Treating Panic Disorder in Veterans with PTSD Ellen J. Teng, Ph.D. Michael E. DeBakey VAMC Trauma...

Treating Panic Disorder in Treating Panic Disorder in Veterans with PTSDVeterans with PTSD

Ellen J. Teng, Ph.D.Ellen J. Teng, Ph.D.

Michael E. DeBakey VAMCMichael E. DeBakey VAMC

Trauma Recovery ProgramTrauma Recovery Program

Research TeamResearch Team

Ellen J. Teng, Ph.D.Ellen J. Teng, Ph.D.Nancy J. Petersen, Ph.D.Nancy J. Petersen, Ph.D.

Sara D. Bailey, Ph.D.Sara D. Bailey, Ph.D.Joseph D. Hamilton, M.D.Joseph D. Hamilton, M.D.

Nancy Jo Dunn, Ph.D. (Mentor)Nancy Jo Dunn, Ph.D. (Mentor)

Angelic D. Chaison, M.A.Angelic D. Chaison, M.A.Katherine H. Graham, M.Ed.Katherine H. Graham, M.Ed.

Derek G. Prins, M.A.Derek G. Prins, M.A.

This research was supported by the South Central Mental Illness, Research, Education, and Clinical This research was supported by the South Central Mental Illness, Research, Education, and Clinical Center as part of the VA Special MIRECC Fellowship Program in Advanced Psychiatry and Center as part of the VA Special MIRECC Fellowship Program in Advanced Psychiatry and

PsychologyPsychology

BackgroundBackground

Panic DisorderPanic Disorder

Among one of the most debilitating and expensive anxiety disorders Among one of the most debilitating and expensive anxiety disorders in the nationin the nation

High rates of healthcare utilizationHigh rates of healthcare utilization

Occupational dysfunction & unemploymentOccupational dysfunction & unemployment

Psychosocial impairmentPsychosocial impairment

Increased rates of substance abuse & antidepressant useIncreased rates of substance abuse & antidepressant use

Background (cont’d)Background (cont’d)

What are the treatments of choice?What are the treatments of choice?

PharmacotherapyPharmacotherapy

Cognitive-behavioral therapyCognitive-behavioral therapy Panic Control Treatment (Barlow & Craske, 1994) consists of Panic Control Treatment (Barlow & Craske, 1994) consists of

education, cognitive restructuring, & interoceptive exposureeducation, cognitive restructuring, & interoceptive exposure

85 to 87% of persons treated are panic-free by the end of 85 to 87% of persons treated are panic-free by the end of treatment (Barlow et al., 1989; Klosko et al, 1995; Telch et al., treatment (Barlow et al., 1989; Klosko et al, 1995; Telch et al., 1993).1993).


So what’s the problem?So what’s the problem?

Treatment is less effective with significant psychiatric comorbidityTreatment is less effective with significant psychiatric comorbidity

Complications from comorbidity & using manualized therapyComplications from comorbidity & using manualized therapy

Increase in attrition & relapse ratesIncrease in attrition & relapse rates

Comorbidity rate of 27% for PD & PTSD based on data from Comorbidity rate of 27% for PD & PTSD based on data from National Comorbidity Study (Leskin & Sheikh, 2002)National Comorbidity Study (Leskin & Sheikh, 2002)


Why do PD and PTSD co-occur so frequently? Why do PD and PTSD co-occur so frequently?

Trauma related cues can trigger a panic attack (Sheikh et al., 1994) Trauma related cues can trigger a panic attack (Sheikh et al., 1994)

Experience of uncued panic attacks can lead to full-blown PD Experience of uncued panic attacks can lead to full-blown PD (Resnick et al., 1994)(Resnick et al., 1994)

Shared symptoms-chronic hyperarousal, hypervigilance, somatic Shared symptoms-chronic hyperarousal, hypervigilance, somatic reactivity, anxiety sensitivity (Falsetti & Resnick, 2000; Jakupcak et reactivity, anxiety sensitivity (Falsetti & Resnick, 2000; Jakupcak et al., 2006)al., 2006)

PurposePurpose

To examine the effectiveness of Panic Control Therapy (PCT) in To examine the effectiveness of Panic Control Therapy (PCT) in improving comorbid panic symptoms in veterans with a primary improving comorbid panic symptoms in veterans with a primary diagnosis of PTSD compared with a control therapydiagnosis of PTSD compared with a control therapy

HypothesesHypotheses

1.1. PCT would outperform a control therapy in reducing the PCT would outperform a control therapy in reducing the frequency, severity, & fearfulness of panic attacks.frequency, severity, & fearfulness of panic attacks.

