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 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

10. 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 Hypervigilance to symptoms Anticipatory anxiety Memory of past attacks Cognitive-Behavioral Model of Panic Disorder Stress Biological Diathesis Conditioned Fear of Somatic Sensations

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 don’t 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. 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

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

26. Meta-Analytic Results of Panic Disorder Treatment Studies CBTBenzo- diazepines Effect Size (Cohen’s d) CBT (IE+CR) Non-SSRI Antide- pressants SSRIs Antide- pressants 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)

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

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) Barlow DH, et al. JAMA. 2000;283:2529-2536. Maintenance (ITT) 6 More Months

33. Panic Disorder: Post–Imipramine Discontinuation % Responders (40%  PDSS) Barlow DH, et al. JAMA. 2000;283:2529-2536. 6 Months Treatment Discontinuation (ITT) (Imipramine over 1 to 2 weeks)

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.1993;162:776-787.

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.1993;162:776-787.

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 benzodiazepines 1,2 –Treatment with SSRIs 3,4 1 Otto MW et al. Psychopharmacol Bull. 1992;28:123-130. 2 Spiegel DA et al. Am J Psychiatry. 1994;151:876-881. 3 Schmidt NB et al. Behav Res Ther. 2002;40:67-73. 4 Whittal ML et al. Behav Res Ther. 2001;39:939-945.

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. 2001;32:725-738.

39. Preventive Treatment % Developing Panic Disorder 121 Participants Gardenswartz CA, Craske MG. Behav Ther. 2001;32:725-738.

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. 1998;66:231-239.