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Cognitive Behavior and Panic Disorder


Permission graciously given by the author to reproduce this paper.

Cognitive Therapy Panic Disorder

Patricia Jindrich
2005

This paper will discuss the treatment modality of cognitive therapy as used in the treatment of panic disorder.  The paper will briefly explain what cognitive therapy is, and how it works.  The paper will also explain the symptoms of panic disorder and how panic disorder can affect the life of the sufferer. Finally the paper will examine five research articles which use cognitive therapy in the treatment of panic disorder, and report the findings of each article.

 According to The Atlanta Center for Cognitive Therapy, cognitive therapy is a therapy that is short-term usually lasting three to six months.  The emphasis in the therapy is between the therapist and his or her client.  Cognitive therapy is more focused than many other treatments.  The therapy examines thinking, perception, interpretations and meanings.  It is useful because psychological disturbances are often associated with poor habits in thinking, such as holding biased or distorted beliefs about oneself or about the world.  These automatic-thinking patterns, if they are not changed, often can limit a person’s perspective on his or her life and may lead to emotional distress.  The automatic-thinking patterns may interfere with problem solving, and result in depression, anxiety hopelessness, and relationship problems.  Cognitive therapy helps to identify maladaptive patterns and replace them with healthy ones (Atlanta Center for Cognitive Therapy, 2005).

According to the American Psychiatric Association (2000), the essential feature of panic disorder is the presence of unexpected panic attacks that reoccur and which are followed by at least one month of worry or concern about having another attack.  The criteria which must be met in order to diagnose this disorder, are as follows:

1. Recurrent unexpected panic attacks in which 4 or more of the following symptoms are present:  palpitations, pounding heart, or accelerated heart rate, sweating, trembling or shaking, sensations of shortness of breath or smothering, feeling of choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady, lightheaded or faint, derealization or depersonalization, fear of losing control or going crazy, fear of dying, paresthesias, chills or hot flashes (American Psychiatric Association, 2000).

2. At least one of the attacks as been followed by a month or more of one of the following: persistent concern about having additional attacks, worry about the implications of the attack or its consequences, significant change in behavior related to the attacks (American Psychiatric Association, 2000).

3. Absence of agoraphobia (or presence of agoraphobia if diagnosing panic disorder with agoraphobia) (American Psychiatric Association, 2000).

4. Panic attacks are not due to physiological effects of substance abuse or a medical condition (American Psychiatric Association, 2000).

5. The panic attacks are not better accounted for by another mental disorder (American Psychiatric Association, 2000).

The reviews of the five articles that follow will all look at the efficacy of cognitive therapy with regards to panic disorder.  The articles chosen all use cognitive therapy, but the cognitive therapy is paired with behavioral therapy.  The behavioral therapy many times consists of imagery and relaxation techniques, which teach the client to relax and to overcome his or her anxiety and panic.  These techniques also involve the mind-body connection.

The first article by Overholser (2000) is an overview of treatment modes which have proven efficacious for panic disorder.  The author discusses how a combination of cognitive therapy and graded exposure works well for the treatment of panic disorder.  Overholser takes the reader though the initial stages of treatment, training in coping skills, exposure to internal and external precipitants, and finally concludes by stating that cognitive therapy combined with behavioral therapy is potent in reducing both the severity and the frequency of panic attacks as well as the worry a client may have about potential future attacks.  The author states that perhaps the best model would include a blending of diverse treatments (which include cognitive therapy, relaxation training, and exposure therapy) can be highly effective treatments of panic disorder (Overholser, 2000).  This article provides an interesting initial overview of the subject of panic disorder and the treatments used to help the sufferers. 

The next article Addis (2004) describes a study done by the author in which he used as subjects eighty clients who were identified with panic disorder.  These clients were randomly assigned to treatment groups. Some of the clients received Panic Control Therapy  (PCT), which is a 12–15-session cognitive-behavioral treatment protocol. Those clients received treatment that included education, breathing retraining, cognitive restructuring, and various introceptive and agoraphobic exposure components.  The control group received treatment done by therapists who conducted therapy as usual (TAU).  These therapists were instructed to provide whatever treatment they deemed appropriate for the clients they treated. In both the TAU and PCT conditions, decisions about medication use was left up to clients, their therapists, and other medical or psychiatric providers involved. 

Which treatment a client received was decided by availability of the therapists, and the measures used were the Panic Disorder Severity Scale and the Fear Questionnaire, The Beck Depression Inventory, The Outcome Questionnaire, and The Treatment Credibility Questionnaire.

The subjects who received PCT showed greater change than those receiving TAU.  Of those subjects who completed therapy, 18.8% in TAU and 42.9 % of those who received PCT showed a significant change across all the measures.  It would appear that the Panic Control Therapy, or the therapy which had a cognitive base, was most effective.

