).
5. For agoraphobia without panic disorder, CBT with a focus on situational exposure can be recommended (evidence grade 1).

     

Implications of naturalistic use of pharmacotherapy in CBT treatment for panic disorder

This study examined naturalistic medication use and cognitive behavioral therapy (CBT) treatment outcomes in 105 patients meeting DSM-IV criteria for panic disorder (PD), assessed by structured clinical interview. The association between pre- and post-treatment use of SSRIs, benzodiazepines (BZs), and any anti-anxiety or anti-depressant (A/D) medication were investigated for three indicators of treatment outcome (PD severity, presence of agoraphobia (AG), anxiety sensitivity) at post-treatment and 6-month follow-up. Controlling for pre-treatment severity, pre-treatment SSRI use was associated with worse outcomes for AG (p=.04) and anxiety sensitivity (p=.047); post-treatment SSRI use was associated with delayed improvements in PD severity (p=.05). Pre-treatment use of A/D was associated with poorer PD severity outcomes (p=.04). Post-treatment use of A/D was associated with higher anxiety sensitivity scores across post-treatment and 6-month follow-up (p=.03). BZ use was not associated with significantly worse outcomes. However, there was a decrease in the number of patients using BZs from pre-treatment to post-treatment (p=.06) and follow-up (p=.006). In conclusion, controlling for pre-treatment severity, pre- and post-treatment use of SSRIs and A/D was associated with poorer outcomes, particularly for PD severity and anxiety sensitivity.     

Selective phosphodiesterase type-5 inhibitor treatment of serotonergic reuptake inhibitor antidepressant-associated sexual dysfunction: a review of diagnosis,treatment, and relevance

Sexual dysfunction related to antidepressants, particularly serotonin reuptake inhibitors is a major cause of premature treatment discontinuation. This places patients at increased risk for recurrence, relapse, chronicity, and mortality (eg, suicide). The clinical assessment requires a comprehensive evaluation of sexual function, including libido, arousal, orgasm, and resolution prior to affective disorder, disturbances associated with the emergence of depression, and changes or dysfunctions associated with antidepressant treatment. Other factors to be included for evaluating sexual dysfunction include inquiry for concurrent medical conditions, somatic treatments, lifestyle risk factors, and response to antidepressants. Current treatment approaches to antidepressant-associated sexual dysfunction have relied on open-label reports, literature reviews, and clinical wisdom. Without double-blind, placebo-controlled studies to support them, too much non-evidence-based treatment may be offered to patients. Advances into nonadrenergic-noncholinergic novel signal transduction, specifically phosphodiesterase type-5 inhibitors, offer new opportunities for developing evidence-based treatments for this side effect and improving depression disease management outcomes.     

EFFECTS OF MATERNAL DEPRESSION AND PANIC DISORDER ON MOTHER-INFANT INTERACTIVE BEHAVIOR IN THE FACE-TO-FACE STILL-FACE PARADIGM

The present study evaluated the interactive behavior of three groups of mothers and their 3-month-old infants in the Face-to-Face Still-Face paradigm. The mothers had either a clinical diagnosis of major depressive disorder (MDD, n = 33) with no comorbidity, a clinical diagnosis of panic disorder (PD, n = 13) with no comorbidity, or no clinical diagnosis (n = 48). The sample was selected to be at otherwise low social and medical risk, and all mothers with PD or MDD were in treatment. The findings indicated that (a) infants of mothers with PD or MDD displayed the traditional still-face and reunion effects described in previous research with nonclinical samples; (b) the 3-month-old infants in this study showed similar, but not identical, gender effects to those described for older infants; and (c) there were no patterns of maternal or infant interactive behavior that were unique to the PD, MDD, or control groups. These results are discussed in light of mothers' risk status, receipt of treatment, severity of illness, and comorbidity of PD and MDD.     

Clinical Experiences in Using Cognitive-Behavior Therapy to Treat Panic Disorder

Although there is a growing body of research to support the use of psychological treatments for specific disorders, there has been no way for practitioners to provide feedback to researchers on the barriers they encounter in implementing these treatments in their day-to-day clinical work. In order to provide practitioners a means to give researchers information about their clinical experience, the Society of Clinical Psychology and the Division of Psychotherapy of the American Psychological Association collaborated on an initiative to build a two-way bridge between practice and research. A questionnaire was developed on the therapist, patient, and contextual variables that undermine the effective use of CBT in reducing the symptoms of panic disorder, a clinical problem that occurs frequently in clinical practice and has an extensive research base. An Internet-based survey was advertised internationally in listservs and professional newsletters, asking clinicians to indicate all aspects of CBT that they used in treating panic disorder, and to respond to a series of questions with variables that presumably limited successful symptom reduction in clinical work using CBT to treat panic disorder. The final database included responses from 338 participants who varied in experience in applying CBT to the treatment of panic disorders. Participants identified a wide range of patient factors that were barriers to symptom reduction, including symptoms related to panic, motivation, social system, and the psychotherapy relationship, in addition to specific problems with implementing CBT for the treatment of panic disorder.