Nociones básicas para el tratamiento del Pánico desde la postura de la Terapia Cognitiva Conductual

1. Cognitive Behavioral Treatment of
Panic Disorder
The original version of these slides was provided by
Michael W. Otto, Ph.D. & Heather W. Murray, Ph.D.,
with support from NIMH Excellence in Training Award
at the Center for Anxiety and Related Disorders at
Boston University
(R25 MH08478)

2. Use of this Slide Set
• Presentation information is listed in the
notes section below the slide (in PowerPoint
normal viewing mode).
• A bibliography for this slide set is provided
below in the note section for this slide.
• References are also provided in note
sections for select subsequent slides

3. Panic Disorder
Diagnostic Considerations

4. DSM Panic Attacks:
Defined by 4 or more of the following 13 symptoms
11 Somatic Symptoms
• Increased heart rate
• Shortness of breath
• Chest pain
• Choking sensation
• Trembling
• Sweating
• Nausea
• Dizziness
• Numbness/Tingling
• Hot flashes or chills
• Depersonalization
2 Cognitive Symptoms
• Fear of dying
• Fear of losing control

5. Panic Disorder
• Recurrent unexpected panic attacks
Criterion B
• Worry about future attacks
• Worry about the consequences of the attack
(i.e., having a heart attack)
• Substantial behavioral changes in response
to the attacks

6. Agoraphobia
• Anxiety about being in situations related to
perceived inability to escape or get help if a
panic attack occurs
• Situations are avoided or endured with
significant distress

7. Core Patterns in Panic Disorder
• Fears of symptoms of anxiety (anxiety
sensitivity)
– Risk for onset of panic attacks
– Risk for biological provocation of panic
– Risk for panic disorder relapse
(McNally , 2002)

8. Common Catastrophic Thoughts
in Panic Disorder
• Fears of death or disability
– Am I having a heart attack?
– I am having a stroke!
– I am going to suffocate!
• Fears of losing control/insanity
– I am going to lose control and scream
– I am having a nervous breakdown
– If I don’t escape, I will go crazy
• Fears of humiliation or embarrassment
– People will think something is wrong with me
– They will think I am a lunatic
– I will faint and be embarrassed

10. Alarm Reaction
Rapid heart rate, heart palpitations
Shortness of breath, smothering sensations
Chest pain or discomfort, numbness or tingling
Increased anxiety and fear
Catastrophic misinterpretations
of symptoms
Hypervigilance to symptoms
Anticipatory anxiety
Memory of past attacks
Cognitive-Behavioral Model of
Panic Disorder Stress
Biological Diathesis
Conditioned
Fear of
Somatic Sensations

11. Case example
• Abby, a 29 year old female, reports unexpected
panic attacks and describes increased heart rate,
lightheadedness, shortness of breath, and tingling
sensations in her arms. When she experiences
these episodes, she believes that she is going to
faint; she describes fainting as both embarrassing
and dangerous. She worries about having these
episodes when in public places and places where
getting help would be difficult. Because of her
fear, she avoids going to public places alone and
always carries her cell phone in case she needs to
call for help.

12. Elements of
Cognitive Behavior Therapy
for Panic Disorder

13. Core Elements of CBT
• Psychoeducation/ Informational
intervention
• Cognitive interventions
• Interoceptive (internal) exposure
• In vivo exposure
• Can be delivered in individual or group
treatment formats

14. Information Interventions
• May include handouts or patient manuals
• Distinguishes between symptoms, thoughts, and
behaviors – and introduces the cascade between these
elements
• Introduces the notion and consequences of catastrophic
thoughts
• Addresses the role of escape and avoidance in
maintaining fear
• Helps the patient adopt an informed and active role in
treatment

15. Cognitive Restructuring - General
• Identify the nature of thoughts: they don’t
have to be true to affect emotions
• Learn about common biases in thoughts
• Treat thoughts as “guesses” or “hypotheses”
about the world

16. Cognitive Restructuring - Specific
• Increase awareness of thinking patterns
– Over-estimating the probability of negative outcomes
– Assuming the consequence will be unmanageable
• Monitor relationship between thinking and panic
episodes
• Challenge thinking
– Evaluating evidence for the thought
– Evaluating the cost of the feared outcome
• Establish adaptive thinking patterns
– Reality based thinking and not just positive thinking

17. Exposure Interventions
• Provide rationale for confronting feared
situations
• Establish a hierarchy of feared situations
• Provide accurate expectations
• Repeat exposure until fear diminishes
• Attend to the disconfirmation of fears
(“What was learned from the exposure?”)

18. Interoceptive Exposures
(exposures to internal sensations)
Rationale:
• Provide opportunities to examine negative
predictions about internal sensations
• Provide opportunities to increasing tolerance to
and acceptance of internal sensations though
repeated exposure to sensations
Method:
• Engage in systematic exercises that induce feared
internal sensations (i.e., dizziness, increased heart
rate).

