Panic Control Treatment for Adolescents

1. Panic Control Treatment for Adolescents An Evidence-Based Treatment for Panic DisorderSteven Malm

2. Contents • Definition of Panic Disorder • Assessment of Panic Disorder • Evidence-Based Treatments • Overview of Program • Recommended Program Schedule • Pros, Cons, and Conclusions • Other Protocols • References

3. What is Panic Disorder? • Panic Disorder is a psychiatric condition characterized by recurrent, unexpected panic attacks. • Can occur with or without Agoraphobia • Acronyms: • Panic Disorder without Agoraphobia (PD) • Panic Disorder with Agoraphobia (PDA)

4. DSM Criteria for Panic Attacks • “A discrete period of intense fear or discomfort in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: • Palpitations, pounding heart, or accelerated heart rate • Sweating • Trembling or shaking • Sensation of shortness of breath or smothering • Feeling of choking • Chest pain or discomfort • Nausea or abdominal distress • Feeling dizzy, unsteady, lightheaded, or faint • Derealization (feelings of unreality) or depersonalization (being detached from oneself) • Fear of losing control or going crazy • Fear of dying • Parasthesias (numbness or tingling sensations) • Chills or hot flushes” (American Psychiatric Association, 2000)

5. DSM Criteria for Agoraphobia • “Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or automobile. • The situations are avoided or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion. • The anxiety or phobic avoidance is not better accounted for by another mental disorder…” (American Psychiatric Association, 2000)

6. DSM Criteria for Panic Disorder • Both of the following: • Recurrent unexpected Panic Attacks • At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: • Persistent concern about having additional attacks • Worry about the implications of the attack or its consequences • A significant change in behavior related to the attacks • Absence/Presence of Agoraphobia* • The Panic Attacks are not due to the direct physiological effects of a substance or a general medical condition. • The Panic Attacks are not better accounted for by another mental disorder. (American Psychiatric Association, 2000) *PD and PDA are coded as separate disorders and differ only on this criterion.

7. Assessment of Panic Disorder in Adolescents • Diagnostic Interview • Schedule for Affective Disorders and Schizophrenia (K-SADS; Orvachel, 1995) • World Health Organization Composite International Diagnostic Interview (CIDI; Green et al., 2011) • Self-Report Measures (Pincus et al., 2008) • Revised-Children’s Manifest Anxiety Scale • Revised-Child Anxiety and Depression Scale • Multidimensional Anxiety Scale for Children • Childhood Anxiety Sensitivity Index • Children’s Depression Inventory • Child Behavior Checklist • Medical Screening Measures • Autonomic Nervous System Questionnaire (ANS; Queen et al., 2012)

8. Evidence from the Literature Treatments for Panic Disorder

9. Medication • Antidepressants • Particularly in combination with CBT (Craske and Simos, 2013). • Benzodiazapines(Moylan et al., 2011) • Alprazolam, Valium, Xanax • Chronic use prior to CBT is linked to poorer short- and long-term outcomes (Craske & Simos, 2013). • Combined treatment linked to poorer outcomes at 24-month follow-up (Brown & Barlow, 1995)

10. CBT in Panic Disorder • CBT is an effective first-line treatment of PD (Otto & Deveney, 2005). • CBT for PD should include: Psychoeducation, Self-Monitoring, Relaxation Techniques, Cognitive Restructuring, and Exposure (Craske & Simos, 2011). • Some evidence exists that “ultra-brief” (5 session) CBT may be efficacious (Otto et al., 2012). • CBT has been shown to be effective in PD, even with comorbid anxiety or depression (Allen et al., 2010)

11. Pincus, Ehrenreich, & Mattis (2008) Panic Control Treatment for Adolescents (PCT-A)

12. Overview of the Program • Adapted from the adult PCT protocol for use with adolescent clients. • 11 weekly CBT sessions • Focuses on the three aspects of panic attacks and anxiety: • Cognitive aspect • Hyperventilatory response • Conditioned response to physical reactions • Incorporates psychoeducation, breathing training, cognitive restructuring, and exposure (interoceptive and situational) • Goals are to reduce irrational thoughts, conditioned fear responses, and avoidance behaviors.

