An open pilot study of interpersonal psychotherapy for panic disorder (IPT-PD)

Interpersonal psychotherapy (IPT) is a time-limited psychotherapy initially developed to treat depression. It has yet to be studied systematically for treatment of panic disorder. We modified IPT for the treatment of panic disorder and tested this treatment in an open clinical trial with 12 patients seeking treatment of DSM-IV panic disorder. Patients were assessed before during and after treatment. At completion of treatment, nine patients (75%) were independently categorized as responders (i.e., rated as much improved or very much improved on the Clinical Global Impression-Change Scale). Substantial improvement was found for panic symptoms, associated anxiety and depressive symptoms, and physical and emotional well-being. Degree of change in this sample approximated that obtained in studies using established treatments such as cognitive behavioral therapy. Results, though preliminary, suggest that IPT may have efficacy as a primary treatment of panic disorder. Further study is warranted.     

Lack of efficacy of carbamazepine in the treatment of panic disorder

The authors conducted a controlled study of carbamazepine in the treatment of 14 patients with panic disorder. Although there was a statistically significant reduction in symptoms of anxiety on several measures, only one of the patients was judged to have a marked and sustained clinical improvement while taking carbamazepine. Forty percent of the patients had a decrease in frequency of panic attacks during carbamazepine treatment, 50% had an increase, and 10% showed no change. The presence of either EEG abnormalities or prominent psychosensory symptoms did not predict response to carbamazepine. These findings are discussed within the context of an epileptiform model for panic disorder.     

Effects of citalopram treatment on behavioural, cardiovascular and neuroendocrine response to cholecystokinin tetrapeptide challenge in patients with panic disorder.

Eight patients with panic disorder were administered 20 micrograms of cholecystokinin tetrapeptide (CCK-4) before and after 8 weeks of treatment with the selective serotonin reuptake inhibitor (SSRI) citalopram. All patients responded to treatment by showing a significant general improvement and reaching a panic-free state for 2 weeks. At the rechallenge with CCK-4, patients displayed a marked reduction in the intensity and number of panic symptoms. The frequency of panic attacks induced with CCK-4 decreased by 50% after treatment. Citalopram treatment had no substantial effect on cardiovascular (heart rate and blood pressure) or hormonal (cortisol, prolactin and growth hormone) responses to CCK-4. Patients who still had panic attacks after treatment demonstrated a blunted growth hormone response to CCK-4 that was not seen in those who did not have panic attacks. This study suggests that treatment with an SSRI can reduce an enhanced sensitivity to CCK-4 without modifying cardiovascular and neuroendocrine responses to CCK-4 in patients with panic disorder.     

Treatment of panic and agoraphobia. An integrative review

There is now agreement about the clinical features of panic disorder and agoraphobia but less agreement about treatment because of controversy over whether the disorder is primarily biological or psychological. The authors were requested to produce an impartial review for continuing education and peer review. We chose to do this by using a quantitative review procedure, by providing a bibliography of studies, and by a literature review. We found that symptoms of panic and phobia did not change significantly while on wait-list control or while receiving placebo. The evidence for the efficacy of the low-potency benzodiazepines or of monoamine oxidase inhibitors was limited. It was also clear that only limited improvement can be expected from behavior therapies that do not involve exposure to the symptoms of panic or to the feared situation. Symptoms of panic, as well as the frequency of spontaneous panic, were shown to be substantially improved following imipramine, high-potency benzodiazepines such as alprazolam, exposure in vivo (especially if a cognitive anxiety management procedure was used), and the combination of imipramine and exposure in vivo. The effects on panic produced by the exposure therapies (with or without imipramine) were maintained over long follow-up periods. Imipramine, alprazolam, exposure therapy, and imipramine plus exposure each produced significant improvements in phobias. In the short term and in the long term, the larger improvements in phobias were associated with exposure therapy, particularly if used in combination with imipramine. We conclude that it would be unwise to theorize about the etiology of this disorder on the basis of response to a specific treatment because, both at the meta-analytic level and from the review of individual studies, it is clear that both drug and nondrug therapies can produce substantial and long-lasting changes in panic and in phobias.     

