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.     

Respiratory symptoms and panic in the National Comorbidity Survey: a test of Klein's suffocation false alarm theory

According to suffocation false alarm theory (Arch. Gen. Psychiatry 50 (1993) 31), respiratory symptoms are the symptoms that best distinguish the panic attacks of individuals with panic disorder (PD) from those of individuals without PD. Using National Comorbidity Survey data from those 609 respondents who had lifetime histories of panic attacks or PD, we tested this prediction. Neither respiratory symptom (smothering; dyspnea) strongly differentiated between respondents with PD and those with only panic attacks. Respiratory symptom endorsement was unrelated to PD when the number of other symptoms endorsed was controlled; furthermore, respiratory symptoms had slight effect sizes and were not included in a multivariate context. In contrast, fear of dying had the largest effect size, an association with PD that persisted after control for other symptom endorsement, and a continuing importance in multivariate analyses. Strikingly, panic attack respondents who reported having had only one panic attack were as likely as PD respondents to report respiratory symptoms during panic. These findings, although based on retrospective self-report and thus subject to recall bias, are inconsistent with the hypothesis that respiratory symptoms during panic have diagnostic significance.     

Competitive Memory Training (COMET) for Panic and Applied Relaxation (AR) Are Equally Effective in the Treatment of Panic in Panic-Disordered Patients

While various psychological interventions, among them Applied Relaxation (AR), are effective in treating patients with panic disorder, there is still room for improvement. Competitive Memory Training (COMET) is a transdiagnostic intervention, slightly different variants of which have proven to be successful in several psychopathological conditions in different patient populations. The objective of this study is to compare the effectiveness of COMET for panic disorder with AR in a group of panic-disordered patients (with or without agoraphobia) in a routine clinical setting. A total of 143 panic-disordered patients were randomized over two (group) treatment conditions: seven sessions of AR, or seven sessions of COMET. Measurements were made at pre- and post intervention. Both treatments resulted in significant amelioration of panic and phobic symptoms; this beneficial effect was relatively large for the primary outcome measure. However, there were no significant differences between the two treatments for any of the outcome measures. COMET and AR appear to be equally effective in treating panic in panic-disordered patients.     

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.     

A Pilot Randomized Clinical Trial of a Novel,Culturally Adapted,Trauma-Focused Cognitive-Behavioral Intervention for War-Related PTSD in Iraqi Women

Trauma-focused cognitive-behavioral therapy (TF-CBT), broadly, is one of the leading evidence-based treatments for youth with posttraumatic stress disorder (PTSD). Generally, few culturally adapted TF-CBT interventions have been examined among war trauma-affected populations in low- and middle-income countries. Using a randomized clinical trial design, a total of 48 war trauma-exposed women in Iraq, M_age (SD) = 32.91 (5.33), with PTSD were randomly assigned to either TF-CBT or wait-list control (WLC) conditions. The intervention group received 12 individual weekly sessions of a culturally adapted TF-CBT intervention. Significant reductions in PTSD symptom severity were reported by women in the TF-CBT condition from pre- to posttreatment. Women in the TF-CBT condition reported significantly greater reductions in PTSD symptoms compared to WLC at 1-month follow-up. Additionally, levels of depression, anxiety, stress, and use of maladaptive emotion regulation strategies were significantly lower in the TF-CBT condition at posttreatment and 1-month follow-up, compared to the WLC condition. Women in the TF-CBT condition also reported significant improvements in various domains of quality of life at posttreatment and 1-month follow-up. This clinical trial provides preliminary cross-cultural support for the feasibility and efficacy of TF-CBT for the treatment of PTSD symptoms among women in non-Western cultures. Future directions and study limitations are discussed.     

