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Cognitive-Behavioral Therapy for Panic Disorder: A Review of Treatment Elements, Strategies, and Outcomes

Published online by Cambridge University Press:  07 November 2014

Abstract

This article provides an overview of cognitive-behavioral therapy (CBT) for panic disorder. CBT is currently considered a first-line treatment for panic disorder. It offers benefit after short-term intervention, typically consisting of 12–15 sessions conducted in either an individual or a group format. The treatment focuses on the elimination of the patterns that underlie and perpetuate the disorder. Through CBT, patients learn about the nature of the disorder and acquire a set of strategies that counter the fears of panic attacks themselves, and break the recurring cycle of anticipatory anxiety, panic, and agoraphobic avoidance. The collaborative format of treatment, and a focus on elimination of core fears may be factors in enhancing longer-term outcome. In this article, we review the efficacy of CBT as a first-line treatment, a strategy for medication nonresponders, a replacement strategy for patients who wish to discontinue pharmacotherapy, and a potential preventive strategy for at-risk individuals. We also discuss some of the complex issues involved with combination-treatment strategies.

Type
Review
Copyright
Copyright © Cambridge University Press 2003

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References

REFERENCES

1.Harvey, JM, Richards, JC, Dziadosz, T, Swindell, A. Misinterpretation of ambiguous stimuli in panic disorder. Cogn Ther Res. 1993;17:235248.CrossRefGoogle Scholar
2.McNally, RJ, Foa, EB. Cognition and agoraphobia: bias in the interpretation of threat. Cogn Ther Res. 1987;11:567581.CrossRefGoogle Scholar
3.Barlow, DH. Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic. New York, NY: Guilford Press; 2001.Google Scholar
4.Clark, DM. A cognitive approach to panic. Behav Res Ther. 1986;24:461470.CrossRefGoogle ScholarPubMed
5.McNally, RJ. Psychological approaches to panic disorder: a review. Psychol Bull. 1990;108:403419.CrossRefGoogle ScholarPubMed
6.Barlow, DH, Craske, MG. Mastery of Your Anxiety and Panic. Albany, NY: Graywind; 1989.Google Scholar
7.Salkovskis, PM, Clark, DM, Gelder, MG. Cognitive-behavior links in the persistence of panic. Behav Res Ther. 1996;34:453458.CrossRefGoogle Scholar
8.Salkovskis, PM. The importance of behavior in the maintenance of anxiety and panic: a cognitive account. Behav Psychother. 1991;19:619.CrossRefGoogle Scholar
9.Salkovskis, PM. Avoidance behavior is motivated by threat beliefs: a possible resolution of the cognitive-behavior debate. In: Salkovskis, PM, ed. Key Trends in Cognitive-Behavior Therapy. New York, NY: Wiley; 1996.Google Scholar
10.McNally, RH. Anxiety sensitivity and panic disorder. Biol Psych. In press.Google Scholar
11.Otto, MW, Reilly-Harrington, N. The impact of treatment on anxiety sensitivity. In: Taylor, S, ed: Anxiety Sensitivity: Theory, Research and Treatment of the Fear of Anxiety. Mahwah, NJ: Lawrence Erlbaum; 1999.Google Scholar
12.Hoffart, A. Cognitive and guided mastery therapy of agoraphobia: long-term outcome and mechanisms of change. Cogn Ther Res. 1998;22:195207.CrossRefGoogle Scholar
13.Gardenschwartz, CA, Craske, MG. Prevention of panic disorder. Behav Ther. 2001;32:725737.CrossRefGoogle Scholar
