Hostname: page-component-78c5997874-j824f Total loading time: 0 Render date: 2024-11-20T04:15:04.614Z Has data issue: false hasContentIssue false
  • English
  • Français

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

Published online by Cambridge University Press:  07 November 2014

Nadine Recker Rayburn  and
Michael W. Otto
Get access Rights & Permissions [Opens in a new window]

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
Information
CNS Spectrums , Volume 8 , Issue 5: Psychosocial Treatment of Anxiety Disorders , May 2003 , pp. 356 - 362
Copyright
Copyright © Cambridge University Press 2003

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1.Harvey, JM, Richards, JC, Dziadosz, T, Swindell, A. Misinterpretation of ambiguous stimuli in panic disorder. Cogn Ther Res. 1993;17:235–248.CrossRefGoogle Scholar
2.McNally, RJ, Foa, EB. Cognition and agoraphobia: bias in the interpretation of threat. Cogn Ther Res. 1987;11:567–581.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;24:461–470.CrossRefGoogle ScholarPubMed
5.McNally, RJ. Psychological approaches to panic disorder: a review. Psychol Bull. 1990;108:403–419.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;34:453–458.CrossRefGoogle Scholar
8.Salkovskis, PM. The importance of behavior in the maintenance of anxiety and panic: a cognitive account. Behav Psychother. 1991;19:6–19.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;22:195–207.CrossRefGoogle Scholar
13.Gardenschwartz, CA, Craske, MG. Prevention of panic disorder. Behav Ther. 2001;32:725–737.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;68:417–424.CrossRefGoogle ScholarPubMed
15.Craske, MG, Brown, TA, Barlow, DH. Behavioral treatment of panic: a two year follow-up. Behav Ther. 1991;22:289–304.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;27:123–130.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;149:486–490.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;16:257–258.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;7:166–172.CrossRefGoogle Scholar
27.Clum, GA, Clum, G, Surls, R. A meta-analysis of treatments for panic disorder. J Consult Clin Psychol. 1993;61:317–326.CrossRefGoogle ScholarPubMed
28.Gould, RA, Otto, MW, Pollack, MH. A meta-analysis of treatment outcome for panic disorder. Clin Psychol Rev. 1995;15:819–844.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;66:231–239.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;158:1989–1992.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;164:759–769.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;58:77–84.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;162:776–787.CrossRefGoogle ScholarPubMed
34.Barlow, DH, Gorman, JM, Shear, MK, Woods, SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder. JAMA. 2000;283:2529–2536.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;49:318–323.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;50:163–169.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;148:517–523.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;69:201–208.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;149:778–783.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;63:754–765.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;68:556–563.CrossRefGoogle ScholarPubMed
44.Mavissakalian, M. The relationship between panic disorder/agoraphobia and personality disorders. Psychiatr Clin North Am. 1990;13:661–684.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;30:273–281.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;13:257–263.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;25:689–708.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;155:43–47.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;36:665–673.CrossRefGoogle ScholarPubMed
50.Mavissakalian, M. Sequential combination of imipramine and self-directed exposure in the treatment of panic with agoraphobia. J Clin Psychiatry. 1990;51:184–188.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;7:763–770.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;55:200–205.Google ScholarPubMed
53.Hegel, MT, Ravaris, CL, Ahles, TA. Combined cognitive-behavioral and time-limited alprazolam treatment of panic disorder. Behav Ther. 1994;25:183–195.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;150:1485–1490.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;151:876–881.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;152:1156–1160.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;40:67–73.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;63:772–777.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;27:473–482.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;51:395–401.CrossRefGoogle ScholarPubMed
68.Mavissakalian, M, Michelson, LTwo-year follow-up of exposure in imipramine treatment of agoraphobia. Am J Psychiatry. 1986;143:1106–1112.Google ScholarPubMed
69.Telch, MJ, Agras, WS, Taylor, CB, Roth, WT, Gallen, C. Combined pharmacological and behavioral treatment for agoraphobia. Behav Res Ther. 1985;23:325–335.CrossRefGoogle ScholarPubMed
70.Swinson, RP, Soulios, C, Cox, BJ, Kuch, K. Brief treatment of emergency room patients with panic attacks. Am J Psychiatry. 1992;149:944–946.Google ScholarPubMed