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

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Treating Panic Disorder in Veterans with PTSD

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Treating Panic Disorder in Veterans with PTSD

Ellen J. Teng, Ph.D.

Michael E. DeBakey VAMC

Trauma Recovery Program

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


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

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

    • 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).

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)

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)


  • 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


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

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

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



  • 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


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


  • Panic Control Treatment (PCT) manual

  • Psychoeducational & Supportive Treatment (SUP) manual

Assessment Instruments


Sess 1

Sess 5

Sess 10


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









  • 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


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)


  • 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

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


  • 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%)

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

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