13. Evidence-Base for PCT-A • Pincus et al. (2008) • N = 26 adolescents (ages 12-17) • 12-week CBT treatment vs. Wait-list (control) group • Treatment was associated with significant reduction in PD severity. • Symptoms remained at clinical levels for control group until subsequent CBT was given • Pincus et al. (2010) • N = 24 adolescents (ages 14-17) • PCT-A Treatment vs. self-monitoring control group • PCT-A resulted in significant reduction in symptom severity • Clinician ratings AND self-report ratings • Symptoms continued to improve at 3- and 6-month follow-up • Chase et al., (2012) • Weekly PCT-A versus intensive (8-day) program • Both resulted in significant reductions in symptoms • Weekly therapy was related to reductions in anxiety sensitivity and depressive symptoms.

14. Session 1 • Introduction to treatment • Review pre-treatment assessment/diagnosis • Discuss nature of anxiety • Introduce the 3 components of anxiety (Affective, Behavioral, Cognitive) • Discuss the model for panic attacks and treatment overview • Discuss importance of practice and self-monitoring • Set goals • Assign homework (readings and start a panic attack record)

15. Session 2 • Physiology of panic attacks and breathing awareness • Review homework • Discuss physiology of anxiety/panic • Hyperventilation exercise and discussion • Simulates feelings of panic • Slow breathing exercise • By controlling breathing, clients can decrease frequency and intensity of sensations which may trigger panic • Assign homework (readings, continue logs, and practice slow breathing)

16. Session 3 • Overview of the Cognitive Component • Review homework • Discuss cognitive aspect of anxiety • Introduce the concepts of: • Probability overestimation (predicting an unlikely event to as likely to happen) • Catastrophic thinking (thinking the worst will happen) • Practice monitoring panic triggers/thoughts • Assign homework (readings, logs, and thought record)

17. Session 4 • Cognitive Restructuring • Review homework • Teaching “thinking like a detective.” • Practice evaluating probability overestimation • Practice evaluating catastrophic thinking • Discuss myths/misconceptions about anxiety • Going crazy, losing control, heart attack, etc. • Assign homework (readings, logs, “thinking like a detective” form.

18. Session 5 • Interoceptive Exposure (“not letting how we feel scare us”) • Review homework • Review: anxiety physiology and model of panic attacks • Introduce and explain interoceptive conditioning/exposure • Associations between situations and panic symptoms • Repeated exposure habituates client to feelings of anxiety • Conduct symptom induction exercises • Examples: shake head for 30 seconds, run in place for 1 minute, hold breath for 30 seconds, breath through a thin straw. • Select the 3 exercises that replicate client’s experience of panic • Assign homework (readings, logs, repeat symptom induction exercises daily)

19. Session 6 • Intro to Situational Exposure • Review homework • Explain rationale for exposure • Deal with any resistance to exposure • Complete Fear and Avoidance Hierarchy form • Rank order 10 situations avoid out of fear of panic attack • Conduct in-session situational exposure • Choose from the FAH list – what you believe they can deal with you present (but they don’t) • Assign homework (readings, logs, repeat in-session situational exposure ONLY)

20. Session 7 • Safety Behaviors and Exposure • Review homework • Review safety behaviors • Discuss rationale for eliminating • List those used by adolescent • Plan for and conduct situational exposure • Assign homework (readings, logs, review safety behaviors, repeat in-session exposure at home)

21. Sessions 8-10 • Exposure sessions • Review homework, FAH form, and exposure procedures • Conduct exposures • Review progress following exposures • Troubleshoot problems/resistence • Plan for homework exposures • Assign homework (logs, and exposure exercises selected from FAH form)

22. Session 11 • Relapse prevention and termination • Review exposure homework • Re-rate FAH form • Revisit goals and accomplishments • Help adolescent to develop a practice plan • Assess “cost of improvement” • Prepare client for symptom relapse • Terminate therapy

23. Pros Cons • CBT has a strong evidence base for dealing with anxiety • Clients report positive changes (even those unrelated to anxiety) • Previously feared situations are reduced  QoL improves • Evidence-base for adolescents (specifically) is growing, but limited • Requires substantial commitment • Needs to be entered into willingly Pros and Cons

24. Conclusions and School Implications • PCT-A is a manualized, structured treatment protocol for adolescents with PD. • Treatment schedule can be modified to fit the client’s needs. • Parents can be involved at every step of the process to support progress and compliance with treatment. • PCT-A can be conducted within a school or clinic setting. School-based PCT-A would be particularly appropriate if client experiences significant panic symptomology at school.

