Transcript Panic Control Treatment for Adolescents

Panic Control Treatment for
Adolescents
An Evidence-Based Treatment for Panic Disorder
Steven Malm
Contents
Definition of Panic Disorder
 Assessment of Panic Disorder
 Evidence-Based Treatments
 Overview of Program
 Recommended Program Schedule
 Pros, Cons, and Conclusions
 Other Protocols
 References

What is Panic Disorder?
Panic Disorder is a psychiatric condition
characterized by recurrent, unexpected
panic attacks.
 Can occur with or without Agoraphobia


Acronyms:
◦ Panic Disorder without Agoraphobia (PD)
◦ Panic Disorder with Agoraphobia (PDA)
DSM Criteria for Panic Attacks

“A discrete period of intense fear or discomfort in which four (or more)
of the following symptoms developed abruptly and reached a peak within
10 minutes:
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sensation of shortness of breath or smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded, or faint
Derealization (feelings of unreality) or depersonalization (being detached from oneself)
Fear of losing control or going crazy
Fear of dying
Parasthesias (numbness or tingling sensations)
Chills or hot flushes”
(American Psychiatric Association, 2000)
DSM Criteria for Agoraphobia
“Anxiety about being in places or situations from which
escape might be difficult (or embarrassing) or in which help
may not be available in the event of having an unexpected or
situationally predisposed Panic Attack or panic-like
symptoms. Agoraphobic fears typically involve characteristic
clusters of situations that include being outside the home
alone; being in a crowd or standing in a line; being on a
bridge; and traveling in a bus, train, or automobile.
 The situations are avoided or else are endured with marked
distress or with anxiety about having a Panic Attack or paniclike symptoms, or require the presence of a companion.
 The anxiety or phobic avoidance is not better accounted for
by another mental disorder…”

(American Psychiatric Association, 2000)
DSM Criteria for Panic Disorder
Both of the following:

◦
◦
Recurrent unexpected Panic Attacks
At least one of the attacks has been followed by 1 month (or more)
of one (or more) of the following:






Persistent concern about having additional attacks
Worry about the implications of the attack or its consequences
A significant change in behavior related to the attacks
Absence/Presence of Agoraphobia*
The Panic Attacks are not due to the direct physiological effects
of a substance or a general medical condition.
The Panic Attacks are not better accounted for by another
mental disorder.
(American Psychiatric Association, 2000)
*PD and PDA are coded as separate disorders and differ only on this
criterion.
Assessment of Panic Disorder in
Adolescents

Diagnostic Interview
◦ Schedule for Affective Disorders and Schizophrenia (KSADS; Orvachel, 1995)
◦ World Health Organization Composite International
Diagnostic Interview (CIDI; Green et al., 2011)

Self-Report Measures (Pincus et al., 2008)







Revised-Children’s Manifest Anxiety Scale
Revised-Child Anxiety and Depression Scale
Multidimensional Anxiety Scale for Children
Childhood Anxiety Sensitivity Index
Children’s Depression Inventory
Child Behavior Checklist
Medical Screening Measures
◦ Autonomic Nervous System Questionnaire (ANS; Queen
et al., 2012)
Evidence from the Literature
TREATMENTS FOR
PANIC DISORDER
Medication

Antidepressants
◦ Particularly in combination with CBT (Craske and
Simos, 2013).

Benzodiazapines (Moylan et al., 2011)
◦ Alprazolam,Valium, Xanax
◦ Chronic use prior to CBT is linked to poorer
short- and long-term outcomes (Craske & Simos,
2013).
◦ Combined treatment linked to poorer outcomes
at 24-month follow-up (Brown & Barlow, 1995)
CBT in Panic Disorder
CBT is an effective first-line treatment of PD
(Otto & Deveney, 2005).
 CBT for PD should include:
Psychoeducation, Self-Monitoring, Relaxation
Techniques, Cognitive Restructuring, and
Exposure (Craske & Simos, 2011).
 Some evidence exists that “ultra-brief” (5
session) CBT may be efficacious (Otto et al.,
2012).
 CBT has been shown to be effective in PD,
even with comorbid anxiety or depression
(Allen et al., 2010)

Pincus, Ehrenreich, & Mattis (2008)
PANIC CONTROL
TREATMENT FOR
ADOLESCENTS (PCT-A)
Overview of the Program
Adapted from the adult PCT protocol for use with
adolescent clients.
 11 weekly CBT sessions
 Focuses on the three aspects of panic attacks and
anxiety:

◦ Cognitive aspect
◦ Hyperventilatory response
◦ Conditioned response to physical reactions
Incorporates psychoeducation, breathing training,
cognitive restructuring, and exposure (interoceptive
and situational)
 Goals are to reduce irrational thoughts, conditioned
fear responses, and avoidance behaviors.