Cognitive behavior therapy vs exposure in vivo in the treatment of panic disorder with agoraphobia (corrected from agrophobia)

Seventy-three psychiatric outpatients with DSM-IV diagnosis of panic disorder with agoraphobia were assessed with a battery of independent assessor, self-observation, self-report and behavioral measures before and after therapy, and at a 1-yr follow-up. They were randomly assigned to Exposure in vivo (E; n = 25), Cognitive Behavior Therapy (CBT; n = 26), or a Wait-list control (WLC; n = 22) and received 12-16 individual therapy sessions, once weekly. The treatments yielded significant improvements, both on panic/agoraphobia measures and on measures of general anxiety, depression, social adjustment and quality of life, which were maintained at follow-up. However, there were no significant differences between E and CBT. The three criteria of clinically significant improvement were achieved by 67% of the E-patients and 79% of the CBT-patients at post-treatment, and 74% and 76%, respectively, at follow-up. The conclusion that can be drawn is that adding cognitive therapy to exposure did not yield significantly better results than for exposure alone.     

Sex differences in response to a panicogenic challenge procedure: an experimental evaluation of panic vulnerability in a non-clinical sample

Epidemiological studies show that women are twice as likely as men to develop panic disorder (PD) during their lifetimes. Data from retrospective studies also suggest that women are more distressed by panic and other negative emotional states than men, and that this tendency may precede the development of PD. The present prospective study sought to expand this work by evaluating sex differences in the predisposition to panic in individuals without PD or other forms of psychopathology. Participants (N=96; 52 women) were exposed to 12 panicogenic inhalations of 20% CO2-enriched air while physiological (e.g., heart rate, electrodermal response, Frontalis EMG) and self-report (e.g., subject distress, fear, frequency and severity of DSM-IV panic symptoms) response domains were monitored. As expected, magnitude of autonomic responding failed to reliably discriminate between women and men. Yet, women reported more fear and panic immediately following the challenge procedure relative to men, and this sex difference persisted when assessed again 30 min post-challenge. Implications of these results are discussed broadly in the context of biopsychosocial accounts of sex differences in the clinical presentation of PD.     

Treating Anti-social Behavior in Adolescents: A Comparison of Multi-modal and Psychodynamic Oriented Group Interventions

This study compared the efficacy of a multimodal intervention (MMI) and a psychodynamic oriented group intervention (POGI) on antisocial behavior among Nigerian adolescents. A pretest-posttest design was used. Forty-one adolescents drawn from the streets of a Nigerian city (N =20), and a state child correction facility (N=21) participated in the study. The children were randomly assigned to a MMI, POGI and waiting list control (WLC) groups. Ages ranged from 10 to 18 years (mean =14.5; SD=2.1). Data collected were analyzed using multiple group comparison procedures. Results showed that MMI significantly reduced self-reported antisocial behavior of the adolescents as compared to WLC and POGI, respectively. A multimodal intervention approach appears to be more effective in treating antisocial behavior in adolescents than a psychodynamic oriented group intervention.     

Avoidant coping in panic disorder: a yohimbine biological challenge study

Few studies have addressed whether the use of avoidance-oriented coping strategies is related to the development of panic in patients with panic disorder(PD). Self-report, clinician-rated, and physiological data were collected from 42 individuals who participated in a yohimbine biological challenge study, performed under double-blind, placebo-controlled conditions. Participants included 20 healthy controls and 22 currently symptomatic patients who met DSM-IV-TR diagnostic criteria for PD. Consistent with prediction, patients with PD who had higher perceived efficacy of avoidance-oriented strategies in reducing anxiety-related thoughts reported increased severity in panic symptoms during the yohimbine challenge condition as compared to the placebo. Further, patients with PD who had more fear of cognitive dyscontrol, cardiovascular symptoms, and publicly observable anxiety also reported increased severity in panic symptoms during the challenge. Healthy controls who had more fear of cardiovascular symptoms similarly reported increased severity in panic symptoms during the challenge. No effects were found for heart rate response to the challenge agent. These results provide support for the role of avoidance-oriented coping strategies and fear of anxiety-related symptoms as risk and maintenance factors in the development of panic symptoms, particularly within a biological challenge model.     

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.     