14.Schmidt, NB, Woolaway-Bickel, K, Trakowski, J, et al.Dismantling cognitive-behavioral treatment for panic disorder: questioning the utility of breathing retraining. J Consult Clin Psychol. 2000;68:417424.CrossRefGoogle ScholarPubMed
15.Craske, MG, Brown, TA, Barlow, DH. Behavioral treatment of panic: a two year follow-up. Behav Ther. 1991;22:289304.CrossRefGoogle Scholar
16.Craske, MG, Meadows, E, Barlow, DH. Mastery of Your Anxiety and Panic and Agoraphobia Supplement (Therapist Guide). 2nd ed. San Antonio, TX: Psychological Corporation; 1994.Google Scholar
17.Margraf, J, Schneider, S. Panik: Angstanfaelle und ihre Behandlung. Berlin, Germany: Springer; 1990.CrossRefGoogle Scholar
18.Otto, MW, Jones, JC, Craske, MG, Barlow, DH. Stopping Anxiety Medication: Panic Control Therapy for Bezodiazepine Discontinuation (Therapist Guide). San Antonio, TX: Psychological Corporation; 1996.Google Scholar
19.Otto, MW, Pollack, MH, Barlow, DH. Stopping Anxiety Medication: A Workbook for Patients Wanting to Discontinue Benzodiazepine Treatment for Panic Disorder. Albany, NY: Graywind Publications; 1995.Google Scholar
20.Öst, LG. A maintenance program for behavioural treatment of anxiety disorders. Behav Res Ther. 1980;27:123130.CrossRefGoogle Scholar
21.Jansson, L, Jerremalm, A, Ost, LG. Follow-up of agoraphobia patients treated with exposure, in vivo, or applied relaxation. Br J Psychiatry. 1986;149:486490.CrossRefGoogle ScholarPubMed
22.Beck, AT. Cognitive Therapy and the Emotional Disorders. New York, NY: International University Press; 1976.Google Scholar
23.Ellis, A. Changing rational-emotive therapy (RET) to rational emotional behavior therapy (REBT). Behav Ther. 1993;16:257258.Google Scholar
24.Ellis, A. Fundamentals of rational-emotive therapy for the 1990s. In: Dryden, W, Hill, L, eds. Innovations in Rational-Emotive Therapy. Newbury Park, CA: Sage; 1993.Google Scholar
25.Young, JE, Weinberger, AD, Beck, AT. Cognitive therapy for depression. In: Barlow, DH, ed. Clinical Handbook of Psychological Disorders. 3rd ed. New York, NY: Guilford Press; 2001.Google Scholar
26.Otto, MW. Stories and metaphors in cognitive-behavior therapy. Cogn Behav Pract. 2000;7:166172.CrossRefGoogle Scholar
27.Clum, GA, Clum, G, Surls, R. A meta-analysis of treatments for panic disorder. J Consult Clin Psychol. 1993;61:317326.CrossRefGoogle ScholarPubMed
28.Gould, RA, Otto, MW, Pollack, MH. A meta-analysis of treatment outcome for panic disorder. Clin Psychol Rev. 1995;15:819844.CrossRefGoogle Scholar
29.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;66:231239.CrossRefGoogle ScholarPubMed
30.Otto, MW, Tuby, KS, Gould, RA, McLean, RYS, Pollack, MH. An effect-size analysis of the relative efficacy and tolerability of serotonin selective reuptake inhibitors for panic disorder. Am J Psychiatry. 2001;158:19891992.CrossRefGoogle ScholarPubMed
31.Clark, DM, Salkovskis, PM, Hackmann, A, Middleton, H, Pavlos, A, Gelder, M. A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. Br J Psychiatry. 1994;164:759769.CrossRefGoogle ScholarPubMed
32.Klosko, JS, Barlow, DH, Tassinari, RB, Cerny, JA. Comparison of alprazolam and behavior therapy in the treatment of panic disorder. J Consult Clin Psychol 1990;58:7784.CrossRefGoogle ScholarPubMed
33.Marks, IM, Swinson, RP, Basaglu, 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;162:776787.CrossRefGoogle ScholarPubMed