Evidence-Base for PCT-A

Pincus et al. (2008)
◦
◦
◦
◦

N = 26 adolescents (ages 12-17)
12-week CBT treatment vs. Wait-list (control) group
Treatment was associated with significant reduction in PD severity.
Symptoms remained at clinical levels for control group until subsequent
CBT was given
Pincus et al. (2010)
◦ N = 24 adolescents (ages 14-17)
◦ PCT-A Treatment vs. self-monitoring control group
◦ PCT-A resulted in significant reduction in symptom severity
 Clinician ratings AND self-report ratings
◦ Symptoms continued to improve at 3- and 6-month follow-up

Chase et al., (2012)
◦ Weekly PCT-A versus intensive (8-day) program
◦ Both resulted in significant reductions in symptoms
 Weekly therapy was related to reductions in anxiety sensitivity and depressive
symptoms.
Session 1

Introduction to treatment
◦ Review pre-treatment assessment/diagnosis
◦ Discuss nature of anxiety
◦ Introduce the 3 components of anxiety (Affective,
Behavioral, Cognitive)
◦ Discuss the model for panic attacks and
treatment overview
◦ Discuss importance of practice and selfmonitoring
◦ Set goals
◦ Assign homework (readings and start a panic
attack record)
Session 2

Physiology of panic attacks and breathing
awareness
◦ Review homework
◦ Discuss physiology of anxiety/panic
◦ Hyperventilation exercise and discussion
 Simulates feelings of panic
◦ Slow breathing exercise
 By controlling breathing, clients can decrease frequency
and intensity of sensations which may trigger panic
◦ Assign homework (readings, continue logs, and
practice slow breathing)
Session 3

Overview of the Cognitive Component
◦ Review homework
◦ Discuss cognitive aspect of anxiety
◦ Introduce the concepts of:
 Probability overestimation (predicting an unlikely
event to as likely to happen)
 Catastrophic thinking (thinking the worst will
happen)
◦ Practice monitoring panic triggers/thoughts
◦ Assign homework (readings, logs, and thought
record)
Session 4

Cognitive Restructuring
◦
◦
◦
◦
◦
Review homework
Teaching “thinking like a detective.”
Practice evaluating probability overestimation
Practice evaluating catastrophic thinking
Discuss myths/misconceptions about anxiety
 Going crazy, losing control, heart attack, etc.
◦ Assign homework (readings, logs, “thinking
like a detective” form.
Session 5

Interoceptive Exposure (“not letting how we feel
scare us”)
◦ Review homework
◦ Review: anxiety physiology and model of panic attacks
◦ Introduce and explain interoceptive conditioning/exposure
 Associations between situations and panic symptoms
 Repeated exposure habituates client to feelings of anxiety
◦ Conduct symptom induction exercises
 Examples: shake head for 30 seconds, run in place for 1 minute,
hold breath for 30 seconds, breath through a thin straw.
 Select the 3 exercises that replicate client’s experience of panic
◦ Assign homework (readings, logs, repeat symptom
induction exercises daily)
Session 6

Intro to Situational Exposure
◦ Review homework
◦ Explain rationale for exposure
 Deal with any resistance to exposure
◦ Complete Fear and Avoidance Hierarchy form
 Rank order 10 situations avoid out of fear of panic
attack
◦ Conduct in-session situational exposure
 Choose from the FAH list – what you believe they can
deal with you present (but they don’t)
◦ Assign homework (readings, logs, repeat insession situational exposure ONLY)
Session 7

Safety Behaviors and Exposure
◦ Review homework
◦ Review safety behaviors
 Discuss rationale for eliminating
 List those used by adolescent
◦ Plan for and conduct situational exposure
◦ Assign homework (readings, logs, review
safety behaviors, repeat in-session exposure at
home)
Sessions 8-10

Exposure sessions
◦ Review homework, FAH form, and exposure
procedures
◦ Conduct exposures
◦ Review progress following exposures
 Troubleshoot problems/resistence
◦ Plan for homework exposures
◦ Assign homework (logs, and exposure
exercises selected from FAH form)
Session 11

Relapse prevention and termination
◦
◦
◦
◦
◦
◦
◦
Review exposure homework
Re-rate FAH form
Revisit goals and accomplishments
Help adolescent to develop a practice plan
Assess “cost of improvement”
Prepare client for symptom relapse
Terminate therapy
Pros



Cons
CBT has a strong evidence
base for dealing with
anxiety
Clients report positive
changes (even those
unrelated to anxiety)
Previously feared situations
are reduced  QoL
improves


Evidence-base for
adolescents (specifically) is
growing, but limited
Requires substantial
commitment
◦ Needs to be entered into
willingly
Pros and Cons
Conclusions and School Implications




