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Adding Cognitive-Behavioral Therapy to Pharmacotherapy for Panic Disorder: Issues and Strategies

Published online by Cambridge University Press:  07 November 2014

Michael W. Otto ,
Mark Powers  and
Jasper A. J. Smits
Michael W. Otto*
Affiliation:
Dr. Otto is professor of psychology and Mr. Powers is research associate in the Department of Psychology at. Boston University in Massachusetts
*
Michael W. Otto, PhD, Center for Anxiety and Related Disorders, Boston University, 648 Beacon St, 4th floor, Boston, MA 02114; Tel: 617-358-0761; Fax: 617-353-9609; E-mail: mwotto@bu.edu.
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Abstract

Despite ample evidence of the efficacy of cognitive-behavioral therapy (CBT) for the treatment of patients with panic disorder (PD), dissemination of this evidence is proceeding slowly. This article highlights some of the issues surrounding the dissemination of CBT for PD and suggests strategies for integrating CBT with pharmacotherapy. Treatment principles, with attention to the modification of CBT protocols for use in a brief-contact format, are reviewed. The principles and application of exposure interventions are discussed for both in vivo (situational) and interoceptive (feared anxiety sensations) exposure, with emphasis on the learning of safety in the context of feared sensations of anxiety. Contextual factors that may affect the success of exposure interventions and cognitive and informational interventions are also discussed.

Information

Type
Research Article
Information
CNS Spectrums , Volume 10 , Issue S12 , September 2005 , pp. 32 - 39
Copyright
Copyright © Cambridge University Press 2005