34.Barlow, DH, Gorman, JM, Shear, MK, Woods, SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder. JAMA. 2000;283:25292536.CrossRefGoogle ScholarPubMed
35.American Psychiatric Association. Practice guidelines for the treatment of patients with panic disorder. In: Practice Guidelines for the Treatment of Psychiatric Disorders. Washington, DC: American Psychiatric Association; 1998.Google Scholar
36.Mavissikalian, M, Perel, JM. Clinical experience in maintenance and discontinuation of imipramine therapy in panic disorder with agoraphobia. Arch Gen Psychiatry. 1993;49:318323.CrossRefGoogle Scholar
37.Noyes, R, Garvey, MJ, Cook, BL, Samuelson, L. Problems with tricyclic antidepressant use in patients with panic disorder or agoraphobia: results of a naturalistic follow-up study. J Clin Psychiatry. 1989;50:163169.Google ScholarPubMed
38.Noyes, R, Garvey, MJ, Cook, B, Suelzer, M. Controlled discontinuation of benzodiazepine treatment for patients with panic disorder. Am J Psychiatry. 1991;148:517523.Google ScholarPubMed
39.Pollack, MH, Smoller, JW. Pharmacologic approaches to treatment resistant panic disorder. In: Pollack, MH, Otto, MW, eds. Challenges in Clinical Practice: Pharmacological and Psychosocial Strategies. New York, NY: Guildford, Press; 1996.Google Scholar
40.Simon, NM, Safren, SA, Otto, MW, Sharma, SG, Lanka, GD, Pollack, MH. Longitudinal outcome with pharmacotherapy in a naturalistic study of panic disorder. J Affect Disord. 2002;69:201208.CrossRefGoogle Scholar
41.Beck, AT, Sokol, L, Clark, DA, Berchick, R, Wright, F. A cross-over study of focused cognitive therapy for panic disorder. Am J Psychiatrty. 1992;149:778783.Google ScholarPubMed
42.Brown, TA, Barlow, DH. Long-term outcome in cognitive-behavioral treatment of panic disorder: Clinical predictors and alternative strategies for assessment. J Consult Clin Psychol. 1992;63:754765.CrossRefGoogle Scholar
43.Otto, MW, Pollack, MH, Maki, KM. Empirically supported treatments for panic disorder: costs, benefits, and stepped care. J Consult Clin Psychol. 2000;68:556563.CrossRefGoogle ScholarPubMed
44.Mavissakalian, M. The relationship between panic disorder/agoraphobia and personality disorders. Psychiatr Clin North Am. 1990;13:661684.CrossRefGoogle ScholarPubMed
45.Pollack, MH, Otto, MW, Sachs, GS, et al.Anxiety and psychopathology predictive of outcome in patients with panic disorder and depression treated with imipramine, alprazolam and placebo. J Affect Disord. 1994;30:273281.CrossRefGoogle ScholarPubMed
46.Pollack, MH, Otto, MW, Tesar, GE, Cohen, LS, Meltzer-Brody, S, Rosenbaum, JF. Long-term outcome after acute treatment with clonazepam and alprazolam for panic disorder. J Clin Psychopharmacol. 1993;13:257263.CrossRefGoogle ScholarPubMed
47.Keijsers, GPJ, Hoogduin, CAL, Schaap, CPDR. Prognostic factors in the behavioral treatment of panic disorder with and without agoraphobia. Behav Ther. 1994;25:689708.CrossRefGoogle Scholar
48.Hofmann, SG, Barlow, DH, Papp, LA, et al.Pretreatment attrition in a comparative treatment outcome study on panic disorder. Am J Psychiatry. 1998;155:4347.CrossRefGoogle Scholar
49.Penava, SJ, Otto, MW, Maki, KM, Pollack, MH. Rate of improvement during cognitive-behavioral group treatment for panic disorder. Behav Res Ther. 1998;36:665673.CrossRefGoogle ScholarPubMed
50.Mavissakalian, M. Sequential combination of imipramine and self-directed exposure in the treatment of panic with agoraphobia. J Clin Psychiatry. 1990;51:184188.Google ScholarPubMed
