treating panic disorder in veterans with ptsd ellen j. teng, ph.d. michael e. debakey vamc trauma...
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Treating Panic Disorder in Treating Panic Disorder in Veterans with PTSDVeterans with PTSD
Ellen J. Teng, Ph.D.Ellen J. Teng, Ph.D.
Michael E. DeBakey VAMCMichael E. DeBakey VAMC
Trauma Recovery ProgramTrauma Recovery Program
Research TeamResearch Team
Ellen J. Teng, Ph.D.Ellen J. Teng, Ph.D.Nancy J. Petersen, Ph.D.Nancy J. Petersen, Ph.D.
Sara D. Bailey, Ph.D.Sara D. Bailey, Ph.D.Joseph D. Hamilton, M.D.Joseph D. Hamilton, M.D.
Nancy Jo Dunn, Ph.D. (Mentor)Nancy Jo Dunn, Ph.D. (Mentor)
Angelic D. Chaison, M.A.Angelic D. Chaison, M.A.Katherine H. Graham, M.Ed.Katherine H. Graham, M.Ed.
Derek G. Prins, M.A.Derek G. Prins, M.A.
This research was supported by the South Central Mental Illness, Research, Education, and Clinical This research was supported by the South Central Mental Illness, Research, Education, and Clinical Center as part of the VA Special MIRECC Fellowship Program in Advanced Psychiatry and Center as part of the VA Special MIRECC Fellowship Program in Advanced Psychiatry and
PsychologyPsychology
BackgroundBackground
Panic DisorderPanic Disorder
Among one of the most debilitating and expensive anxiety disorders Among one of the most debilitating and expensive anxiety disorders in the nationin the nation
High rates of healthcare utilizationHigh rates of healthcare utilization
Occupational dysfunction & unemploymentOccupational dysfunction & unemployment
Psychosocial impairmentPsychosocial impairment
Increased rates of substance abuse & antidepressant useIncreased rates of substance abuse & antidepressant use
Background (cont’d)Background (cont’d)
What are the treatments of choice?What are the treatments of choice?
PharmacotherapyPharmacotherapy
Cognitive-behavioral therapyCognitive-behavioral therapy Panic Control Treatment (Barlow & Craske, 1994) consists of Panic Control Treatment (Barlow & Craske, 1994) consists of
education, cognitive restructuring, & interoceptive exposureeducation, cognitive restructuring, & interoceptive exposure
85 to 87% of persons treated are panic-free by the end of 85 to 87% of persons treated are panic-free by the end of treatment (Barlow et al., 1989; Klosko et al, 1995; Telch et al., treatment (Barlow et al., 1989; Klosko et al, 1995; Telch et al., 1993).1993).
Background (cont’d)Background (cont’d)
So what’s the problem?So what’s the problem?
Treatment is less effective with significant psychiatric comorbidityTreatment is less effective with significant psychiatric comorbidity
Complications from comorbidity & using manualized therapyComplications from comorbidity & using manualized therapy
Increase in attrition & relapse ratesIncrease in attrition & relapse rates
Comorbidity rate of 27% for PD & PTSD based on data from Comorbidity rate of 27% for PD & PTSD based on data from National Comorbidity Study (Leskin & Sheikh, 2002)National Comorbidity Study (Leskin & Sheikh, 2002)
Background (cont’d)Background (cont’d)
Why do PD and PTSD co-occur so frequently? Why do PD and PTSD co-occur so frequently?
Trauma related cues can trigger a panic attack (Sheikh et al., 1994) Trauma related cues can trigger a panic attack (Sheikh et al., 1994)
Experience of uncued panic attacks can lead to full-blown PD Experience of uncued panic attacks can lead to full-blown PD (Resnick et al., 1994)(Resnick et al., 1994)
Shared symptoms-chronic hyperarousal, hypervigilance, somatic Shared symptoms-chronic hyperarousal, hypervigilance, somatic reactivity, anxiety sensitivity (Falsetti & Resnick, 2000; Jakupcak et reactivity, anxiety sensitivity (Falsetti & Resnick, 2000; Jakupcak et al., 2006)al., 2006)
PurposePurpose
To examine the effectiveness of Panic Control Therapy (PCT) in To examine the effectiveness of Panic Control Therapy (PCT) in improving comorbid panic symptoms in veterans with a primary improving comorbid panic symptoms in veterans with a primary diagnosis of PTSD compared with a control therapydiagnosis of PTSD compared with a control therapy
HypothesesHypotheses
1.1. PCT would outperform a control therapy in reducing the PCT would outperform a control therapy in reducing the frequency, severity, & fearfulness of panic attacks.frequency, severity, & fearfulness of panic attacks.
2.2. PCT would result in a greater reduction in anxiety sensitivity and PCT would result in a greater reduction in anxiety sensitivity and improve general anxiety & depression symptoms compared to the improve general anxiety & depression symptoms compared to the control therapy.control therapy.
