CBT interventions for Panic Disorder
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Transcript of CBT interventions for Panic Disorder
Early CBT Interventions for prevention of Panic Disorder
Systematic Review
John Sikorski, October 2010
How effective are early cognitive-behavioural interventions in reducing risk of
developing panic disorder (PD) in individuals with a history of infrequent
panic?
Risk Factors for onset of PD Previous history of infrequent panic
attacks (PAs) (Ehlers, 1995)
High level of Anxiety Sensitivity trait (misinterpretation of dangerousness of fear symptoms – not just the original stimulus)
(Reiss et al., 1985; 1986)
Methodology Exclusion criteria:-
Majority of sample with existing PD diagnosis
Non-CBT treatments PAs accounted for by more primary
psychiatric/medical conditions
Methodology Inclusion Criteria:-
Subjects at risk of developing PD (i.e. 1+ infrequent PAs or an above average AS score, measured using ASI)
Preventative studies Controlled clinical trials Brief interventions or components of CBT
treatments
Methodology
Initial Search Strategy:-
PsychINFO; CINAHL; Medline:
Cochrane database; Google Scholar
Methodological Evaluation
CREST rating tool (Peck et al.) Assesses overall research quality
(design + write-up) 42 checkpoints on aspects of
Reliability & Validity 3-point rating scale Calculates % rating for each study
Results = 8 clinical trials 2 brief intervention studies in A&E
settings (Swinson et al., 1992; Nuthall & Townend, 2007)
borderline sample sizes low internal validity high external validity of A&E settings
Results = 8 clinical trials 2 unpublished university dissertations employing
graduates with seemingly minimal clinical qualifications (Abplanalp, 2001; Maltby, 2001)
2 relatively well-designed RCTs, including a carefully-planned, didactic 1 day workshop (Gardenswartz & Craske, 2001) and a computerised self-help course (Kenardy, 2003)
Results = 8 clinical trials 1 sufficiently well-designed, sizeable
(n=114) pilot study in 12 community mental health centres (Meulenbeek et al, 2009)
1 very well-designed, pilot-tested RCT (n=217) run in 17 community mental health centres (Meulenbeek et al., 2010)
Results : Overall study quality
Study CREST rating (%)
Meulenbeek et al. (2010) 86
Kenardy et al. (2006) 74
Gardenswartz & Craske (2001) 71
Meulenbeek et al. (2009) 64
Abplanalp (2001) 63
Maltby (2001) 53
Nuthall & Townend (2007) 39
Swinson et al. (1992) 36
Results : Overall study quality
Studies ranged significantly in terms of design quality
A few statistics from the four best-designed trials……
Meulenbeek (2009) Pilot-study 2 group pre-post design Non-clinical volunteers (n=114) Sub-threshold/mild PD (PDSS score <13) ‘Don’t Panic’ manualised CBT group 8 week vs 12 week course (2 hrs)
Meulenbeek (2009) Large Effect of treatment on panic &
agoraphobia symptoms, measured by PDSS, at 6 months follow up (d=0.71)
8 week course potentially as effective as 12 weeks
Meulenbeek (2010) Multi-site RCT (17 community MH
centres) 2 group pre-post design Adult volunteers (n=217) Sub-threshold/mild PD (PDSS <13) 8 week ‘Don’t Panic’ CBT group vs.
waiting list control
Meulenbeek (2010) 39% (43/109) ‘Don’t Panic’ group achieve
clinically significant change on PDSS, versus 16% (17/108) of control group
Odds ratio for favourable treatment response: OR=3.49, 95% CI 1.77-6.88, p<0.001
Effects maintained at 6 months
Gardenswartz & Craske (2001) Between-groups experiment Undergraduate volunteers (n=121) 1+ Panic Attacks in previous year, but not
satisfying PD diagnosis One 5 hr didactic, group workshop versus waiting
list control Quizzed Participants frequently to check retention 10 min. monthly phonecalls (non-advisory) to
obtain anxiety ratings
Gardenswartz & Craske (2001) Greater decrease in panic symptoms for
workshop group, measured using CIDI (panic section), F(1,120)=4.07, p<0.05
Only 1.8% (workshop group) developed PD at 6 months, versus 13.6% (waiting list control), χ2(1)=5.53, p<0.05
Kenardy et al. (2006) Between groups experiment University students (n=42) with elevated
Anxiety Sensitivity scores (>24 = upper 1/3 on ASI)
Online Anxiety Prevention package
(6 weeks x 5-7 hrs internet self-help) Waiting list control
Kenardy et al. (2006) Initial treatment gains in agoraphobic
cognitions (ACQ) & catastrophic cognitions (CCQ-M) maintained at 6 months
Internet package is not effective in reducing fears of physical sensations (BSQ scores) at 6 months, F(2,80)=1.32, p=0.273
SUMMARY of key findings
Summary: Group interventions Strongest treatment gains were found
from group interventions (n=3)
These studies included all of:-
1. Anxiety education
2. Breathing retraining/relaxation
3. Interoceptive exposure
Summary: Brief interventions
1 of 3 studies suggested a reduction in PA frequency through advising Ps to go back to the panic situation (Swinson et al., 1992)
BUT…. Not sufficiently well-designed or reported
to rely on findings from these 3 studies
Summary: Online self-help
Online panic prevention programs may not be suitable for treating panic
Computerised self-help may be inadequate for the essential (but least tolerated) component of interoceptive exposure
Recommendations: In 4 of 8 studies it may be unwise to rely
on findings, as these were not:
1. Sufficiently well designed/conducted
AND
1. Sufficiently well reported
Recommendations 8 week comprehensive Panic Prevention group
treatments OR
Single 5-hr day workshop, including:1. Panic education2. Breathing retraining3. Interoceptive exposure4. Cognitive restructuring5. + Frequent testing for retention of material