Use of selective serotonin reuptake inhibitors for the treatment of childhood panic disorder: a pilot study.

This preliminary study examines the effectiveness and safety of selective serotonin reuptake inhibitors (SSRIs) for the treatment of panic disorder in children and adolescents. In a prospective open label study, 12 children and adolescents with panic disorder were treated with SSRIs, and if necessary, with benzodiazepines, for a period of 6-8 weeks and were followed for approximately 6 months. During the trial, clinician-based and self-report rating scales for anxiety and depression, functioning, and side effects, were administered. Using the Clinical Global Impression Scale (CGIS) 75% of patients showed much to very much improvement with SSRIs without experiencing significant side effects. After controlling for changes in depressive symptoms, self-report and clinician-based anxiety scales also showed significant improvement. At the end of the trial, 67% of patients no longer fulfilled criteria for panic disorder and 4 patients remained with significant residual symptoms. In conclusion, SSRIs appear to be a safe and promising for the treatment of children and adolescents with panic disorder, however, randomized controlled trials evaluating the effects of SSRIs and other interventions (e.g., cognitive therapy) for treating panic disorder in children and adolescents are warranted. It appears that until the SSRIs begin to exert their effects, a benzodiazepine adjunct treatment might be helpful for patients with severe panic disorder.     

Treatment of mitral valve prolapse and panic disorder with metoprolol.

The prevalence of mitral valve prolapse (MVP) and panic disorder (PD) has been reported to range from 0-50% depending on the respective diagnostic manuals and described selection criteria. We report the case of a 44-year-old patient suffering from both panic disorder and mitral valve prolapse. While antidepressants did not result in any improvement of panic symptoms, a fast remission was achieved by treating the patient with metoprolol. This case report suggests that betablockers might represent a useful tool in the treatment of panic disorder and mitral valve prolapse.     

Selective GABAergic treatment for panic? Investigations in experimental panic induction and panic disorder

gamma-Aminobutyric acid (GABA) is the most important inhibitory neurotransmitter in the central nervous system (CNS). It exerts its rapid inhibitory action mostly through GABA(A) receptors, which are targets for benzodiazepines, barbiturates, neuroactive steroids and distinct anticonvulsive agents. There is considerable evidence that dysfunction of GABA(A) receptors or dysregulation of GABA concentrations in the CNS (or both) plays an important role in the pathophysiology of panic disorder. Currently, benzodiazepines are the only drugs directly targeting the GABA(A) receptors that are approved for the treatment of anxiety disorders. Because of their well-known anxiolytic effects, they are widely used in this setting, but side effects limit their use in long-term treatment. The question of whether drugs that selectively increase GABA concentrations in the CNS could improve symptoms of anxiety has been discussed. Recent investigations by our group have demonstrated that enhancement of endogenous GABA (through blockade of GABA transaminase by vigabatrin or through inhibition of GABA transporters by tiagabine) exerts anxiolytic effects on experimentally induced panic. Our studies in healthy volunteers have shown that both compounds lead to a significant reduction in panic symptoms elicited by cholecystokinin-tetrapeptide. Moreover, benzodiazepine-like effects on the activity of the hypothalamic-pituitary-adrenal axis have been observed in association with vigabatrin treatment. Small open studies in patients with panic disorder also showed an improvement in panic and anxiety with both compounds. This review summarizes our recent research on the effects of selective GABAergic treatment in experimentally induced panic and outlines the possible role of compounds targeting the GABA binding site of the GABA(A)-benzodiazepine receptor for the treatment of panic and anxiety.     

Treatment of mitral valve prolapse and panic disorder with metoprolol

Summary: The prevalence of mitral valve prolapse (MVP) and panic disorder (PD) has been reported to range from 0-50% depending on the respective diagnostic manuals and described selection criteria. We report the case of a 44-year-old patient suffering from both panic disorder and mitral valve prolapse. While antidepressants did not result in any improvement of panic symptoms, a fast remission was achieved by treating the patient with metoprolol. This case report suggests that betablockers might represent a useful tool in the treatment of panic disorder and mitral valve prolapse.     