Responses to symptom induction exercises in panic disorder

Exposure to panic symptoms (interoceptive exposure) is often included as part of treatment for panic disorder (PD), although little is known about the relative effects of particular symptom induction exercises. This study describes responses of individuals with PD and nonclinical controls to 13 standard symptom induction exercises and 3 control exercises. Generally, individuals with PD responded more strongly to symptom induction exercises than did controls. The exercises producing the most fear included spinning, hyperventilation, breathing through a straw, and using a tongue depressor. This study also reports findings regarding specific symptoms triggered by each exercise, the percentage of participants reporting fear during each exercise, and predictors of fear.     

Avoidant coping in panic disorder: a yohimbine biological challenge study

Abstract

Few studies have addressed whether the use of avoidance-oriented coping strategies is related to the development of panic in patients with panic disorder(PD). Self-report, clinician-rated, and physiological data were collected from 42 individuals who participated in a yohimbine biological challenge study, performed under double-blind, placebo-controlled conditions. Participants included 20 healthy controls and 22 currently symptomatic patients who met DSM-IV-TR diagnostic criteria for PD. Consistent with prediction, patients with PD who had higher perceived efficacy of avoidance-oriented strategies in reducing anxiety-related thoughts reported increased severity in panic symptoms during the yohimbine challenge condition as compared to the placebo. Further, patients with PD who had more fear of cognitive dyscontrol, cardiovascular symptoms, and publicly observable anxiety also reported increased severity in panic symptoms during the challenge. Healthy controls who had more fear of cardiovascular symptoms similarly reported increased severity in panic symptoms during the challenge. No effects were found for heart rate response to the challenge agent. These results provide support for the role of avoidance-oriented coping strategies and fear of anxiety-related symptoms as risk and maintenance factors in the development of panic symptoms, particularly within a biological challenge model.     

Internet-based treatment for panic disorder

Increasingly, the internet is being used as a source of mental health information as well as structured treatment programs for people with mental health concerns or problems. The present review focuses mainly on research conducted at the University of Ballarat in Australia, and Uppsala University in Sweden, on internet-based treatment for panic disorder, one of the more common and disabling anxiety disorders. Our studies suggest that internet-based cognitive behavioural therapy is an effective intervention for panic disorder, and that it is more effective than some other self-help therapies. We have found that this mode of intervention is associated with clinically significant change, improved psychological well-being and functioning, and low participant attrition, provided that timely, limited therapist assistance is also provided. This review also discusses treatment credibility and participant satisfaction, as well as assessment and crisis management issues. Although promising as a form of intervention, there is a need for more research on the efficacy of internet-based treatment for PD and on comparisons with evidence-based face-to-face therapies.     

Cognitive-Behavioral Therapy for Insomnia Co-Morbid with Hearing Impairment: A Randomized Controlled Trial

The purpose of the current study was to examine the effects of cognitive behavior therapy (CBT-I) for insomnia on patients with insomnia co-morbid with hearing impairment. A randomized controlled design was used with a 3-month follow-up. Thirty-two patients with insomnia co-morbid with hearing impairment were randomized to either CBT-I or a waitlist condition (WLC). The primary outcome was insomnia severity. Secondary outcomes were sleep diary parameters, dysfunction, anxiety, and depression. Compared to WLC, CBT-I resulted in lower insomnia severity at post-treatment and at follow-up (d = 1.18–1.56). Relative to WLC, CBT-I also led, at both assessment points, to reduced total wake time (d = 1.39) and increased sleep restoration (d = 1.03–1.07) and sleep quality (d = 0.91–1.16). Both groups increased their total sleep time, but no significant group difference emerged. Compared to WLC, CBT-I resulted in higher function (d = 0.81–0.96) and lower anxiety (d = 1.29–1.30) at both assessment points. Neither CBT-I nor WLC led to improvement on depression. Based on the Insomnia Severity Index, more CBT-I (53–77%) than WLC participants (0–7%) were treatment responders. Also, more CBT-I (24%) than WLC participants (0%) remitted. In patients with insomnia co-morbid with hearing impairment, CBT-I was effective in decreasing insomnia severity, subjective sleep parameters, dysfunction, and anxiety. These findings are in line with previous results on the effects of CBT-I in other medical conditions.     

