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Treatment of Panic Disorder Lecture Overview. Nature and epidemiology Etiology Empirically-supported treatments Efficacy data Moderator variables Class discussion. Epidemiology of Panic Disorder. Defining features Unexpected panic attacks. Distinguishing Features of Panic Attacks.

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Treatment of Panic DisorderLecture Overview

  • Nature and epidemiology

  • Etiology

  • Empirically-supported treatments

  • Efficacy data

  • Moderator variables

  • Class discussion

Behavior Therapy Class


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Epidemiology of Panic Disorder

  • Defining features

    • Unexpected panic attacks

Behavior Therapy Class


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Distinguishing Featuresof Panic Attacks

  • Intensity

  • Sudden onset

  • Unexpected nature

  • *Urge to flee

  • Feeling of impending doom

  • Four or more “key symptoms”

Behavior Therapy Class


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Panic Attack Symptoms

  • Shortness of breath or smothering sensations

  • Dizziness or unsteadiness

  • Heart racing or pounding

  • Trembling or shaking

  • Sweating

  • Feelings of choking (feeling throat constrict)

Behavior Therapy Class


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Panic Attack Symptoms Cont.

  • Nausea or abdominal distress

  • Numbness or tingling sensations

  • Chest pain or discomfort

  • Feelings of unreality

  • Feeling of dying

  • Feeling of going crazy or losing control

Behavior Therapy Class


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Epidemiology of Panic Disorder

  • Defining features

    • Panic-related apprehension

      • Persistent worry about having more attacks

      • Unrealistic concern about the consequences of panic attacks

      • Changes in behavior to cope with fear of mpanic (safety behaviors)

Behavior Therapy Class


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Panic-Related Appraisals(Telch et al, 1989)

  • Perceived negative consequences of panic attacks

    • Physical

    • Social

    • Loss of control/mental illness

    • *Functional incapacitation

Behavior Therapy Class


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Panic-Related Appraisals(Telch et al, 1989)

  • Overestimate the likelihood of panic occurrence

  • Underestimate one’s ability to cope with panic

  • Exaggerate the negative consequences of panic attacks

Behavior Therapy Class


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Epidemiology of Panic Disorder

  • Prevalence

    • General population…………………. 3.5%*

    • Primary care………………………… 6 - 10%

    • Cardiologists………………………… 30-50%

  • Gender Distribution

    • 2 to 1 Women for PD uncomplicated

    • 4 to 1 Women for PD with agoraphobia

*Data from the National Comorbidity Study - Kessler et al, (1994)

Behavior Therapy Class


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Epidemiology of Panic Disorder

  • Onset and course

    • Onset occurs early to mid 20s

    • Course is chronic

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Consequences of Panic Disorder

  • Over utilization of medical services

  • Work social, and family disability

  • Substance abuse

  • Depression

  • Agoraphobia

Behavior Therapy Class


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What Causes Panic Disorder

Behavior Therapy Class


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Factors Associated With First Panic Attack

  • Stress

  • Drugs

  • Exercise

  • Hyperventilation

  • Relaxation/Meditation

  • Physical/Medical Conditions

Behavior Therapy Class



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“Men are disturbed not bythings but by the views which they take of them”(Epictetus, 60 A.D.)“Meanings are not determined by situations, but we determine ourselves by the meanings we give to situations”(Adler, 1931)

Behavior Therapy Class


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Cognitive Model of Panic(Clarke, 1986)

  • Panic stems from a catastrophic misinterpretation of benign bodily sensations

  • Treatment is aimed at correcting the patient’s tendency to misperceive benign bodily sensations as threatening.

Behavior Therapy Class


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Heart racing………...

Lightheadedness……

Breathlessness………

Dissociation…………

Stomach distress……

Sweating…………….

Muscle tightness……

Heart Attack

Faint

Suffocation

Insanity

Vomit

Faint

Choking

Examples of Somatic Misinterpretation

Behavior Therapy Class


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Anxiety Sensitivity Construct

“Fear of Anxiety”

(Petersen & Reiss, 1987)

“Perceived Negative Consequences of Anxiety”

(Telch et al, 1989)

Behavior Therapy Class


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Evidence Implicating Anxiety Sensitivity As a Risk Factor in Panic

  • Elevated AS in panic disorder patients relative to normal and psychiatric controls

Behavior Therapy Class


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Anxiety Sensitivity Across the Anxiety Disorders Panic

Data from Taylor et al (1992) Journal of Anxiety Disorders, 6, 249-259.