19. Common Interoceptive Exposure Procedures
• Headrolling – 30 seconds - dizziness, disorientation
• Hyperventilation – 1 minute - produces dizziness
lightheadedness, numbness, tingling, hot flushes, visual
distortion
• Stair running – a few flights – produces breathlessness,
a pounding heart, heavy legs, trembling
• Full body tension – 1 minute – produces trembling,
heavy muscles, numbness
• Chair spinning – several times around – produces strong
dizziness, disorientation
• Mirror (or hand) staring – 1 minute – produces
derealization

20. Uh oh!
What if:
•This gets worse?
•I lose control?
•This is a stroke?
I have to control
this!
Panic Cycle Relative Comfort
•Notice the
sensation
•Do nothing to
control it.
•Relax WITH
the sensation

21. Learning Safety in Panic
Interoceptive exposure
• Feared sensations become safe sensations
– in the office with the therapist
– at home
– independent of the treatment context

22. Situational Exposures
• Rationale:
– Providing a new learning opportunity to
examine negative predictions about feared
outcomes
– Increasing tolerance to internal sensations in
feared situations

23. Situational Exposure Guidelines
• Prior to completing in-vivo exposures, create a
fear hierarchy identifying feared and avoided
situations
• Identify safety behaviors- actions taken to avoid,
prevent, or manage a potential threat
– Avoidance
– Checking (pulse, exits, hospitals)
– Carrying aids (rescue medications, cellular phones)

24. Application of CBT
• An effective first-line treatment
• A replacement strategy for medication
treatment (medication discontinuation)
• In combination with medication treatment
– Treatment resistance
– Standard strategy

25. CBT for Panic Disorder
And it is acceptable, tolerable, and cost effective

26. Meta-Analytic Results of
Panic Disorder Treatment Studies
CBT Benzo-
diazepines
Effect
Size
(Cohen’s
d)
CBT
(IE+CR)
Non-SSRI
Antide-
pressants
SSRIs
Antide-
pressants
Gould et al, 1995; Otto et al., 2001

27. CBT for Panic Disorder
In addition to core panic, anxiety, and avoidance
outcomes, CBT has broader-based benefits,
including:
• Improvements in quality of life
• Improvement in comorbid conditions
(e.g., Allen et al., 2010; Telch et al., 1995; Tsao et al., 1998)

29. Treatment Acceptability
(dropout rates)
Percent
Dropout

30. Treatment Acceptability
Refusal Rate in the Multicenter Panic Trial
1
34
0
5
10
15
20
25
30
35
CBT Imipramine
Hofmann SG, et al. Am J Psychiatry. 1998;155:43-47.
Treatment
Percent

31. Strategies to Enhance CBT
• Combination with standard
pharmacotherapy (CBT plus antidepressants
or benzodiazepines)
– Some acute benefits
– Benefits lost with medication discontinuation
• Novel combination treatment
– Memory enhancers

32. Panic Disorder:
Continuation Treatment
0
10
20
30
40
50
60
CBT + imipramine
CBT + placebo
CBT
Imipramine
Placebo
%
Responders
(40%

PDSS)
Barlow DH, et al. JAMA. 2000;283:2529-2536.
Maintenance (ITT) 6 More Months

33. Panic Disorder:
Post–Imipramine Discontinuation
0
10
20
30
40
50
60
CBT + imipramine
CBT + placebo
CBT
Imipramine
Placebo
%
Responders
(40%

PDSS)
Barlow DH, et al. JAMA. 2000;283:2529-2536.
6 Months Treatment Discontinuation (ITT)
(Imipramine over 1 to 2 weeks)

34. Panic Disorder:
After 8 Weeks of Treatment
-0.1
0.1
0.3
0.5
0.7
0.9
1.1
1.3 EXP + ALP
EXP + PBO
ALP + Relax
Effect Size
(CGI relative to PR)
EXP = exposure treatment.
ALP = alprazolam treatment.
PBO = placebo treatment.
Relax = relaxation treatment.
Marks IM et al. Br J Psychiatry.1993;162:776-787.

35. Panic Disorder: Post Benzodiazepine
Discontinuation (Week 18)
-0.3
-0.1
0.1
0.3
0.5
0.7
0.9
1.1
1.3 EXP + ALP
EXP + PBO
ALP + Relax
Effect Size
(CGI relative to PR)
EXP = exposure treatment.
ALP = alprazolam treatment.
PBO = placebo treatment.
Relax = relaxation treatment.
Marks IM et al. Br J Psychiatry.1993;162:776-787.

36. The Solution
• Apply (re-apply) CBT at the time of
medication taper and thereafter
• Remember, it works for medication
discontinuation with expansion of treatment
gains
– Treatment with benzodiazepines1,2
– Treatment with SSRIs3,4
1Otto MW et al. Psychopharmacol Bull. 1992;28:123-130.
2Spiegel DA et al. Am J Psychiatry. 1994;151:876-881.
3Schmidt NB et al. Behav Res Ther. 2002;40:67-73.
4Whittal ML et al. Behav Res Ther. 2001;39:939-945.

37. Greater success with a novel
combination strategy
• Combination of CBT with the putative memory
enhancer, d-cycloserine
• 2 small treatment trials suggest that d-cycloserine
helps consolidate therapeutic learning from
exposure, helping speed treatment outcome
• Similar benefits for d-cycloserine + exposure is
seen for other anxiety disorders

38. Preventive Treatment
• Target a putative risk factor for Panic
Disorder (anxiety sensitivity)
• 5-hour prevention workshop:
– Psychoeducation
– Cognitive restructuring
– Interoceptive exposure
– Instruction for in vivo exposure
Gardenswartz CA, Craske MG. Behav Ther. 2001;32:725-738.

39. Preventive Treatment
13.6
1.8
0
5
10
15
20
25
Wait List
Workshop
%
Developing
Panic
Disorder
121 Participants
Gardenswartz CA, Craske MG. Behav Ther. 2001;32:725-738.

40. Exporting Treatment:
Benchmarking Research
• CBT for panic disorder can be transported to
a community setting and achieve
effectiveness in accordance with
expectations from clinical trials
Wade WA, et al. J Consult Clin Psychol. 1998;66:231-239.