The third article by, Smits, Powers, Cho, & Telch (2004) discusses how fear of fear may be a mediating factor in how people recover from panic disorder. The authors looked a sample of a 130 participants (99 women and 31 men). All of the participants were referred to from physicians and mental health professionals.  Forty of these subjects were assigned to a waitlist and 90 of them were given a treatment that consisted of education, cognitive therapy techniques, training in diaphragmatic breathing, interoceptive exposure exercises to reduce fear of somatic sensations, and self-directed exposure to feared situations.  The authors used Texas Panic Attack Record Form, Sheehan Patient-Rated Anxiety Scale (SPRAS), The Fear Questionnaire, The Sheehan Disability Scale, the ASI, and the BSQ as instruments to measure response to treatment received or not received.  The results showed that group-administered therapy led to a statistically significant improvement across the major symptom facets of the disorder (Smits, Powers, Cho, & Telch, 2004).

The fourth study by Stuart, Treat, & Wade (2000) looked at 81 participants who had a diagnosis of panic disorder with or without agoraphobia, and compared the data from a previous study.  The instruments the authors used were a modified version of the Anxiety Disorders Interview Schedule, a battery of self-report questionnaires (pre and post treatment and 1-year follow-up, the Fear Questionnaire, the Beck Depression Inventory, and the Positive and Negative Affect Schedule.  After they were admitted to treatment, the clients self-monitored their panic attacks using self-monitoring records.  They also recorded daily mood and anxiety ratings (Stuart, Treat, & Wade, 2000). 

 Results showed that even though there were differences in settings, treatment providers and clients, the magnitude of change from pretreatment to follow-up was comparable to the original efficacy studies.  At follow-up 89% of the clients were free of panic (Stuart, Treat, & Wade, 2000).

The final article by Telch, Schmidt, Jaimez, Jacquin, & Harrington (1995) is a study that looked at the affect cognitive behavioral of treatment on panic disorder on 156 participant’s quality of life.  The participants were randomly assigned to treatment groups.  Treatment consisted of 4 components: education, cognitive therapy, training in diaphragmatic breathing, and interceptive exposure to bodily cues.  There were specific goals and strategies for each session.

The authors used an assessment battery which included the Social Adjustment Scale – self-report and the Sheehan Disability Scale.  Panic was assessed with the Texas Panic Attack Record Form, the Sheehan Patient Rated Anxiety Scale and the Agoraphobia scale which is part of the Fear Questionnaire.  The SAS was also used, as were the SDS, SPRAS and the Fear Questionnaire.

At intake the participants with panic disorder had a significant impairment in their quality of life.  After the cognitive behavioral treatment, those participants who received the treatment showed a significant reduction in their impairment compared with those participants who had been waitlisted.  The authors also found that phobic avoidance and anxiety were significantly associated with quality of life, but the frequency of panic attacks was not (Telch et al., 1995).

<>This paper has looked at the cognitive therapy as a treatment for panic disorder, and in doing so it has also looked at some behavioral treatments such as relaxation, breath training and education, as cognitive therapy for panic disorder is generally used in tandem with other mind-body treatments.  The paper has looked at the principles of cognitive therapy, as well as the diagnostic criteria for panic disorder.  The paper then examined five articles that looked at cognitive or cognitive-behavioral therapy as a treatment for panic disorder.  Each of these article spoke to the effectiveness of cognitive or cognitive-behavioral therapy as a treatment for this disorder.  

References

Addis, M.E., Hatgis, C., Krasnow, A.D., Jacob, K.,Bourne, L., Mansfield, A. (2004). 
Effectiveness of cognitive-behavioral treatment for panic disorder versus treatment as usual in a managed care setting. Journal o f Consulting and Clinical Psychology,72(4), 625-635

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th Text Revision ed.). Washington, D.C.: American Psychiatric Association.

Atlanta Center for Cognitive Therapy. (2005). Cognitive therapy. Retrieved March 6, 2005, 2005, from http://www.cognitiveatlanta.com/index.html
Overholser, J. C. (2000). Cognitive-Behavioral treatment of panic disorder. Psychotherapy: Theory, Research, Practice, Training, 37(3), 247-256.

Smits, J. A., Powers, M. B., Cho, Y., & Telch, M. (2004). Mechanism of change in cognitive-behavioral treatment of panic disorder: Evidence for the fear of fear mediational hypothesis. Journal of Consulting and Clinical Psychology, 72(4), 646-652.

Stuart, G. L., Treat, T. A., & Wade, W. A. (2000). Effectiveness of an empirically based treatment for panic disorder delivered in a service clinic setting 1-year follow-up. Journal of Consulting & Clinical Psychology, 68(3), 506-512.

Telch, M., Schmidt, N. B., Jaimez, T. L., Jacquin, K. M., & Harrington, P. J. (1995). Impact of cognitive-behavioral treatment on quality of life in panic disorder patients. Journal of Consulting & Clinical Psychology, 63(5), 823-830.

Abstracts

Overholser, J. C. (2000). Cognitive-Behavioral treatment of panic disorder. Psychotherapy: Theory, research, practice, training, 37(3), 247-256.