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References

1.Otto, MW, Pollack, MH, Maki, KM. Empirically supported treatments for panic disorder: costs, benefits, and stepped care. J Consult Clin Psychol. 2000;68:556–563.CrossRefGoogle ScholarPubMed
2.Margraf, J, Barlow, DH, Clark, DM, Telch, MJ. Psychological treatment of panic: work in progress on outcome, active ingredients, and follow-up. Behav Res Ther. 1993;31:1–8.CrossRefGoogle ScholarPubMed
3.Clark, DM, Salkovskis, PM, Hackmann, A, Middleton, H, Anastasiades, P, Gelder, M. A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. Br J Psychiatry. 1994;164:759–69.CrossRefGoogle ScholarPubMed
4.Gould, RA, Otto, MW, Pollack, MH. A meta-analysis of treatment outcome for panic disorder. Clin Psychol Rev. 1995;15:819–844.CrossRefGoogle Scholar
5.Barlow, DH, Gorman, JM, Shear, MK, Woods, SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. JAMA. 2000;283:2529–2536.CrossRefGoogle ScholarPubMed
6.Hofmann, SG, Barlow, DH, Papp, LA, et al.Pretreatment attrition in a comparative treatment outcome study on panic disorder. Am J Psychiatry. 1998;155:43–47.CrossRefGoogle Scholar
7.Craske, MG, Brown, TA, Barlow, DH. Behavioral treatment of panic: a two year follow-up. Behav Ther. 1991;22:289–304.CrossRefGoogle Scholar
8.Tsao, JC, Lewin, MR, Craske, MG. Effects of cognitive-behavior therapy for panic disorder on comorbid conditions: replication and extension. Behav Ther. 2002;33:493–509.CrossRefGoogle Scholar
9.Telch, MJ, Schmidt, NB, Jaimez, TL, Jacquin, KM, Harrington, PJ. Impact of cognitive-behavioral treatment on quality of life in panic disorder patients. J Consult Clin Psychol. 1995;63:823–830.CrossRefGoogle ScholarPubMed
10.Telch, MJ, Lucas, RA. Combined pharmacological and psychological treatment of panic disorder; current status and future directions. In: Wolfe, BE, Maser, JD, eds. Treatment of Panic Disorder. Washington DC: American Psychiatric Association Press; 1994:177–197.Google Scholar
11.Schmidt, NB, Wollaway-Bickel, K, Trakowski, JH, Santiago, HT, Vasey, M. Antidepressant discontinuation in the context of cognitive behavioral treatment for panic disorder. Behav Res Ther. 2002;40:67–73.CrossRefGoogle ScholarPubMed
12.Mavissakalian, M. Sequential combination of imipramine and self-directed exposure in the treatment of panic disorder with agoraphobia. J Clin Psychiatry. 1990;51:184–188.Google ScholarPubMed
13.Marks, IM, Swinson, RP, Basoglu, M, et al.Alprazolam and exposure alone and combined in panic disorder with agoraphobia. A controlled study in London and Toronto. Br J Psychiatry. 1993;162:776–787.CrossRefGoogle ScholarPubMed
14.Whittal, ML, Otto, MW, Hong, JJ. Cognitive-behavior therapy for discontinuation of SSRI treatment of panic disorder: a case series. Behav Res Ther. 2001;39:939–945.CrossRefGoogle ScholarPubMed
15.Otto, MW, Hong, JJ, Safren, SA. Benzodiazepine discontinuation difficulties in panic disorder: conceptual model and outcome for cognitive-behavior therapy. Curr Pharm Des. 2002;8:75–80.CrossRefGoogle ScholarPubMed
16.Pollack, MH, Otto, MW, Kaspi, SP, Hammerness, PG, Rosenbaum, JF. Cognitive behavior therapy for treatment-refractory panic disorder. J Clin Psychiatry. 1994;55:200–205.Google ScholarPubMed
17.Otto, MW, Pollack, MH, Penava, SJ, Zucker, BG. Group cognitive-behavior therapy for patients failing to respond to pharmacotherapy for panic disorder: a clinical case series. Behav Res Ther. 1999;37:763–770.CrossRefGoogle ScholarPubMed
18.Heldt, E, Manfro, GG, Kipper, L, et al.Treating medication-resistant panic disorder: predictors and outcome of cognitive-behavior therapy in a Brazilian public hospital. Psychother Psychosom. 2003;72:43–48.CrossRefGoogle Scholar
19.Heldt, E, Manfro, GG, Kipper, L, Blaya, C, Isolan, L, Otto, MW. One-year follow-up of pharmacotherapy-resistant patients with panic disorder treated with cognitive-behavior therapy: outcome and predictors of remission. Behav Res Ther. In press.Google Scholar
20.Hirschmann, S, Dannon, PN, Iancu, I, Dolberg, OT, Zohar, J, Grunhaus, L. Pindolol augmentation in patients with treatment-resistant panic disorder: A double-blind, placebo-controlled trial. J Clin Psychopharmacol. 2000;20:556–559.CrossRefGoogle ScholarPubMed