3.3. No change in PTSD symptoms for patients receiving either No change in PTSD symptoms for patients receiving either therapy.therapy.
MethodMethod
ParticipantsParticipants49 outpatients from the Trauma Recovery Program 49 outpatients from the Trauma Recovery Program
Overall Sample CharacteristicsOverall Sample CharacteristicsAge: Age: MM=52 years, =52 years, SDSD=8.44=8.44
14% women; 86% men14% women; 86% men
43% African American43% African American
43% Caucasian43% Caucasian
14% Hispanic14% Hispanic
MethodMethod
Inclusion Criteria: Inclusion Criteria: current PTSD diagnosis; current PTSD diagnosis; >> 1 PA in past month; 1 PA in past month; IQ IQ >> 80 80
Exclusion CriteriaExclusion Criteria: current substance dependence, mania, psychosis; : current substance dependence, mania, psychosis; severe depression; PA exclusive to specific phobias; medical severe depression; PA exclusive to specific phobias; medical conditions that mimic anxiety symptomsconditions that mimic anxiety symptoms
MaterialsMaterialsPanic Control Treatment (PCT) manualPanic Control Treatment (PCT) manual
Psychoeducational & Supportive Treatment (SUP) manualPsychoeducational & Supportive Treatment (SUP) manual
Assessment Instruments Pre-Tx Sess 1 Sess 5 Sess 10
Post-Tx
3 Mo F/U
Wechsler Test of Adult Reading *
Personality Diagnostic Quest. *
Treatment Evaluation Inventory *
Anxiety Disorders Interview Sch * * *
Posttraumatic Stress Disorder CL * * *
Anxiety Sensitivity Index * * * * * *
Beck Anxiety Inventory * * * * * *
Beck Depression Inventory * * * * * *
Panic Attack Records * * * * * *
ProcedureProcedure
DesignDesign
Blocked randomization Blocked randomization
Assessed at pre-treatment, mid-treatment, post-treatment, and a 3-Assessed at pre-treatment, mid-treatment, post-treatment, and a 3-month follow-upmonth follow-up
Both treatments delivered in weekly, 1 hr, individual sessions over a Both treatments delivered in weekly, 1 hr, individual sessions over a 10-week period10-week period
Treatments conducted by trained masters & doctoral level graduate Treatments conducted by trained masters & doctoral level graduate studentsstudents
Treatment fidelity ratings completed by independent ratersTreatment fidelity ratings completed by independent raters
ResultsResults
Primary AnalysesPrimary Analyses
A higher % of patients in PCT (63%, n=10) was panic-free at the 3-A higher % of patients in PCT (63%, n=10) was panic-free at the 3-month follow-up than the SUP group (19%, n=3), month follow-up than the SUP group (19%, n=3), 22 (1, N= (1, N=3232) = ) = 6.356.35, p, p=.01)=.01)
Means, Standard Deviations, and mixed ANOVA Source Tables Comparing Panic Control Treatment to Psychoeducational Supportive Treatment for the Intent-to-Treat Sample
Intervention Control Repeated measures ANOVA tables
Time M SD N M SD N Source dfs f p η2
Panic Severity
Pre 58.33 18.34 18 51.71 14.11 17 Time 2, 66 6.45 .16 .003
Post 41.89 18.37 56.65 21.30 Group 1, 66 1.42 .24 .04
Follow-up 36.89 18.64 44.94 22.20 Interaction 2, 66 3.84 .03 .10
Panic Fear
Pre 5.11 1.87 14 3.77 1.99 14 Time 2, 52 6.89 .002 .21
Post 2.79 3.26 2.73 2.43 Group 1, 52 .006 .94 .00
Follow-up 2.32 3.24 3.90 2.36 Interaction 2, 52 4.67 .01 .15
Anxiety Sensitivity Index
Pre 41.83 11.78 18 42.47 9.53 17 Time 2, 66 8.36 .001 .20
Post 29.61 14.48 40.53 13.44 Group 1, 66 3.64 .07 .10
Follow-up 31.50 14.94 40.65 10.87 Interaction 2, 66 4.30 .02 .12
Hamilton Anxiety Rating Scale
Pre 25.50 9.34 18 24.24 7.16 17 Time 2, 66 12.87 .28 < .001
Post 19.94 8.48 23.24 9.83 Group 1, 66 0.63 .43 .02
Follow-up 15.83 9.02 19.82 8.91 Interaction 2, 66 2.11 .13 .06
Beck Anxiety Inventory
Pre 37.33 10.32 18 30.35 10.48 17 Time 2, 66 1.33 .27 .04
Post 29.61 14.89 31.71 15.02 Group 1, 66 0.26 .61 .008
Follow-up 30.94 15.39 30.29 11.47 Interaction 2, 66 2.11 .13 .06
Intervention Control Repeated measures ANOVA tables
Time M SD N M SD N Source dfs f p η2
Hamilton Rating Scale for Depression
Pre 18.44 4.38 18 18.35 5.77 17 Time 2, 66 5.36 .007 .14