PCT-A is a manualized, structured treatment
protocol for adolescents with PD.
Treatment schedule can be modified to fit
the client’s needs.
Parents can be involved at every step of the
process to support progress and compliance
with treatment.
PCT-A can be conducted within a school or
clinic setting. School-based PCT-A would be
particularly appropriate if client experiences
significant panic symptomology at school.
Other Protocols for PD
The Clinical Research Unit for Anxiety
and Depression (CRUfAD) protocol and
client workbook:
http://www.crufad.com/index.php/treatme
nt-support/treatment-manuals
 Boston Counseling Therapy schedule and
outline of treatment:
http://www.thriveboston.com/counseling/
panic-disorder-and-agoraphobia-overviewand-cbt-treatment/

Questions?
Comments?
 Concerns?
 Statements?
 Anecdotes?
 Epiphanies?
 Criticisms?
 Compliments?
 Digressions?

References








Allen, L. B., White, K. S., Barlow, D. H., Shear, M. K., Gorman, J. M., & Woods, S. W. (2010). Cognitivebehavior therapy (CBT) for panic disorder: Relationship of anxiety and depression comorbidity with
treatment outcome. Journal of Psychopathological and Behavioral Assessment, 32, 185-192. DOI:
10.1007/s10862-009-9151-3
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th Edition,
Text Revision. American Psychiatric Association: Arlington, VA.
Brown, T. A. & Barlow, D. H. (1995). Long-term outcomes in cognitive-behavioral treatment of panic
disorder: Clinical predictors and alternative strategies for assessment. Journal of Consulting and Clinical
Psychology, 63(5), 754-765. DOI: 0022-006X/95/$3.00
Centore, A. (2010). Panic disorder and agoraphobia: Overview and CBT treatment. ThriveBoston.
Retrieved 10/6/2013. http://www.thriveboston.com/counseling/panic-disorder-and-agoraphobiaoverview-and-cbt-treatment/
Clinical Research Unit for Anxiety Disorders (2010). Anxiety and panic disorder: Patient treatment
manual. St. Vincent’s Hospital. Retrieved: 10/6/2013. www.crufad.org
Craske, M. G. & Simos, G. (2013). Panic disorder and agoraphobia. In Simos, G. & Hofmann, S. G. (Eds.).
CBT for Anxiety Disorders: A Practitioner Book, 3-24. John Wiley & Sons: New York, NY.
Chase, R. M., Whitton, S. W., & Pincus, D. B. (2012). Treatment of adolescent panic disorder: A
nonrandomized comparison of intensive versus weekly CBT. Child & Family Behavior Therapy, 34, 305-323.
DOI: 10.1080/07317107.2012.732873
Green, J. G., Avenevolli, S., Finkelman, M., Gruber, M. J., Kessler, R. C., Merikangas, K. R., Sampson, N. A., &
Zaslavsky, A. M. (2011). Validation of the diagnosis of panic disorder and phobic disorder in the US
national comorbidity survey replication adolescent (NCSA-A) supplement. International Journal of
Methods in Psychiatric Research, 20(2), 105-115. DOI: 10.1002/mpr.336
References (Cont.)







Moylan, S., Sstaples, J., Ward, S. A., Rogerson, J., Stein, D. J., & Berk, M. (2011). The efficacy
and safety of alprazolam versus other benzodiazepines in the treatment of panic disorder.
Journal of Clinical Psychopharmacology, 31(5), 647-652.
Orvaschel, H. (1995). Schedule for affective disorders and schizophrenia for school-aged
children, epidiologic version – 5. Center for Psychological Studies. Nova Southeastern
University: Fort Lauderdale, FL.
Otto, M. W. & Deveney, C. (2005). Cognitive-behavioral therapy and the treatment of panic
disorder: Efficacy and strategies. Journal of Clinical Psychiatry, 66, 28-32.
Otto, M.W., Tolin, D. F., Nations, K. R., Utschig, A. C., Rothbaum, B. O., Hofmann, S. G., &
Smits, J. A. (2012). Five sessions and counting: Considering ultra-brief treatment for panic
disorder. Depression and Anxiety, 29, 465-470.
Pincus, D. B., Ehrenreich, J. T., & Mattis, S. G. (2008). Mastery of Anxiety and Panic for
Adolescents: Riding the Wave. Oxford University Press: New York, NY.
Pincus, D. B., Ehrenreich-May, J., Whitton, S. W., Mattis, S. G., & Barlow, D. H. (2010).
Cognitive-behavioral treatment of panic disorder in adolescence. Journal of Clinical Child
and Adolescent Psychology, 39(5), 638-649. DOI: 10.1080/15374416.2010.501288
Queen, A. H., Ehrenreich-May, J., & Hershorin, E. R. (2012). Preliminary validation of a
screening tool for adolescent panic disorder in pediatric primary care clinics. Child
Psychiatry and Human Development, 43, 171-183. DOI: 10.1007/s10578-011-0256-z