Personality traits associated with panic disorder: change associated with treatment

Eighty-two subjects with panic disorder completed the Personality Diagnostic Questionnaire (PDQ) before treatment and again after a period of relatively stable improvement 3 years later. At baseline, panic subjects scored higher than normal control subjects, who had been matched for age and sex, on avoidant, dependent, histrionic, and paranoid personality subscales. Improvement in panic symptoms after 3 years was associated with reductions in these same subscale scores. Examination of individual items that distinguished panic from normal subjects showed themes of dependency, lack of self-confidence, emotional instability, and sensitivity to criticism that reflected demoralization in the panic disorder subjects. To a large extent, the findings reveal nonspecific, state-dependent effects of panic and agoraphobic symptoms on the personality functioning and morale of patients with panic disorder.     

Situational exposure treatment versus panic control treatment for agoraphobia. A case study

Situational in vivo exposure has been widely used in the treatment of agoraphobia. However, only a low to moderate proportion of individuals treated with this approach have shown a high level of therapeutic gain. The recent recognition of panic as central to the development and maintenance of a great many cases of agoraphobic avoidance suggests that treatments focused directly on panic may contribute to a more comprehensive approach to agoraphobia. The present single case demonstrates that whereas two modes of situational exposure produced only limited improvement an approach focused directly on panic had greater effectiveness. The specific effects of the treatment components within the panic control package are analyzed in detail.     

The sequence of improvement of the symptoms encountered in patients with panic disorder

Patients who meet DSM-III-R criteria for a diagnosis of panic disorder often show a complex mixture of psychopathological symptoms, including panic attacks (spontaneous and situational), anxiety (anticipatory and generalized), phobias (fear and avoidance), depression/dysphoria, and social and occupational disability. Various theories about the pathogenesis of these symptoms have been advanced that focus on a given symptom (e.g., panic, phobia) being primary in these disorders, with concurrent symptoms seen as epiphenomena or as secondary and reactive to a core symptom. This study, conducted on a large sample of panic disorder patients (N = 1,168), examines the temporal sequential pattern of symptom improvement in these patients, and explores how these relationships relate to various pathogenic theories. Our multiple analyses, when considered together, tend not to support any pathogenic theory that views a given symptom as being central to the overall disorder; our findings have obvious implications for theoreticians and clinicians interested in the study and treatment of panic and anxiety disorders.     

The effects of aggression on symptom severity and treatment response in a trial of cognitive behavioral therapy for panic disorder

BackgroundPrevious research suggests that patients with panic disorder exhibit higher levels of aggression than patients with other anxiety disorders. This aggression is associated with more severe symptomatology and interpersonal problems. However, few studies have examined whether higher levels of aggression are associated with a worse treatment response in this population.MethodsThe present study sought to examine the association of aggression with panic disorder symptom severity in a sample of 379 patients who participated in a trial examining long-term strategies for the treatment of panic disorder.ResultsWe found that aggression was significantly associated with higher baseline levels of panic disorder symptoms, anxiety, depression, and functional impairment. Further, we found that patients higher in aggression did not achieve the same level of improvement in general anxiety symptoms during treatment compared to patients lower in aggression, even when controlling for baseline anxiety symptom severity.ConclusionThese results suggest that more research is needed concerning patients with anxiety disorders with higher aggression, as they may be a group in need of additional treatment considerations.     

The effects of pregnancy on preexisting panic disorder.

BACKGROUND: Limited evidence suggests that pregnancy may be associated with a reduction of panic and related symptoms. The authors investigate reported changes in panic symptoms during pregnancy. METHOD: Questionnaires asking about changes in panic and phobic avoidance symptoms during pregnancy were mailed to 129 women who had previously participated in our Anxiety Disorders Program over a 5-year period; all had diagnoses of panic disorder by DSM-III-R criteria. Reported here are responses from 22 of the women who experienced pregnancy after the onset of panic disorder. RESULTS: A majority of women (14 of 22) reported a decrease in panic symptoms during pregnancy, but significant variability in this phenomenon occurs between and within individuals. CONCLUSION: A subpopulation of women may experience improvement in panic symptoms during pregnancy, which has implications for management of these patients. Further research is needed to verify the existence of such a subpopulation and to determine an etiology.     