21.Khaldi, S, Kornreich, C, Dan, B, Pelc, I. Usefulness of olanzapine in refractory panic attacks. J Clin Psychopharmacol. 2003;23:100–101.CrossRefGoogle ScholarPubMed
22.Pollack, MH, Matthews, J, Scott, EL. Gabapentin as a potential treatment for anxiety disorders. Am J Psychiatry. 1998;155:992–3.CrossRefGoogle ScholarPubMed
23.Addis, ME, Hatgis, C, Krasnow, AD, Jacob, K, Bourne, L, Mansfield, A. Effectiveness of cognitive--behavioral treatment for panic disorder versus treatment as usual in a managed care setting. J Consult Clin Psychol. 2004;72:625–635.CrossRefGoogle Scholar
24.Stuart, GL, Treat, TA, Wade, WA. Effectiveness of an empirically based treatment for panic disorder delivered in a service clinic setting: 1-year follow-up. J Consult Clin Psychol. 2000;68:506–512.CrossRefGoogle Scholar
25.Wade, WA, Treat, TA, Stuart, GL. Transporting an empirically supported treatment for panic disorder to a service clinic setting: a benchmarking strategy. J Consult Clin Psychol. 1998;66:231–239.CrossRefGoogle ScholarPubMed
26.Goisman, RM, Warshaw, MG, Keller, MB. Psychosocial treatment prescriptions for generalized anxiety disorder, panic disorder, and social phobia, 1991-1996. Am J Psychiatry. 1999;156:1819–21.CrossRefGoogle ScholarPubMed
27.Stein, MB, Sherbourne, CD, Craske, MG, et al.Quality of care for primary care patients with anxiety disorders. Am J Psychiatry. 2004;161:2230–2237.CrossRefGoogle ScholarPubMed
28.Addis, ME. Methods for disseminating research products and increasing evidence-based practice: promises, obstacles, and future directions. Clin Psychol Sci Pract. 2002;9:367–378.CrossRefGoogle Scholar
29.Gotham, HJ. Diffusion of mental health and substance abuse treatments: development. dissemination, and implementation. Clin Psychol Sci Pract. 2004;11:160–176.CrossRefGoogle Scholar
30.Stirman, SW, Chrits-Shristoph, P, DeRubeis, RJ. Achieving successful dissemination of empirically supported psychotherapies: a synthesis of dissemination theory. Clin Psychol Sci Pract. 2004;11:343–359.CrossRefGoogle Scholar
31.Craske, MG, Barlow, DH, Meadows, EA. Mastery of Your Anxiety and Panic: Therapist Guide for Anxiety, Panic, and Agoraphobia. 3rd ed. Oxford: Oxford University Press (Graywind Publications); 2000.Google Scholar
32.Zinbarg, RE, Craske, MG, Barlow, DH. Mastery of Your Anxiety and Worry: Therapists Guide (Treatments That Work). Oxford: Oxford University Press (Graywind Publications); 1993.Google Scholar
33.Barlow, DA, Allen, LB, Choate, ML. Toward a unified treatment for emotional disorders. Behav Ther. 2004;35:205–230.CrossRefGoogle Scholar
34.Otto, MW, Jones, JC, Barlow, DH, Craske, MG. Stopping Anxiety Medication (SAM): Panic Control Therapy for Benzodiazepine Discontinuation. San Antonio, Texas: Oxford University Press; 1996.Google Scholar
35.Salkovskis, PM, Clark, DM, Hackmann, A. Treatment of panic attacks using cognitive therapy without exposure or breathing retraining. Behav Res Ther. 1991;29:161–166.CrossRefGoogle ScholarPubMed
36.Beck, AT, Sokol, L, Clark, DA, Berchick, R, Wright, F. A crossover study of focused cognitive therapy for panic disorder. Am J Psychiatry. 1992;149:778–783.Google ScholarPubMed
37.Clark, DM, Salkovskis, PM, Hackmann, A, Wells, A, Ludgate, J, Gelder, M. Brief cognitive therapy for panic disorder: a randomized controlled trial. J Consult Clin Psychol. 1999;67:583–589.CrossRefGoogle ScholarPubMed
38.Craske, MG, Maidenberg, E, Bystritsky, A. Brief cognitive-behavioral versus nondirective therapy for panic disorder. J Behav Ther Exp Psychiatry. 1995;26:113–120.CrossRefGoogle ScholarPubMed
39.Hecker, JE, Losee, MC, Roberson-Nay, R, Maki, K. Mastery of Your Anxiety and Panic and brief therapist contact in the treatment of panic disorder. J Anxiety Disord. 2004;18:111–126.CrossRefGoogle ScholarPubMed
40.Otto, MW, Smits, JA, Reese, HE. Cognitive-behavioral therapy for the treatment of anxiety disorders. J Clin Psychiatry. 2004;65(suppl 5):34–41.Google ScholarPubMed
41.Clark, DM. A cognitive approach to panic. Behav Res Ther. 1986;24:461–470.CrossRefGoogle ScholarPubMed
