CBT of PD(A)

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CBT of PD(A)

• Maureen L. Whittal, Ph.D.
• Adam Chodkiewicz, M.D.
• UBC Hospital
• September, 2006

2
Factoids

• Lifetime prevalence is between 2-6
• Mean age of onset 23-29 yoa
• Typically seek treatment around 34 yoa
• Most report a stressor prior to onset
• 21 femalemale for PD and 31 for PDA

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Treatment

• Not surprisingly, individual treatment is thought
  to be better than group treatment
• Efficacy not impacted by co-morbid depression

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Efficacy of CBT for PD(A)

• 76 of completers are panic free after 11
  sessions of therapy and 78 remain so at 2-year
  f/u with a 10 attrition rate
• 52 panic free and no excessive anxiety and 66
  at f/u

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The caveats

• Panic free decreases as agoraphobia increases
  (most studies exclude those with severe
  agoraphobia)
• Agoraphobia more difficult than PD (12 sessions
  with 17 attrition results in 50 with
  substantial improvement at post and 59 at f/u).

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More caveats

• 1/3 of those who were panic free at 24 months
  reported a panic attack in the previous year
• 27 received additional treatment for panic
• Highly selected settings and samples

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Multisite comparative trial for tx of PDA

• 312 patients treated between 1991-98
• 5 groups IMI only, CBT only, placebo, CBT
  placebo, CBT IMI
• 3 mths of tx, 6 months of maintenance, tx d/c,
  f/u 6 mths later
• IMI and CBT and combo tx sig better than placebo
  after acute phase

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Multisite (2)

• Combo not better than either indiv tx
• Those taking IMI were less depressed after acute
  tx
• At end of maintenance phase all tx sig better
  than placebo
• Combo slightly better than indiv tx but not much
  better than CBT placebo

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Multisite (3)

• 6 mths after d/c tx CBT or CBT placebo doing
  sig better than those who had taken IMI

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Assessment of PD(A)

• Anxiety Sensitivity Index (ASI)
• Mobility Inventory (MI)
• Panic Disorder Severity Scale (PDSS)

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Components of treatment

• Education
• Somatic Management
• Cognitive Restructuring
• Exposure
• Relapse prevention

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The fear of fear model
Alarm reaction
Uh-oh reaction
Heart rate sweating dizziness depersonalization so
b chest pain etc.
Whats wrong?!? Whats happening? What if
I ..have a heart attack? ..embarrass
myself? ..go crazy? ..lose control?
memories

Increased bodily sensations
Anxiety/fear hurry up/tense up (get out)
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Maintaining factors

• Agoraphobic avoidance
• Anticipatory anxiety

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Somatic Management

• Diaphagramatic Breathing
• Progressive Muscle Relaxation
• Cued Relaxation

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Is it necessary?

• Some suggest that DB and PMR amount to avoidance

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Exposure

• Interoceptive exposure
• Naturalistic exposure
• In-vivo exposure

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Interoceptive exposure

• Straw breathing
• Headrolling/spinning
• Stair running
• Hyperventilation
• Hand staring
• Throat constriction

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Naturalistic exposure

• Caffeine
• Alcohol
• Exercise
• Sex
• Sauna/whirlpool
• Suspense/scary movies
• Getting overheated

• Showering with the door closed
• Amusement park rides
• Eating certain foods
• Sugar
• Allowing self to become hungary

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In-vivo exposure

• Common situations include bridges, malls,
  theatres
• Use Mobility Inventory to assist in hierarchy
  construction
• Watch for use of safety signals

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Safety signals

• Medication
• Cell phone
• Vomit bag
• Paper bag for rebreathing
• Alcohol
• Water
• Comfort person

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Cognitive Restructuring

• Catastrophizing
• Overestimating

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The need for a downward arrow

• What if I faint?
• Ill make a fool of myself
• Catastrophizing

• What if I faint?
• I wont wake up
• Overestimating

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Catastrophizing

• Definition predicting the outcome of events to
  be much worse than they actually are mountain
  out a molehill
• Egs. What if I embarrass myself (social)
• Challenge (1) Imagine the worst (2) critically
  analyze it (3) hassle or horror (4) will it
  change my life (5) can I cope?

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Overestimating

• Definition Overestimating the probability of
  something negative happening
• Egs What if I have a heart attack? What if I
  die?
• Challenge (1) Treat the thought as a hypothesis
  (2) Review evidence for and against the thought
  (3) Conclusion that is based upon the evidence.

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Being careful with yourself

• Purposely trying to keep stress low by
• getting enough sleep
• not taking on too much
• avoiding confrontation
• Generally treating self like a china doll

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The subtlety of distraction

• Can look the same as avoidance
• Intention is everything

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Relapse Prevention

• Education and the importance of motivation
• Differentiating between panic attacks and panic
  disorder
• Identifying red flags
• How to prevent relapse review of skills

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The use of metaphor

• Used throughout treatment of panic to illustrate
  
• anticipatory anxiety
• relationship between self-statements and mood
• Making use of all available opportunities

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Making a case for medication discontinuation

• Patients attribute success to meds which
  decreases sense of self-confidence
• Medication as safety signal
• Blocking of physical symptoms interferes with IE
• Symptoms experienced during a taper may
  precipitate a panic and relapse

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Nocturnal panic

• Approximately 25 will experience it
• First symptom upon awakening is split almost
  evenly between somatic and cognitive
• Tend to occur in non-REM sleep most often in
  late stage 2 and early stage 3 slow-wave sleep

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A model of nocturnal panic

• Panic patients who were told that autonomic
  changes during the night were expected and not
  dangerous experienced sig. less anxiety, panic,
  and woke abruptly sig. more than a comparable
  group not given the reassurance.
• Possible to detect and interpret sx in SWS