25. Other Protocols for PD • The Clinical Research Unit for Anxiety and Depression (CRUfAD) protocol and client workbook: http://www.crufad.com/index.php/treatment-support/treatment-manuals • Boston Counseling Therapy schedule and outline of treatment: http://www.thriveboston.com/counseling/panic-disorder-and-agoraphobia-overview-and-cbt-treatment/

26. Questions? • Comments? • Concerns? • Statements? • Anecdotes? • Epiphanies? • Criticisms? • Compliments? • Digressions?

27. References • Allen, L. B., White, K. S., Barlow, D. H., Shear, M. K., Gorman, J. M., & Woods, S. W. (2010). Cognitive-behavior therapy (CBT) for panic disorder: Relationship of anxiety and depression comorbidity with treatment outcome. Journal of Psychopathological and Behavioral Assessment, 32, 185-192. DOI: 10.1007/s10862-009-9151-3 • American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. American Psychiatric Association: Arlington, VA. • Brown, T. A. & Barlow, D. H. (1995). Long-term outcomes in cognitive-behavioral treatment of panic disorder: Clinical predictors and alternative strategies for assessment. Journal of Consulting and Clinical Psychology, 63(5), 754-765. DOI: 0022-006X/95/$3.00 • Centore, A. (2010). Panic disorder and agoraphobia: Overview and CBT treatment. ThriveBoston. Retrieved 10/6/2013. http://www.thriveboston.com/counseling/panic-disorder-and-agoraphobia-overview-and-cbt-treatment/ • Clinical Research Unit for Anxiety Disorders (2010). Anxiety and panic disorder: Patient treatment manual. St. Vincent’s Hospital. Retrieved: 10/6/2013. www.crufad.org • Craske, M. G. & Simos, G. (2013). Panic disorder and agoraphobia. InSimos, G. & Hofmann, S. G. (Eds.). CBT for Anxiety Disorders: A Practitioner Book, 3-24. John Wiley & Sons: New York, NY. • Chase, R. M., Whitton, S. W., & Pincus, D. B. (2012). Treatment of adolescent panic disorder: A nonrandomized comparison of intensive versus weekly CBT. Child & Family Behavior Therapy, 34, 305-323. DOI: 10.1080/07317107.2012.732873 • Green, J. G., Avenevolli, S., Finkelman, M., Gruber, M. J., Kessler, R. C., Merikangas, K. R., Sampson, N. A., & Zaslavsky, A. M. (2011). Validation of the diagnosis of panic disorder and phobic disorder in the US national comorbidity survey replication adolescent (NCSA-A) supplement. International Journal of Methods in Psychiatric Research, 20(2), 105-115. DOI: 10.1002/mpr.336

28. References (Cont.) • Moylan, S., Sstaples, J., Ward, S. A., Rogerson, J., Stein, D. J., & Berk, M. (2011). The efficacy and safety of alprazolam versus other benzodiazepines in the treatment of panic disorder. Journal of Clinical Psychopharmacology, 31(5), 647-652. • Orvaschel, H. (1995). Schedule for affective disorders and schizophrenia for school-aged children, epidiologic version – 5. Center for Psychological Studies. Nova Southeastern University: Fort Lauderdale, FL. • Otto, M. W. & Deveney, C. (2005). Cognitive-behavioral therapy and the treatment of panic disorder: Efficacy and strategies. Journal of Clinical Psychiatry, 66, 28-32. • Otto, M.W., Tolin, D. F., Nations, K. R., Utschig, A. C., Rothbaum, B. O., Hofmann, S. G., & Smits, J. A. (2012). Five sessions and counting: Considering ultra-brief treatment for panic disorder. Depression and Anxiety, 29, 465-470. • Pincus, D. B., Ehrenreich, J. T., & Mattis, S. G. (2008). Mastery of Anxiety and Panic for Adolescents: Riding the Wave. Oxford University Press: New York, NY. • Pincus, D. B., Ehrenreich-May, J., Whitton, S. W., Mattis, S. G., & Barlow, D. H. (2010). Cognitive-behavioral treatment of panic disorder in adolescence. Journal of Clinical Child and Adolescent Psychology, 39(5), 638-649. DOI: 10.1080/15374416.2010.501288 • Queen, A. H., Ehrenreich-May, J., & Hershorin, E. R. (2012). Preliminary validation of a screening tool for adolescent panic disorder in pediatric primary care clinics. Child Psychiatry and Human Development, 43, 171-183. DOI: 10.1007/s10578-011-0256-z