Relationships between depressive symptoms and panic disorder symptoms during guided internet-delivered cognitive behavior therapy for panic disorder

Abstract

Aims: The current study explore the relationship between the trajectories of primary panic disorder symptoms and secondary depressive symptoms during guided internet-delivered cognitive behaviour therapy for panic disorder.

Materials and methods: The patients (N=143) were recruited from an ongoing effectiveness study in secondary mental health outpatient services in Norway. Weekly self-reported primary panic disorder symptoms and secondary depressive symptoms were analysed.

Results: primary panic disorder symptoms and secondary depressive symptoms improved significantly during the course of treatment, and at six months follow-up. Parallel process latent growth curve modelling showed that the trajectory of depressive symptoms and trajectory of panic disorder symptoms were significantly related. A supplementary analysis with cross-lagged panel modelling showed that (1) pre-treatment depressive symptoms predicted a positive effect of panic disorder symptoms early in treatment; (2) high early treatment panic disorder symptoms predicted low depressive symptoms at post-treatment.

Conclusions: Guided ICBT for panic disorder is effective for both primary panic disorder symptoms and secondary depressive symptoms. Patients with high pre-treatment secondary depressive symptoms may constitute a vulnerable subgroup. A high level of panic disorder symptoms early in treatment seems beneficiary for depressive symptoms outcome. A time-dependent model may be necessary to describe the relationship between PAD symptoms and depressive symptoms during the course of treatment.     

Application of the relaxation technique in general hospital psychiatry

Abstract The present article demonstrates the clinical application and the efficacy of relaxation techniques in general hospital psychiatry in Japan. During April to December 1993, 20 patients were treated with progressive muscle relaxation and 'modified' autogenic training therapies. The targeted symptoms were anxiety attacks (or panic attacks), neurotic insomnia, hyperventilation syndrome, agoraphobia, chronic pain, and distress. Most patients (18/20) improved rapidly with the use of these techniques and their excellence encourages increased use in general hospital psychiatry for the following reasons. First, physically ill patients are likely to show unexpected reactions to psychotropic medications. Second, some patients prefer these treatment methods rather than medications because they feel that they are participating voluntarily in their own treatment and also because they are fearful of being addicted to tranquilizers. Third, these treatments have produced rapid improvement especially for patients with panic attacks and/or hyperventilation. This study strongly suggests that progressive muscle relaxation and 'modified' autogenic training are simple and useful methods which can be easily employed in the clinical practice of general hospital psychiatry.     

Treating panic symptoms within everyday clinical settings: the feasibility of a group cognitive behavioural intervention

Panic disorder is a common and debilitating disorder that has a prevalence rate of 3-5% in the general population. Cognitive-behavioural interventions have been shown to be an efficacious treatment for panic, although a limited number of studies have examined the effectiveness of such interventions implemented in everyday clinical settings. The aim of the following pilot study was to examine the feasibility of a brief group cognitive-behavioural intervention carried out in a clinical setting. Salient issues in determining feasibility include: representativeness of patient group treated, amount of significant clinical change displayed and resources required to carry out the intervention. A small sample of GP-referred patients displaying panic symptoms completed a 2-week intensive cognitive-behavioural intervention. Results collected post-intervention revealed significant clinical reductions in panic, anxiety and depressive symptoms and marked improvement in mobility. These improvements were maintained at 12-month follow-up. Outcomes supported the feasibility of a brief group cognitive-behavioural intervention for GP-referred patients. Implications of these results are discussed in terms of implementing effective treatments in everyday clinical practice and developing a stepped care approach to treating panic symptoms.     