42.McNally, RJ. Psychological approaches to panic disorder: a review. Psychol Bull. 1990;108:403–419.CrossRefGoogle ScholarPubMed
43.Barlow, DH. Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic. New York, NY: The Guilford Press; 1988.Google Scholar
44.Bouton, ME, Mineka, S, Barlow, DH. A modern learning theory perspective on the etiology of panic disorder. Psychol Rev. 2001;108:4–32.CrossRefGoogle ScholarPubMed
45.Salkovskis, PM, Clark, DM, Gelder, MG. Cognition-behaviour links in the persistence of panic. Behav Res Ther. 1996;34:453–458.CrossRefGoogle Scholar
46.Manfro, GG, Otto, MW, McArdle, ET, Worthington, JJ 3, Rosenbaum, JF, Pollack, MH. Relationship of antecedent stressful life events to childhood and family history of anxiety and the course of panic disorder. J Affect Disord. 1996;41:135–139.CrossRefGoogle ScholarPubMed
47.Jang, KL, Stein, MB, Taylor, S, Livesley, WJ. Gender differences in the etiology of anxiety sensitivity: a twin study. J Gend Specif Med. 1999;2:39–44.Google ScholarPubMed
48.Peterson, RA, Reiss, S. Anxiety Sensitivity Index Manual. Worthington, Ohio: IDS; 1987.Google Scholar
49.McNally, RJ. Anxiety sensitivity and panic disorder. Biol Psychiatry. 2002;52:938–946.CrossRefGoogle ScholarPubMed
50.Gardenswartz, CA, Craske, ME. Prevention of panic disorder. Behav Ther. 2001;32:725–737.CrossRefGoogle Scholar
51.Park, JM, Mataix-Cols, D, Marks, IM, et al.Two-year follow-up after a randomised controlled trial of self- and clinician-accompanied exposure for phobia/panic disorders. Br J Psychiatry. 2001;178:543–548.CrossRefGoogle ScholarPubMed
52.Sutherland, SM, Davidson, JRT. B-blockers and benzodiazepines in pharmacotherapy. In: Stein, MB, ed. Social Phobia: Clinical and Research Perspectives. Washington DC: American Psychiatric Press; 1995:323–6.Google Scholar
53.Powers, MB, Smits, J, Leyro, TM, Otto, M. Translational Research Perspectives on Maximizing the Effectiveness of Exposure Therapy. Academic Press; 2005. In press.Google Scholar
54.Bouton, ME. Context, ambiguity, and unlearning: sources of relapse after behavioral extinction. Biol Psychiatry. 2002;52:976–986.CrossRefGoogle ScholarPubMed
55.Otto, MW, Smits, JAJ, Reese, HE. Combined psychotherapy and pharmacotherapy for mood and anxiety disorders in adults: review and analysis. Clin Psychol Sci Pract. 2005;12:72–86.CrossRefGoogle Scholar
56.Bouton, ME, Kenney, FA, Rosengard, C. State-dependent fear extinction with two benzodiazepine tranquilizers. Behav Neurosci. 1990;104:44–55.CrossRefGoogle ScholarPubMed
57.Craske, MG, Lang, AJ, Aikens, D, Mystowski, JL. Cognitive behavioral therapy for nocturnal panic. Behav Ther. 2005;36:43–54..CrossRefGoogle Scholar
58.Broman-Fulks, JJ, Berman, ME, Rabian, BA, Webster, MJ. Effects of aerobic exercise on anxiety sensitivity. Behav Res Ther. 2004;42:125–136.CrossRefGoogle ScholarPubMed
59.Broocks, A, Bandelow, B, Pekrun, G, et al.Comparison of aerobic exercise, clomipramine, and placebo in the treatment of panic disorder. Am J Psychiatry. 1998;155:603–609.CrossRefGoogle ScholarPubMed
60.Ito, LM, de Araujo, LA, Tess, VL, Barros-Neto, TP, Asbahr, FR, Marks, I. Self-exposure therapy for panic disorder with agoraphobia: randomised controlled study of external v. interoceptive self-exposure. Br J Psychiatry. 2001;178:331–336.CrossRefGoogle ScholarPubMed
61.Otto, MW, Pollack, MH, Barlow, DH. Stopping Anxiety Medication: Client Workbook. Oxford University Press (Graywind Publications); 1996.Google Scholar
62.Salkovskis, PM, Clark, DM, Hackmann, A, Wells, A, Gelder, MG. An experimental investigation of the role of safety-seeking behaviours in the maintenance of panic disorder with agoraphobia. Behav Res Ther. 1999;37:559–574.CrossRefGoogle ScholarPubMed
63.Lidren, DM, Watkins, PL, Gould, RA, Clum, GA, Asterino, M, Tulloch, HL. A comparison of bibliotherapy and group therapy in the treatment of panic disorder. J Consult Clin Psychol. 1994;62:865–869.CrossRefGoogle ScholarPubMed
64.Association for Advancement of Behavior Therapy. Available at: http://www.aabt.org. Accessed August 2005.Google Scholar
65.Anxiety Disorders Association of America. Available at: http://www.adaa.org. Accessed August 2005.Google Scholar