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)
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
Panic Disorder
Diagnostic Considerations
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
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
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
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)
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
Cognitive-Behavioral Model of
Panic Disorder
Stress
Biological Diathesis
Alarm Reaction
Rapid heart rate, heart palpitations
Shortness of breath, smothering sensations
Chest pain or discomfort, numbness or tingling
Increased anxiety and fear
Conditioned
Fear of
Somatic Sensations
Catastrophic misinterpretations
of symptoms
Hypervigilance to symptoms
Anticipatory anxiety
Memory of past attacks
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.
Elements of
Cognitive Behavior Therapy
for Panic Disorder
Core Elements of CBT
• Psychoeducation/ Informational
intervention
• Cognitive interventions
• Interoceptive (internal) exposure
• In vivo exposure
• Can be delivered in individual or group
treatment formats
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
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
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
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?”)
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).
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
Panic Cycle
Uh oh!
What if:
•This gets worse?
•I lose control?
•This is a stroke?
I have to control
this!
Relative Comfort
•Notice the
sensation
•Do nothing to
control it.
•Relax WITH
the sensation
Learning Safety in Panic
Interoceptive exposure
• Feared sensations become safe sensations
– in the office with the therapist
– at home
– independent of the treatment context
Situational Exposures
• Rationale:
– Providing a new learning opportunity to
examine negative predictions about feared
outcomes
– Increasing tolerance to internal sensations in
feared situations
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)
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
CBT for Panic Disorder
And it is acceptable, tolerable, and cost effective
Meta-Analytic Results of
Panic Disorder Treatment Studies
Effect Size (Cohen’s d)
CBT
(IE+CR)
CBT
Non-SSRI
Antidepressants
Benzodiazepines
SSRIs
Antidepressants
Gould et al, 1995; Otto et al., 2001
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)
Percent Dropout
Treatment Acceptability
(dropout rates)
Treatment Acceptability
Refusal Rate in the Multicenter Panic Trial
34
35
30
Percent
25
20
15
10
5
1
0
CBT
Imipramine
Treatment
Hofmann SG, et al. Am J Psychiatry. 1998;155:43-47.
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
Panic Disorder:
Continuation Treatment
% Responders (40%  PDSS)
60
50
40
CBT + imipramine
CBT + placebo
CBT
Imipramine
Placebo
30
20
10
0
Maintenance (ITT) 6 More Months
Barlow DH, et al. JAMA. 2000;283:2529-2536.
Panic Disorder:
Post–Imipramine Discontinuation
% Responders (40%  PDSS)
60
50
CBT + imipramine
CBT + placebo
CBT
Imipramine
Placebo
40
30
20
10
0
6 Months Treatment Discontinuation (ITT)
(Imipramine over 1 to 2 weeks)
Barlow DH, et al. JAMA. 2000;283:2529-2536.
Panic Disorder:
After 8 Weeks of Treatment
1.3
1.1
0.9
Effect Size
0.7
(CGI relative to PR)
0.5
0.3
0.1
-0.1
EXP = exposure treatment.
ALP = alprazolam treatment.
PBO = placebo treatment.
Relax = relaxation treatment.
Marks IM et al. Br J Psychiatry.1993;162:776-787.
EXP + ALP
EXP + PBO
ALP + Relax
Panic Disorder: Post Benzodiazepine
Discontinuation (Week 18)
1.3
1.1
0.9
0.7
Effect Size
(CGI relative to PR)
0.5
0.3
0.1
-0.1
-0.3
EXP = exposure treatment.
ALP = alprazolam treatment.
PBO = placebo treatment.
Relax = relaxation treatment.
Marks IM et al. Br J Psychiatry.1993;162:776-787.
EXP + ALP
EXP + PBO
ALP + Relax
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 benzodiazepines1,2
– Treatment with SSRIs3,4
1Otto
MW et al. Psychopharmacol Bull. 1992;28:123-130.
2Spiegel DA et al. Am J Psychiatry. 1994;151:876-881.
3Schmidt NB et al. Behav Res Ther. 2002;40:67-73.
4Whittal ML et al. Behav Res Ther. 2001;39:939-945.
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
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.
% Developing Panic Disorder
Preventive Treatment
25
Wait List
Workshop
20
15
13.6
10
5
1.8
0
121 Participants
Gardenswartz CA, Craske MG. Behav Ther. 2001;32:725-738.
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.