Changes in anxiety sensitivity with pharmacotherapy for panic disorder

Fear of anxiety symptoms (anxiety sensitivity) has been implicated in the etiology and maintenance of panic disorder, and has been shown to improve with cognitive-behavioral treatment. The impact of pharmacotherapy on anxiety sensitivity is less clear. We administered the Anxiety Sensitivity Index (ASI) during a 12-week randomized controlled trial investigating the relative efficacy of paroxetine, paroxetine plus sustained clonazepam, and paroxetine plus brief clonazepam for patients with panic disorder. We found a mean reduction in ASI scores of 9.6 points, which correlated with symptomatic improvement, and did not differ significantly between groups. Our data provides further evidence that pharmacotherapy leads to significant acute reductions in fears of anxiety symptoms in patients with panic disorder, albeit at levels that may be somewhat less than the changes associated with CBT. Implications of these findings are discussed relative to optimizing pharmacologic treatment of panic disorder.     

The latent structure of anxiety symptoms in anxiety disorders.

OBJECTIVE: Research in the psychopathology of panic and anxiety disorders, particularly agoraphobia, suggests that fear of fear may be the basis of these conditions. However, there is little empirical research on the definition and validity of the concept of fear of fear in a clinical study group. The authors' aims are 1) to determine empirically if particular associations between symptoms and beliefs exist in a group of patients with anxiety disorders and what underlying dimensions of perceived threat they represent and 2) to assess the relative importance of these associations in agoraphobia with panic attacks, panic disorder, social phobia, and generalized anxiety disorder. METHOD: In an anxiety disorders treatment unit, 390 outpatients with anxiety disorders diagnosed according to DSM-III criteria completed the Anxiety Symptoms and Beliefs Scale. RESULTS: A principal components analysis of the patients' ratings on the Anxiety Symptoms and Beliefs Scale produced a four-factor solution in which specific sets of anxiety symptoms loaded with specific beliefs. These four factors were interpreted as respiratory symptoms, vestibular symptoms, autonomic arousal, and psychological threat. Respiratory and vestibular symptoms were more associated with panic disorder diagnoses than with social phobia and generalized anxiety disorder diagnoses. CONCLUSIONS: These findings support a conception of fear of fear in anxiety disorders as fearful beliefs concerning the experience of anxiety symptoms. Associations between symptoms and fear of fear are present across anxiety disorders but are most pronounced in agoraphobia with panic attacks.     

A pilot study of sensation-focused intensive treatment for panic disorder with moderate to severe agoraphobia: preliminary outcome and benchmarking data

This report presents results of a treatment for panic disorder with moderate to severe agoraphobia (PDA-MS) called sensation-focused intensive treatment (SFIT). SFIT is an 8-day intensive treatment that combines features of cognitive- behavioral treatment for panic disorder, such as interoceptive exposure and cognitive restructuring with ungraded situational exposure. SFIT focuses on feared physical sensations as well as agoraphobic avoidance. Preliminary data support the utility of SFIT in improving PDA-MS. The goal of this exploratory study was to further investigate the effectiveness of SFIT and evaluate factors related to treatment outcome, including severity of panic symptoms, gender, comorbidity, self-efficacy, and place of residence (local vs. remote). SFIT was found to be effective in decreasing panic symptoms from pre- to posttreatment, with treatment gains maintained at follow-up. The implications of these findings for the treatment of PDA are discussed.     

Behavior therapy for panic disorder

Eleven patients who met DSM-III criteria for panic disorder were treated with behavior therapy techniques. Seven patients had mixed phobic avoidance and none were agoraphobic; three had no phobic symptoms. Mean duration of symptoms was 3.4 years. Treatment lasted a mean of 14 weeks and consisted of 1) education about physiology and management of panic symptoms; 2) relaxation, abdominal breathing, and cognitive anxiety management skills; and 3) imaginal and in vivo exposure. Upon termination of treatment, 10 of 11 patients were panic-free and six of seven mixed phobics showed complete remission or significant improvement of phobias. Follow-up data revealed excellent stability of remission. Clinical implications for the use of behavior therapy for panic disorder and directions for future research are discussed.