Post 15.06 4.95 17.47 9.33 Group 1, 66 1.39 .25 .04
Follow-up 12.78 5.87 16.41 6.90 Interaction 2, 66 1.33 .27 .04
Beck Depression Inventory-II
Pre 35.78 8.40 18 30.65 12.75 17 Time 2, 66 6.22 .003 .16
Post 29.50 13.52 25.47 12.46 Group 1, 66 0.83 .37 .03
Follow-up 27.78 14.51 27.29 10.76 Interaction 2, 66 0.85 .43 .03
Posttraumatic Stress Disorders Checklist
Pre 69.33 7.76 18 67.29 9.77 17 Time 2, 66 2.11 .13 .06
Post 64.56 13.37 65.41 10.94 Group 1, 66 0.01 .92 .00
Follow-up 64.06 10.98 66.12 12.06 Interaction 2, 66 0.65 .52 .02
Intervention Control Repeated measures ANOVA tables
Time M SD N M SD N Source dfs f p η2
Panic Control Treatment
PsychoeducationalSupportive Treatment
______________________ _____________________
Period n % n % Fisher’s Exact pIntent-to-Treat Sample (N=35)
1-week post
ASI 7 38.9 1 5.9 .04
BAI 5 27.8 1 5.9 .06
BDI 8 44.4 6 35.3 .69
HARS 7 38.9 6 37.5 .64
HRSD 8 44.4 4 25.0 .45
PCL 7 38.9 7 41.2 .38
3-month follow-up
ASI 5 27.7 2 11.8 .40
BAI 4 22.2 2 11.8 .86
BDI 7 38.9 5 29.4 .86
HARS 10 55.6 10 62.5 .44
HRSD 9 50.0 5 31.3 .23
PCL 6 33.3 7 41.2 .06
Percentage of Participants with Clinically Significant Improvement at Each Follow-up Period
Percentage of Participants with Clinically Significant Improvement at Each Follow-up Period
Panic Psychoeducational Control Treatment Supportive Treatment Period n % n % Fisher’s Exact p
Treatment Completers (n=26)1-week post
3-month follow-up
ASI 7 58.3 1 7.1 .009
BAI 4 33.3 2 14.3 .63
BDI 7 58.3 4 28.6 .31
HARS 11 91.7 9 64.3 .28
HRSD 9 75.0 5 35.7 .03
PCL 6 50.0 6 42.9 .34
ASI 8 66.7 1 7.1 .003
BAI 4 33.3 1 7.1 .13
BDI 8 66.7 5 35.7 .09
HARS 8 66.7 5 35.7 .39
HRSD 8 66.7 4 28.6 .17
PCL 7 58.3 6 42.9 .88
DiscussionDiscussion
PCT effectively reduced severity and fear of panic symptoms PCT effectively reduced severity and fear of panic symptoms compared with SUPcompared with SUP
PCT reduced the frequency of panic attacks by the 3-month follow-PCT reduced the frequency of panic attacks by the 3-month follow-upup
PCT produced significant reductions in anxiety sensitivity at post- PCT produced significant reductions in anxiety sensitivity at post- and follow-up periodsand follow-up periods
Discussion (cont’d)Discussion (cont’d)
Clinician & Self-Report RatingsClinician & Self-Report Ratings
Anxiety symptoms: both groups improved at post and follow-up Anxiety symptoms: both groups improved at post and follow-up (patient self-report indicated no improvement at either period)(patient self-report indicated no improvement at either period)
Depression symptoms: both groups improved at 3-month follow-up Depression symptoms: both groups improved at 3-month follow-up (consistent with patient self-report)(consistent with patient self-report)
By the follow-up period, 59% of both groups showed improvement in By the follow-up period, 59% of both groups showed improvement in anxiety symptoms and 41% in depressive symptomsanxiety symptoms and 41% in depressive symptoms
LimitationsLimitations
Small sample sizeSmall sample size
Service connection for PTSD may be related to disparity between Service connection for PTSD may be related to disparity between self-report & clinician ratingsself-report & clinician ratings
Sessions were unevenly dispersedSessions were unevenly dispersed
Drop-out rate was double for PCT (33%) compared with SUP (12%)Drop-out rate was double for PCT (33%) compared with SUP (12%)
Future DirectionsFuture Directions
Need to understand better the mechanisms leading to the Need to understand better the mechanisms leading to the development & maintenance of comorbid PTSD and PDdevelopment & maintenance of comorbid PTSD and PD
Compare the effectiveness of integrated treatment approaches vs. Compare the effectiveness of integrated treatment approaches vs. sequential onessequential ones
Develop briefer interventions to increase treatment acceptability and Develop briefer interventions to increase treatment acceptability and adherence for patientsadherence for patients