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)

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

Panic Disorder

Diagnostic Considerations

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

Panic Disorder

• Recurrent unexpected panic attacksCriterion 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

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)

Common Catastrophic Thoughts Common Catastrophic Thoughts in Panic Disorderin 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 don’t 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

Alarm ReactionRapid heart rate, heart palpitations

Shortness of breath, smothering sensationsChest pain or discomfort, numbness or tingling

Increased anxiety and fearCatastrophic misinterpretations

of symptoms

Hypervigilance to symptomsAnticipatory anxiety

Memory of past attacks

Cognitive-Behavioral Model of Panic Disorder Stress

Biological Diathesis

ConditionedFear of

Somatic Sensations

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.

Elements of Cognitive Behavior Therapy

for Panic Disorder

Core Elements of CBT

• Psychoeducation/ Informational intervention• Cognitive interventions• Interoceptive (internal) exposure• In vivo exposure

• Can be delivered in individual or group treatment formats

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

Cognitive Restructuring - General

• Identify the nature of thoughts: they don’t have to be true to affect emotions

• Learn about common biases in thoughts

• Treat thoughts as “guesses” or “hypotheses” about the world

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

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?”)

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).

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

Uh oh!What if:

•This gets worse?•I lose control?

•This is a stroke?

I have to control this!

Panic Cycle Relative Comfort

•Notice the sensation

•Do nothing to control it.

•Relax WITH the sensation

Learning Safety in Panic

Interoceptive exposure • Feared sensations become safe sensations

– in the office with the therapist– at home– independent of the treatment context

Situational Exposures

• Rationale: – Providing a new learning opportunity to

examine negative predictions about feared outcomes

– Increasing tolerance to internal sensations in feared situations

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)

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

CBT for Panic DisorderCBT for Panic Disorder

And it is acceptable, tolerable, and cost effective

Meta-Analytic Results of Panic Disorder Treatment Studies

CBT Benzo-diazepines

Effe

ct S

ize

(Coh

en’s

d)

CBT(IE+CR)

Non-SSRIAntide-

pressants

SSRIsAntide-

pressants

Gould et al, 1995; Otto et al., 2001

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)

Treatment Acceptability (dropout rates)

Perc

ent D

ropo

ut

Treatment AcceptabilityRefusal Rate in the Multicenter Panic Trial

1

34

0

5

10

15

20

25

30

35

CBT Imipramine

Hofmann SG, et al. Am J Psychiatry. 1998;155:43-47.

Treatment

Perc

ent

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

Panic Disorder: Panic Disorder: Continuation TreatmentContinuation Treatment

0

10

20

30

40

50

60

CBT + imipramineCBT + placeboCBTImipraminePlacebo

% R

espo

nder

s (4

0%

PDSS

)

Barlow DH, et al. JAMA. 2000;283:2529-2536.

Maintenance (ITT) 6 More Months

Panic Disorder:Panic Disorder: PostPost––Imipramine DiscontinuationImipramine Discontinuation

0

10

20

30

40

50

60

CBT + imipramineCBT + placeboCBTImipraminePlacebo

% R

espo

nder

s (4

0%

PDSS

)

Barlow DH, et al. JAMA. 2000;283:2529-2536.

6 Months Treatment Discontinuation (ITT)

(Imipramine over 1 to 2 weeks)

Panic Disorder: After 8 Weeks of Treatment

-0.1

0.1

0.3

0.5

0.7

0.9

1.1

1.3 EXP + ALPEXP + PBOALP + Relax

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.1993;162:776-787.

Panic Disorder: Post Benzodiazepine Discontinuation (Week 18)

-0.3

-0.1

0.1

0.3

0.5

0.7

0.9

1.1

1.3 EXP + ALPEXP + PBOALP + Relax

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.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

11Otto MW et al. Otto MW et al. Psychopharmacol BullPsychopharmacol Bull. 1992;28:123-130. . 1992;28:123-130. 22Spiegel DA et al. Spiegel DA et al. Am J PsychiatryAm J Psychiatry. 1994;151:876-881.. 1994;151:876-881.33Schmidt NB et al. Schmidt NB et al. Behav Res TherBehav Res Ther. 2002;40:67-73.. 2002;40:67-73.44Whittal ML et al. Whittal ML et al. Behav Res TherBehav Res Ther. 2001;39:939-945.. 2001;39:939-945.

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

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. 2001;32:725-738.

Preventive Treatment

13.6

1.8

0

5

10

15

20

25Wait ListWorkshop

% D

evel

opin

g Pa

nic

Dis

orde

r

121 Participants

Gardenswartz CA, Craske MG. Behav Ther. 2001;32:725-738.

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. 1998;66:231-239.