Cognitive-behavioral therapy can be effective for many clients with panic disorder. Therapy can be conceptualized in terms of four central components. First, the initial preparation for therapy involves establishing a working alliance, educating the client about panic symptoms and treatments, and conducting a diagnostic assessment. Second, skills training is used to cultivate active coping skills that the client can use to tolerate symptoms of emotional distress. Third, exposure is used to encourage clients to test and refine their newly developed coping skills. Fourth, relapse prevention is used to help clients discontinue psychological and biological treatments without suffering lasting setbacks. Through the use of cognitive-behavioral therapy, most clients can learn to control their symptoms of panic and reduce their anticipatory anxiety. Treatment gains can be maintained after therapy is discontinued.
 

Addis, M.E., Hatgis, C., Krasnow, A.D., Jacob, K.,Bourne, L., Mansfield, A. (2004).
Effectiveness of cognitive-behavioral treatment for panic disorder versus 
treatment as usual in a managed care setting. Journal o f Consulting and Clinical       Psychology,72(4),625-635.

Eighty clients enrolled in a managed care health plan who identified panic disorder as their primary presenting problem were randomly assigned to treatment by a therapist recently trained in a manual-based empirically supported psychotherapy (M. G. Craske, E. Meadows, & D. H. Barlow, 1994) or a therapist conducting treatment as usual (TAU). Participants in both conditions showed significant change from pre- to posttreatment on a number of measures. Those receiving panic control therapy (PCT) showed greater levels of change than those receiving TAU. Among treatment completers, an average of 42.9% of those in PCT and 18.8% in TAU achieved clinically significant change across measures. The results are discussed with reference to the dissemination of PCT and other evidence-based psychotherapies to clinical practice settings. 
 

Smits, J. A., Powers, M. B., Cho, Y., & Telch, M. J. (2004). Mechanism of change in cognitive-behavioral treatment of panic disorder: Evidence for the fear of fear mediational hypothesis. Journal of Consulting & Clinical Psychology, 72(4), 646-652.

Numerous clinical trials have demonstrated the efficacy of cognitive-behavioral treatment (CBT) for panic disorder. However, studies investigating the mechanisms responsible for improvement with CBT are lacking. The authors used regression analyses outlined by R. M. Baron and D. A. Kenny (1986) to test whether a reduction in fear of fear (FOF) underlies improvement resulting from CBT. Pre- and posttreatment measures were collected from 90 CBT-treated patients and 40 wait-list control participants. Overall, treatment accounted for 31% of the variance in symptom reduction. The potency of FOF as a mediator varied as a function of symptom facet, as full mediation was observed for the change in global disability, whereas the effects of CBT on agoraphobia, anxiety, and panic frequency were partially accounted for by reductions in FOF. Clinical implications and future research directions are discussed.
 

Stuart, G. L., Treat, T. A., & Wade, W. A. (2000). Effectiveness of an empirically based treatment for panic disorder delivered in a service clinic setting 1-year follow-up.  Journal of Consulting & Clinical Psychology, 68(3), 506-512.

The transportability of cognitive–behavioral therapy (CBT) for panic disorder to a community mental health center (CMHC) setting at 1-year follow-up was examined by comparing CMHC treatment outcome data with results obtained in controlled efficacy studies. Participants were 81 CMHC clients with a primary diagnosis of panic disorder with or without agoraphobia who completed CBT for panic disorder. Despite differences in settings, clients, and treatment providers, both the magnitude of change from pretreatment to follow-up and the maintenance of change from posttreatment to follow-up in the CMHC sample were comparable with the parallel findings in the efficacy studies. At follow-up, 89% of the CMHC clients were panic free and a substantial proportion of the sample successfully discontinued benzodiazepine use.
 

Telch, M., Schmidt, N. B., Jaimez, T. L., Jacquin, K. M., & Harrington, P. J. (1995). Impact of cognitive-behavioral treatment on quality of life in panic disorder patients. Journal of Consulting & Clinical Psychology, 63(5), 823-830.

Panic disorder (PD) is associated with significant social and health consequences. The present study examined the impact of treatment on PD patients' quality of life. Patients (N = 156) meeting DSM–III–R (Diagnostic and Statistical Manual of Mental Disorders [3rd ed., rev.]; American Psychiatric Association, 1987) criteria for PD with agoraphobia were randomly assigned to group cognitive–behavioral treatment (CBT) or a delayed-treatment control. An assessment battery measuring the major clinical features of PD as well as quality of life was administered at baseline (Week 0), posttreatment (Week 9) and 6-month follow-up (Week 35). Consistent with previous studies, PD patients displayed significant impairment in quality of life at intake. Compared with delayed-treatment control participants, CBT-treated participants showed significant reductions in impairment that were maintained at follow-up. Consistent with prediction, anxiety and phobic avoidance were significantly associated with quality of life, whereas frequency of panic attacks was not.