Effects of a Self-Help Program on Depressed Mood for Women with an Unfulfilled Child Wish

This randomized controlled trial aimed to examine the effectiveness of a cognitive behavioral self-help program (CBS) with minimal coaching in improving depressed mood for women with a permanent unfulfilled child wish. Participants completed pretest, posttest, and follow-up questionnaires and were randomly allocated to CBS (n = 27) or a waiting list condition (WLC, n =27). Respondents who followed the CBS improved significantly on depression scores compared to the WLC. This positive effect remained at follow-up. This study suggests that a low-resource, low-cost self-help program could be an effective intervention in reducing depressed mood in women living with the loss of a desired child.     

Pilot Mindfulness Intervention for Children Born with Esophageal Atresia and Their Parents

A pilot mindfulness home intervention was conducted for 6 weeks among 8–12-year-old children born with esophageal atresia and their parents. Participants were randomly assigned to a waiting list control (WLC) group (n?=?8) and an experimental group (n?=?12). When all participants had completed the mindfulness-based program, data were pooled and treated for the entire sample (n?=?19). Self-assessment measures included the Mindful Attention Awareness Scale for Adolescents (MAAS-A), the Child and Adolescent Mindfulness Measure (CAMM), the modified Spielberger State-Trait Anxiety Inventory—Child (STAI-C), the Children’s Depression Inventory (CDI), and the Cognitive Emotion Regulation Questionnaire Kids version (CERQ-k). Parental assessment measures included the modified STAI-C. The results underlined the program’s feasibility and acceptability. Clinical effects of the mindfulness-based program were observed. Self-assessed data for children who had practiced mindfulness compared to the WLC group showed increased mindfulness and decreased depression. Reduced anxiety was found in all groups. Positive affect tended to improve from pre-test to post-test in children who had practiced mindfulness compared to the WLC group. Parental assessments showed significant improvement in positive affect and decreases in anxiety and negative affect in the intervention group compared to the WLC group. Cognitive emotion regulation strategies were also affected by the mindfulness-based program. Rumination scores significantly decreased from pre-test to post-test in the intervention group. This preliminary study suggests that regular mindfulness practice presents a promising approach to reducing the burden of this neonatal malformation.     

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.     

Is panic a unique emotional experience?

The establishment of Panic Disorder (PD) as a distinct diagnostic category stems largely from the conceptualization of panic as a phenomenon qualitatively different from severe levels of anxiety. The current study utilized patients with Generalized Anxiety Disorder (GAD) and Obsessive Compulsive Disorder (OCD) as comparison groups to examine the validity of this conceptualization. Seventeen PD, 29 OCD, and 12 GAD patients completed self-report inventories from which a panic factor was derived. Controlling for level of overall anxiety, the total panic factor was rated significantly higher by the PD group. A cluster of symptoms emerged which differentiated the PD group from the other two groups. The panic items and total score were correlated with total levels of state and trait anxiety but correlations were generally low, accounting for a limited amount of the total variance. Results were interpreted as providing only equivocal support for viewing panic as a separate dimension apart from high levels of general anxiety. A discussion of conceptual issues is presented.     

Panic disorder and suicide attempt in the National Comorbidity Survey

Clinical and some epidemiological data conflict concerning the likelihood of suicide attempt in individuals with panic disorder (PD). The purpose of this study was to illuminate the panic disorder-suicide attempt association in the National Comorbidity Survey (NCS; R. C. Kessler et al., 1994). Specifically, suicide attempt histories of those 5,872 respondents answering "yes" or "no" to the suicide attempt question were regressed against lifetime diagnostic histories. Lifetime PD history, in the presence of other disorders, was unrelated to elevated risk of suicide attempt and did not account for additional variance. PD respondents who had made a suicide attempt were characterized by Comorbidity. Epidemiological respondents with lifetime histories of PD alone are not at heightened risk for self-reported suicide attempt.