Behavior Therapy Class


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Evidence Implicating Anxiety Sensitivity As a Risk Factor in Panic

  • Elevated AS increases panicogenic response to biologic challenge

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Panic in Response to PanicCO2 Challenge

Data taken from Telch & Harrington (under review)

Behavior Therapy Class



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Evidence Implicating Anxiety Sensitivity As a Risk Factor in Panic

  • Prospective studies showing high AS increases risk for the development of panic attacks

Behavior Therapy Class


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Anxiety Sensitivity as a Risk Factor in Stress-Induced Panic Panic

Data from Schmidt et al (1999). Journal of Abnormal Psychology, 108, 532-537.

Behavior Therapy Class


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Anxiety Sensitivity and 12-Month Panic Incidence Panic

Data from Telch et al (in preparation)

Behavior Therapy Class


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12-month Incidence of Unexpected Panic by ASI Scores Panic

Data from Telch et al (in preparation)

Behavior Therapy Class


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Anxiety Sensitivity and PanicPanic-Related Apprehension

Data from Telch et al (in preparation)

Behavior Therapy Class


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Evidence Implicating Anxiety Sensitivity As a Risk Factor in Panic

  • Interventions which lower AS reduce panic in response to biological challenge

Behavior Therapy Class


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Effects of CBT on CO2 Fear Panic

Data from Jaimez & Telch (in preparation)

Behavior Therapy Class


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Effects of CBT on CO2 Panic Panic

Data from Jaimez & Telch (in preparation)

Behavior Therapy Class


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Evidence Implicating Anxiety Sensitivity As a Risk Factor in Panic

  • Changes in AS mediate the effects of CBT of panic

Behavior Therapy Class


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Role of Fear of Fear in Mediating Treatment Response Panic

Data from Telch et al (in prep)

Behavior Therapy Class


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Treatment of Panic Disorder Panic

  • Insight-oriented psychotherapies

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Treatment of Panic Disorder Panic

  • Pharmacotherapy

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Medications with Established Efficacy in Panic Disorder Panic

  • TCAs (e.g., imipramine)

  • MAOIs (e.g., phenelzine)

  • High-potency BZs (e.g., alprazolam)

  • SSRIs (e.g., paroxetine)

Behavior Therapy Class




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Major Treatment Components of CBT for Panic Disorder Panic

  • Education

    • Major Aim:

      • Provide information to enhance the patient’s knowledge concerning anxiety and panic and to reduce misconceptions that anxiety/panic are dangerous.

    • Strategy:

      • Didactic instruction and hand-outs

Behavior Therapy Class


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Major Treatment Components of CBT for Panic Disorder Panic

  • Breathing retraining

    • Major Aim:

      • Teach the patient a coping skill that can be used to: (a) prevent hyperventilation and (b) manage anxiety

    • Strategy:

      • Training in diaphragmatic breathing

Behavior Therapy Class


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Major Treatment Components of CBT for Panic Disorder Panic

  • Cognitive restructuring

    • Major Aim:

      • Teach patients to identify and correct faulty threat perceptions that are maintaining their panic/anxiety.

    • Strategy: Cognitive therapy techniques

Behavior Therapy Class


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Targets for Cognitive Intervention in Panic Disorder Panic

  • Faulty beliefs about physical sensations

  • Overestimations in the likelihood of panic occurrence

  • Faulty beliefs about the the consequences of anxiety or panic

  • Faulty beliefs about coping strategies (e.G., Safety behaviors)

  • Faulty beliefs about CBT (e.g., treatment is designed to bring on panic attacks)

Behavior Therapy Class


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Major Treatment Components of CBT for Panic Disorder Panic

  • Interoceptive exposure

    • Major Aim:

      • To reduce fear of harmless bodily sensations such as heart racing, dizziness, lightheadedness, etc.

    • Strategies:

      • Exercises designed to intentionally induce the feared sensations.