2.2. PCT would result in a greater reduction in anxiety sensitivity and PCT would result in a greater reduction in anxiety sensitivity and improve general anxiety & depression symptoms compared to the improve general anxiety & depression symptoms compared to the control therapy.control therapy.

3.3. No change in PTSD symptoms for patients receiving either No change in PTSD symptoms for patients receiving either therapy.therapy.

MethodMethod

ParticipantsParticipants49 outpatients from the Trauma Recovery Program 49 outpatients from the Trauma Recovery Program

Overall Sample CharacteristicsOverall Sample CharacteristicsAge: Age: MM=52 years, =52 years, SDSD=8.44=8.44

14% women; 86% men14% women; 86% men

43% African American43% African American

43% Caucasian43% Caucasian

14% Hispanic14% Hispanic

MethodMethod

Inclusion Criteria: Inclusion Criteria: current PTSD diagnosis; current PTSD diagnosis; >> 1 PA in past month; 1 PA in past month; IQ IQ >> 80 80

Exclusion CriteriaExclusion Criteria: current substance dependence, mania, psychosis; : current substance dependence, mania, psychosis; severe depression; PA exclusive to specific phobias; medical severe depression; PA exclusive to specific phobias; medical conditions that mimic anxiety symptomsconditions that mimic anxiety symptoms

MaterialsMaterialsPanic Control Treatment (PCT) manualPanic Control Treatment (PCT) manual

Psychoeducational & Supportive Treatment (SUP) manualPsychoeducational & Supportive Treatment (SUP) manual

Assessment Instruments Pre-Tx Sess 1 Sess 5 Sess 10

Post-Tx

3 Mo F/U

Wechsler Test of Adult Reading *

Personality Diagnostic Quest. *

Treatment Evaluation Inventory *

Anxiety Disorders Interview Sch * * *

Posttraumatic Stress Disorder CL * * *

Anxiety Sensitivity Index * * * * * *

Beck Anxiety Inventory * * * * * *

Beck Depression Inventory * * * * * *

Panic Attack Records * * * * * *

ProcedureProcedure

DesignDesign

Blocked randomization Blocked randomization

Assessed at pre-treatment, mid-treatment, post-treatment, and a 3-Assessed at pre-treatment, mid-treatment, post-treatment, and a 3-month follow-upmonth follow-up

Both treatments delivered in weekly, 1 hr, individual sessions over a Both treatments delivered in weekly, 1 hr, individual sessions over a 10-week period10-week period

Treatments conducted by trained masters & doctoral level graduate Treatments conducted by trained masters & doctoral level graduate studentsstudents

Treatment fidelity ratings completed by independent ratersTreatment fidelity ratings completed by independent raters

ResultsResults

Primary AnalysesPrimary Analyses

A higher % of patients in PCT (63%, n=10) was panic-free at the 3-A higher % of patients in PCT (63%, n=10) was panic-free at the 3-month follow-up than the SUP group (19%, n=3), month follow-up than the SUP group (19%, n=3), 22 (1, N= (1, N=3232) = ) = 6.356.35, p, p=.01)=.01)

Means, Standard Deviations, and mixed ANOVA Source Tables Comparing Panic Control Treatment to Psychoeducational Supportive Treatment for the Intent-to-Treat Sample