51.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;7:763770.CrossRefGoogle Scholar
52.Pollack, MH, Otto, MW, Kaspi, SP, Hammerness, PG, Rosenbaum, JF, Cognitive-behavior therapy for treatment-refractory panic disorder. J Clin Psychiatry. 1994;55:200205.Google ScholarPubMed
53.Hegel, MT, Ravaris, CL, Ahles, TA. Combined cognitive-behavioral and time-limited alprazolam treatment of panic disorder. Behav Ther. 1994;25:183195.CrossRefGoogle Scholar
54.Otto, MW, Pollack, MH, Sachs, GS, Reiter, SR, Meltzer-Brody, S, Rosenbaum, JF. Discontinuation of benzodiazepine treatment: efficacy of cognitive-behavior therapy for patients with panic disorder. Am J Psychiatry. 1993;150:14851490.Google ScholarPubMed
55.Spiegel, DA, Bruce, TA, Gregg, SF, Nuzzarello, A. Does cognitive behavior therapy assist slow-taper alprazolam discontinuation in panic disorder? Am J Psychiatry. 1994;151:876881.Google ScholarPubMed
56.Otto, MW, Barlow, DH, Pollack, MH, Spiegel, DA. Further evaluation of panic control therapy for benzodiazepine discontinuation. Paper presented at: Annual Convention of the Association for the Advancement of Behavior Therapy; November 11-14, 1999; Toronto, Ontario.Google Scholar
57.Bruce, TJ, Spiegel, DA, Gregg, SF, Nuzzarello, A. Predictors of alprazolam discontinuation with and without cognitive behavior therapy in panic disorder. Am J Psychiatry. 1995;152:11561160.Google ScholarPubMed
59.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;40:6773.CrossRefGoogle ScholarPubMed
60.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.Google Scholar
61.Kampman, M, Keijsers, GP, Hoogduin, CA, Hendriks, GJ. A randomized, double-blind, placebo-controlled study of the effects of adjunctive paroxetine in panic disorder patients unsuccessfully treated with cognitive-behavioral therapy alone. J Clin Psychiatry. 2002;63:772777.CrossRefGoogle ScholarPubMed
62.Foa, EB, Franklin, ME, Moser, J. Context in the clinic: How well do CBT and medications work in combination. Biol Psychiatry. In press.Google Scholar
63.Bouton, ME. Context, ambiguity, and unlearning: Sources of relapse after behavioral extinction. Biol Psychiatry. In pressGoogle Scholar
64.Otto, MW, Pollack, MH, Sabatino, SA. Maintenance of remission following cognitive behavior therapy for panic disorder: possible deleterious effects of concurrent medication treatment. Behav Ther. 1996;27:473482.CrossRefGoogle Scholar
65.Otto, MW. Learning and “unlearning” fears: preparedness, neural pathways, and patients. Biol Psychiatry. In press.Google Scholar
66.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
67.Shear, KS, Pilkonis, PA, Cloitre, M, Leon, AC. Cognitive behavioral treatment compared with nonprescriptive treatment of panic disorder. Arch Gen Psychiatry. 1994;51:395401.CrossRefGoogle ScholarPubMed
68.Mavissakalian, M, Michelson, LTwo-year follow-up of exposure in imipramine treatment of agoraphobia. Am J Psychiatry. 1986;143:11061112.Google ScholarPubMed
69.Telch, MJ, Agras, WS, Taylor, CB, Roth, WT, Gallen, C. Combined pharmacological and behavioral treatment for agoraphobia. Behav Res Ther. 1985;23:325335.CrossRefGoogle ScholarPubMed
70.Swinson, RP, Soulios, C, Cox, BJ, Kuch, K. Brief treatment of emergency room patients with panic attacks. Am J Psychiatry. 1992;149:944946.Google ScholarPubMed