Behavior Therapy Class


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Cardiovascular sensitivity Panic

Vestibular sensitivity

Respiratory sensitivity

Dissociation sensitivity

Running in place, stair climbing, caffeine ingestion

Spinning, head shaking, saunas, alcohol ingestion

Hyperventilation, breath-holding, 35% CO2 inhalation

Starring into a mirror, hyperventilation; marijuana ingestion, D.A.V.I.D.

Examples of Interoceptive Exposure Exercises

Behavior Therapy Class


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Major Treatment Components of CBT for Panic Disorder Panic

  • In vivo exposure

    • Major Aim:

      • To reduce panic-related avoidance and agoraphobic fear

    • Strategies:

      • Therapist-assisted and self-directed practice confronting external situations (crowds, busses, long lines, etc.)

Behavior Therapy Class


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Major Treatment Components of CBT for Panic Disorder Panic

  • *Safety behavior fading.

    • Major aims:

      • To reduce the patient’s use of anxiety-maintaining safety behaviors.

    • Strategies:

      • Self-monitoring and behavioral prescriptions for gradually eliminating safety-seeking behaviors.

Behavior Therapy Class


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Summary of 20 RCTs of CBT Panicin Panic Disorder (Craske, 1999)

  • 76% of treatment completers are free of panic at posttreatment; whereas 78% are free of panic attacks at follow-up

  • Attrition rate averaged 10%

  • 50% show substantial improvement in agoraphobia (13 studies) at posttreatment; 59% at follow-up

  • Results of dismantling studies have generally found that cognitive procedures do not add significantly to the efficacy of exposure-based therapy

  • No data yet available to support treatment matching

Behavior Therapy Class


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Dismantling CBT Panic

Data from Telch et al (in prep)

Behavior Therapy Class


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Dismantling CBT Panic

Data from Telch et al (in prep)

Behavior Therapy Class


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MCC Study Panic

  • Primary aim

    • Investigate the independent and combined effects of CBT and imipramine in the treatment of panic disorder

Behavior Therapy Class


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MCC Study Panic

  • Design

    • 5-arm randomized clinical trial conducted at four sites

    • Treatment conditions

      • CBT alone

      • Imipramine alone

      • Pill placebo alone

      • CBT plus imipramine

      • CBT plus pill placebo

Behavior Therapy Class


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MCC Study Panic

  • 3 Phases of the Study

    • Acute phase (12 weeks)

    • Continuation treatment (6 months)

    • No treatment follow-up (6 months)

Behavior Therapy Class


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MCC Study Panic

  • Major Study Findings

    • Acute phase

      • All active treatments outperformed pill placebo

      • No significant differences between the active treatments

    • Continuation Phase

      • Same as acute phase

    • No treatment follow-up

      • CBT alone or CBT + placebo outperformed imipramine alone and CBT + imipramine

Behavior Therapy Class


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MCC Study Findings Panicat 12-month Follow-up

Behavior Therapy Class


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Moderators of Treatment Outcome Panic

  • Pretreatment agoraphobia severity

  • Pretreatment depression

  • Comorbid personality pathology

  • Compliance with homework

Behavior Therapy Class


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Predictors of Treatment Response at Posttreatment Panic

Data from Telch et al (in prep)

Behavior Therapy Class


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Predictors of Treatment Response at Follow-up Panic

Data from Telch et al (in prep)

Behavior Therapy Class


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CBT and Quality of Life in Panic Disorder Panic

  • Summary of major findings

    • Panic disorder exerts a marked negative effect on patients’ QOL equal to or greater than many psychiatric and medical disorders

    • Relative to non-treated controls, CBT exerted significant improvement in patients’ QOL

Behavior Therapy Class


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Effects of CBT on Quality of Life in Panic Disorder Panic

Data from Telch et al (1995). Journal of Consulting and Clinical Psychology, 63, 823-830.

Behavior Therapy Class


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CBT and Quality of Life in Panic Disorder Panic

  • Summary of major findings cont.

    • It is the panic-related anxiety and avoidance facets of the disorder that are associated with the greatest disruption in patients’ QOL

    • Changes in panic-related anxiety was the best predictor of changes in patients’ QOL.

Behavior Therapy Class


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