Intervention Control Repeated measures ANOVA tables

Time M SD N M SD N Source dfs f p η2

Panic Severity

Pre 58.33 18.34 18 51.71 14.11 17 Time 2, 66 6.45 .16 .003

Post 41.89 18.37 56.65 21.30 Group 1, 66 1.42 .24 .04

Follow-up 36.89 18.64 44.94 22.20 Interaction 2, 66 3.84 .03 .10

Panic Fear

Pre 5.11 1.87 14 3.77 1.99 14 Time 2, 52 6.89 .002 .21

Post 2.79 3.26 2.73 2.43 Group 1, 52 .006 .94 .00


Anxiety Sensitivity Index

Pre 41.83 11.78 18 42.47 9.53 17 Time 2, 66 8.36 .001 .20

Post 29.61 14.48 40.53 13.44 Group 1, 66 3.64 .07 .10


Hamilton Anxiety Rating Scale

Pre 25.50 9.34 18 24.24 7.16 17 Time 2, 66 12.87 .28 < .001

Post 19.94 8.48 23.24 9.83 Group 1, 66 0.63 .43 .02


Beck Anxiety Inventory

Pre 37.33 10.32 18 30.35 10.48 17 Time 2, 66 1.33 .27 .04

Post 29.61 14.89 31.71 15.02 Group 1, 66 0.26 .61 .008




Hamilton Rating Scale for Depression

Pre 18.44 4.38 18 18.35 5.77 17 Time 2, 66 5.36 .007 .14

Post 15.06 4.95 17.47 9.33 Group 1, 66 1.39 .25 .04


Beck Depression Inventory-II

Pre 35.78 8.40 18 30.65 12.75 17 Time 2, 66 6.22 .003 .16

Post 29.50 13.52 25.47 12.46 Group 1, 66 0.83 .37 .03


Posttraumatic Stress Disorders Checklist

Pre 69.33 7.76 18 67.29 9.77 17 Time 2, 66 2.11 .13 .06

Post 64.56 13.37 65.41 10.94 Group 1, 66 0.01 .92 .00




Panic Control Treatment

PsychoeducationalSupportive Treatment

______________________ _____________________

Period n % n % Fisher’s Exact pIntent-to-Treat Sample (N=35)

1-week post

ASI 7 38.9 1 5.9 .04

BAI 5 27.8 1 5.9 .06

BDI 8 44.4 6 35.3 .69

HARS 7 38.9 6 37.5 .64

HRSD 8 44.4 4 25.0 .45

PCL 7 38.9 7 41.2 .38

3-month follow-up

ASI 5 27.7 2 11.8 .40

BAI 4 22.2 2 11.8 .86

BDI 7 38.9 5 29.4 .86

HARS 10 55.6 10 62.5 .44

HRSD 9 50.0 5 31.3 .23

PCL 6 33.3 7 41.2 .06

Percentage of Participants with Clinically Significant Improvement at Each Follow-up Period

Percentage of Participants with Clinically Significant Improvement at Each Follow-up Period

Panic Psychoeducational Control Treatment Supportive Treatment Period n % n % Fisher’s Exact p

Treatment Completers (n=26)1-week post

3-month follow-up

ASI 7 58.3 1 7.1 .009

BAI 4 33.3 2 14.3 .63

BDI 7 58.3 4 28.6 .31

HARS 11 91.7 9 64.3 .28

HRSD 9 75.0 5 35.7 .03

PCL 6 50.0 6 42.9 .34

ASI 8 66.7 1 7.1 .003

BAI 4 33.3 1 7.1 .13

BDI 8 66.7 5 35.7 .09

HARS 8 66.7 5 35.7 .39

HRSD 8 66.7 4 28.6 .17

PCL 7 58.3 6 42.9 .88

DiscussionDiscussion

PCT effectively reduced severity and fear of panic symptoms PCT effectively reduced severity and fear of panic symptoms compared with SUPcompared with SUP

PCT reduced the frequency of panic attacks by the 3-month follow-PCT reduced the frequency of panic attacks by the 3-month follow-upup

PCT produced significant reductions in anxiety sensitivity at post- PCT produced significant reductions in anxiety sensitivity at post- and follow-up periodsand follow-up periods

Discussion (cont’d)Discussion (cont’d)

Clinician & Self-Report RatingsClinician & Self-Report Ratings

Anxiety symptoms: both groups improved at post and follow-up Anxiety symptoms: both groups improved at post and follow-up (patient self-report indicated no improvement at either period)(patient self-report indicated no improvement at either period)

Depression symptoms: both groups improved at 3-month follow-up Depression symptoms: both groups improved at 3-month follow-up (consistent with patient self-report)(consistent with patient self-report)

By the follow-up period, 59% of both groups showed improvement in By the follow-up period, 59% of both groups showed improvement in anxiety symptoms and 41% in depressive symptomsanxiety symptoms and 41% in depressive symptoms

LimitationsLimitations

Small sample sizeSmall sample size

Service connection for PTSD may be related to disparity between Service connection for PTSD may be related to disparity between self-report & clinician ratingsself-report & clinician ratings

Sessions were unevenly dispersedSessions were unevenly dispersed

Drop-out rate was double for PCT (33%) compared with SUP (12%)Drop-out rate was double for PCT (33%) compared with SUP (12%)

Future DirectionsFuture Directions

Need to understand better the mechanisms leading to the Need to understand better the mechanisms leading to the development & maintenance of comorbid PTSD and PDdevelopment & maintenance of comorbid PTSD and PD

Compare the effectiveness of integrated treatment approaches vs. Compare the effectiveness of integrated treatment approaches vs. sequential onessequential ones

Develop briefer interventions to increase treatment acceptability and Develop briefer interventions to increase treatment acceptability and adherence for patientsadherence for patients

Treating Panic Disorder in Veterans with PTSD Ellen J. Teng, Ph.D. Michael E. DeBakey VAMC Trauma...

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