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

2. Research Team Ellen J. Teng, Ph.D. Nancy J. Petersen, Ph.D. Sara D. Bailey, Ph.D. Joseph D. Hamilton, M.D. Nancy Jo Dunn, Ph.D. (Mentor) Angelic D. Chaison, M.A. Katherine H. Graham, M.Ed. Derek G. Prins, M.A. 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 Psychology

3. Background Panic Disorder Among one of the most debilitating and expensive anxiety disorders in the nation High rates of healthcare utilization Occupational dysfunction & unemployment Psychosocial impairment Increased rates of substance abuse & antidepressant use

4. Background (cont’d) What are the treatments of choice? Pharmacotherapy Cognitive-behavioral therapy Panic Control Treatment (Barlow & Craske, 1994) consists of education, cognitive restructuring, & interoceptive exposure Panic Control Treatment (Barlow & Craske, 1994) consists of education, cognitive restructuring, & interoceptive exposure 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., 1993). 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., 1993).

5. Background (cont’d) So what’s the problem? Treatment is less effective with significant psychiatric comorbidity Complications from comorbidity & using manualized therapy Increase in attrition & relapse rates Comorbidity rate of 27% for PD & PTSD based on data from National Comorbidity Study (Leskin & Sheikh, 2002)

6. Background (cont’d) Why do PD and PTSD co-occur so frequently? Trauma related cues can trigger a panic attack (Sheikh et al., 1994) Experience of uncued panic attacks can lead to full-blown PD (Resnick et al., 1994) Shared symptoms-chronic hyperarousal, hypervigilance, somatic reactivity, anxiety sensitivity (Falsetti & Resnick, 2000; Jakupcak et al., 2006)

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

8. Hypotheses 1.PCT would outperform a control therapy in reducing the frequency, severity, & fearfulness of panic attacks. 2.PCT would result in a greater reduction in anxiety sensitivity and improve general anxiety & depression symptoms compared to the control therapy. 3.No change in PTSD symptoms for patients receiving either therapy.

9. Method Participants 49 outpatients from the Trauma Recovery Program Overall Sample Characteristics Age: M=52 years, SD=8.44 14% women; 86% men 43% African American 43% Caucasian 14% Hispanic

10. Method Inclusion Criteria: current PTSD diagnosis; > 1 PA in past month; IQ > 80 Exclusion Criteria: current substance dependence, mania, psychosis; severe depression; PA exclusive to specific phobias; medical conditions that mimic anxiety symptoms Materials Panic Control Treatment (PCT) manual Psychoeducational & Supportive Treatment (SUP) manual

11. Assessment InstrumentsPre-TxSess 1Sess 5Sess 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******

12. Procedure Design Blocked randomization Assessed at pre-treatment, mid-treatment, post-treatment, and a 3- month follow-up Both treatments delivered in weekly, 1 hr, individual sessions over a 10-week period Treatments conducted by trained masters & doctoral level graduate students Treatment fidelity ratings completed by independent raters

13. Results Primary Analyses 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),  2 (1, N=32) = 6.35, p=.01)

14. Means, Standard Deviations, and mixed ANOVA Source Tables Comparing Panic Control Treatment to Psychoeducational Supportive Treatment for the Intent-to-Treat Sample Intervention ControlRepeated measures ANOVA tables TimeMSDNM N Sourcedfsfpη2η2 Panic Severity Pre58.3318.341851.7114.1117Time 2, 666.45.16.003 Post41.8918.3756.6521.30Group1, 661.42.24.04 Follow-up36.8918.6444.9422.20Interaction2, 663.84.03.10 Panic Fear Pre5.111.87143.771.9914Time2, 526.89.002.21 Post2.793.262.732.43Group1, 52.006.94.00 Follow-up2.323.243.902.36Interaction2, 524.67.01.15

15. Anxiety Sensitivity Index Pre41.8311.781842.479.5317Time2, 668.36.001.20 Post29.6114.4840.5313.44Group1, 663.64.07.10 Follow-up31.5014.9440.6510.87Interaction2, 664.30.02.12 Hamilton Anxiety Rating Scale Pre25.509.341824.247.1617Time2, 6612.87.28<.001 Post19.948.4823.249.83Group1, 660.63.43.02 Follow-up15.839.0219.828.91Interaction2, 662.11.13.06 Beck Anxiety Inventory Pre37.3310.321830.3510.4817Time2, 661.33.27.04 Post29.6114.8931.7115.02Group1, 660.26.61.008 Follow-up30.9415.3930.2911.47Interaction2, 662.11.13.06 Intervention ControlRepeated measures ANOVA tables TimeMSDNM N Sourcedfsfpη2η2

16. Hamilton Rating Scale for Depression Pre18.444.381818.355.7717Time2, 665.36.007.14 Post15.064.9517.479.33Group1, 661.39.25.04 Follow-up12.785.8716.416.90Interaction2, 661.33.27.04 Beck Depression Inventory-II Pre35.788.401830.6512.7517Time2, 666.22.003.16 Post29.5013.5225.4712.46Group1, 660.83.37.03 Follow-up27.7814.5127.2910.76Interaction2, 660.85.43.03 Posttraumatic Stress Disorders Checklist Pre69.337.761867.299.7717Time2, 662.11.13.06 Post64.5613.3765.4110.94Group1, 660.01.92.00 Follow-up64.0610.9866.1212.06Interaction2, 660.65.52.02 Intervention ControlRepeated measures ANOVA tables TimeMSDNM N Sourcedfsfpη2η2

17. Panic Control Treatment Psychoeducational Supportive Treatment ___________________________________________ Period n %n%Fisher’s Exact p Intent-to-Treat Sample (N=35) 1-week post ASI738.915.9.04 BAI527.815.9.06 BDI844.4635.3.69 HARS738.9637.5.64 HRSD844.4425.0.45 PCL738.9741.2.38 3-month follow-up ASI527.7211.8.40 BAI422.2211.8.86 BDI738.9529.4.86 HARS1055.61062.5.44 HRSD950.0531.3.23 PCL633.3741.2.06 Percentage of Participants with Clinically Significant Improvement at Each Follow-up Period

18. Panic Psychoeducational Control Treatment Supportive Treatment Period n % n % Fisher’s Exact p Treatment Completers (n=26) 1-week post 3-month follow-up ASI758.317.1.009 BAI433.3214.3.63 BDI758.3428.6.31 HARS1191.7964.3.28 HRSD975.0535.7.03 PCL650.0642.9.34 ASI866.717.1.003 BAI433.317.1.13 BDI866.7535.7.09 HARS866.7535.7.39 HRSD866.7428.6.17 PCL758.3642.9.88

19. Discussion PCT effectively reduced severity and fear of panic symptoms compared with SUP PCT reduced the frequency of panic attacks by the 3-month follow- up PCT produced significant reductions in anxiety sensitivity at post- and follow-up periods

20. Discussion (cont’d) Clinician & Self-Report Ratings Anxiety symptoms: both groups improved at post and follow-up (patient self-report indicated no improvement at either period) Depression symptoms: both groups improved at 3-month follow-up (consistent with patient self-report) By the follow-up period, 59% of both groups showed improvement in anxiety symptoms and 41% in depressive symptoms

21. Limitations Small sample size Service connection for PTSD may be related to disparity between self-report & clinician ratings Sessions were unevenly dispersed Drop-out rate was double for PCT (33%) compared with SUP (12%)

22. Future Directions Need to understand better the mechanisms leading to the development & maintenance of comorbid PTSD and PD Compare the effectiveness of integrated treatment approaches vs. sequential ones Develop briefer interventions to increase treatment acceptability and adherence for patients