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Cognitive Behavioral Treatment of Panic Disorder

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Cognitive Behavioral Treatment of Panic Disorder The original version of these s was provided by Michael W. Otto, Ph.D. & Heather W. Murray, Ph.D., – PowerPoint PPT presentation

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Title: Cognitive Behavioral Treatment of Panic Disorder


1
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)

2
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

3
Panic Disorder
  • Diagnostic Considerations

4
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

5
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

6
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

7
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)

8
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 dont escape, 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

9
(No Transcript)
10
Cognitive-Behavioral Model of Panic Disorder
Stress Biological Diathesis
Alarm Reaction Rapid heart rate, heart
palpitations Shortness of breath, smothering
sensations Chest pain or discomfort, numbness or
tingling
Increased anxiety and fear
Catastrophic misinterpretations of symptoms
Conditioned Fear of Somatic Sensations
Hypervigilance to symptoms Anticipatory
anxiety Memory of past attacks
11
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.

12
  • Elements of
  • Cognitive Behavior Therapy
  • for Panic Disorder

13
Core Elements of CBT
  • Psychoeducation/ Informational intervention
  • Cognitive interventions
  • Interoceptive (internal) exposure
  • In vivo exposure
  • Can be delivered in individual or group treatment
    formats

14
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

15
Cognitive Restructuring - General
  • Identify the nature of thoughts they dont have
    to be true to affect emotions
  • Learn about common biases in thoughts
  • Treat thoughts as guesses or hypotheses about
    the world

16
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

17
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?)

18
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.e., dizziness, increased
    heart rate).

19
Common Interoceptive Exposure Procedures
  • Headrolling 30 seconds - dizziness,
    disorientation
  • Hyperventilation 1 minute - produces dizziness
    lightheadedness, numbness, tingling, hot flushes,
    visual distortion
  • Stair running a few flights produces
    breathlessness, a pounding heart, heavy legs,
    trembling
  • Full body tension 1 minute produces
    trembling, heavy muscles, numbness
  • Chair spinning several times around produces
    strong dizziness, disorientation
  • Mirror (or hand) staring 1 minute produces
    derealization

20
Dizziness
Relative Comfort
Panic Cycle
  • Uh oh!
  • What if
  • This gets worse?
  • I lose control?
  • This is a stroke?
  • I have to control this!
  • Notice the sensation
  • Do nothing to control it.
  • Relax WITH the sensation

21
Learning Safety in Panic
  • Interoceptive exposure
  • Feared sensations become safe sensations
  • in the office with the therapist
  • at home
  • independent of the treatment context

22
Situational Exposures
  • Rationale
  • Providing a new learning opportunity to examine
    negative predictions about feared outcomes
  • Increasing tolerance to internal sensations in
    feared situations

23
Situational Exposure Guidelines
  • Prior to completing in-vivo exposures, create a
    fear hierarchy identifying feared and avoided
    situations
  • Identify safety behaviors- actions taken to
    avoid, prevent, or manage a potential threat
  • Avoidance
  • Checking (pulse, exits, hospitals)
  • Carrying aids (rescue medications, cellular
    phones)

24
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

25
CBT for Panic Disorder
  • And it is acceptable, tolerable, and cost
    effective

Works!
26
Meta-Analytic Results of Panic Disorder
Treatment Studies
CBT(IECR)
CBT
Benzo-diazepines
SSRIsAntide-pressants
Non-SSRIAntide-pressants
Effect Size (Cohens d)
Gould et al, 1995 Otto et al., 2001
27
CBT for Panic Disorder
  • In addition to core panic, anxiety, and avoidance
    outcomes, CBT has broader-based benefits,
    including
  • Improvements in quality of life
  • Improvement in comorbid conditions

(e.g., Allen et al., 2010 Telch et al., 1995
Tsao et al., 1998)
28
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29
Treatment Acceptability (dropout rates)
Table 1. Treatment Acceptability as assessed by
drop-out rates in controlled trials  
Percent Dropout
30
Treatment Acceptability
  • Refusal Rate in the Multicenter Panic Trial

Percent
Treatment
Hofmann SG, et al. Am J Psychiatry.
199815543-47.
31
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

32
Panic Disorder Continuation Treatment
Responders (40 ? PDSS)
Maintenance (ITT) 6 More Months
Barlow DH, et al. JAMA. 20002832529-2536.
33
Panic Disorder PostImipramine Discontinuation
Responders (40 ? PDSS)
6 Months Treatment Discontinuation (ITT)
(Imipramine over 1 to 2 weeks)
Barlow DH, et al. JAMA. 20002832529-2536.
34
Panic Disorder After 8 Weeks of Treatment
Effect Size (CGI relative to PR)
EXP exposure treatment. ALP alprazolam
treatment. PBO placebo treatment. Relax
relaxation treatment. Marks IM et al. Br J
Psychiatry.1993162776-787.
35
Panic Disorder Post Benzodiazepine
Discontinuation (Week 18)
Effect Size (CGI relative to PR)
EXP exposure treatment. ALP alprazolam
treatment. PBO placebo treatment. Relax
relaxation treatment. Marks IM et al. Br J
Psychiatry.1993162776-787.
36
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.
199228123-130. 2Spiegel DA et al. Am J
Psychiatry. 1994151876-881. 3Schmidt NB et al.
Behav Res Ther. 20024067-73. 4Whittal ML et al.
Behav Res Ther. 200139939-945.
37
Greater success with a novel combination strategy
  • Combination of CBT with the putative memory
    enhancer, d-cycloserine
  • 2 small treatment trials suggest that
    d-cycloserine helps consolidate therapeutic
    learning from exposure, helping speed treatment
    outcome
  • Similar benefits for d-cycloserine exposure is
    seen for other anxiety disorders

38
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, Craske MG. Behav Ther.
200132725-738.
39
Preventive Treatment
Developing Panic Disorder
121 Participants
Gardenswartz CA, Craske MG. Behav Ther.
200132725-738.
40
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. J Consult Clin Psychol.
199866231-239.
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