Panic Control Treatment for AdolescentsAn Evidence-Based Treatment for Panic Disorder

Steven Malm

ContentsDefinition of Panic DisorderAssessment of Panic DisorderEvidence-Based TreatmentsOverview of ProgramRecommended Program SchedulePros, Cons, and ConclusionsOther ProtocolsReferences

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 panic-like 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 AdolescentsDiagnostic Interview

◦ Schedule for Affective Disorders and Schizophrenia (K-SADS; 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)

TREATMENTS FOR PANIC DISORDER

Evidence from the Literature

MedicationAntidepressants

◦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 DisorderCBT 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)

PANIC CONTROL TREATMENT FOR ADOLESCENTS (PCT-A)

Pincus, Ehrenreich, & Mattis (2008)

Overview of the ProgramAdapted from the adult PCT protocol for use with

adolescent clients.11 weekly CBT sessionsFocuses 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 1Introduction 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 self-

monitoring◦Set goals◦Assign homework (readings and start a

panic attack record)

Session 2Physiology 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 3Overview 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 4Cognitive 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 6Intro 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 in-session situational exposure ONLY)

Session 7Safety 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 8-10Exposure 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 11Relapse 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 and Cons

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

Conclusions and School ImplicationsPCT-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 PDThe Clinical Research Unit for

Anxiety and Depression (CRUfAD) protocol and client workbook: http://www.crufad.com/index.php/treatment-support/treatment-manuals

Boston Counseling Therapy schedule and outline of treatment: http://www.thriveboston.com/counseling/panic-disorder-and-agoraphobia-overview-and-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).

Cognitive-behavior 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-agoraphobia-overview-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