# Presentation: 017077

## Treating Panic Disorder in Veterans with PTSD

- Ellen J. Teng, Ph.D.
- Michael E. DeBakey VAMC
*Trauma Recovery Program*

## Research Team

- Ellen J. Teng, Ph.D.
- Nancy J. Petersen, Ph.D.
- Sara D. Bailey, Ph.D.
- Joseph D. Hamilton, M.D.
- Nancy Jo Dunn, Ph.D. (Mentor)
- Angelic D. Chaison, M.A.
- Katherine H. Graham, M.Ed.
- Derek G. Prins, M.A.
- This research was supported by the South Central Mental Illness, Research, Education, and Clinical Center as part of the VA Special MIRECC Fellowship Program in Advanced Psychiatry and Psychology

## Background

- _Panic Disorder_
- Among one of the most debilitating and expensive anxiety disorders in the nation
- High rates of healthcare utilization
- Occupational dysfunction & unemployment
- Psychosocial impairment
- Increased rates of substance abuse & antidepressant use

## Background (cont’d)

- What are the treatments of choice?
- Pharmacotherapy
- Cognitive-behavioral therapy
- Panic Control Treatment (Barlow & Craske, 1994) consists of education, cognitive restructuring, & interoceptive exposure
- 85 to 87% of persons treated are panic-free by the end of treatment (Barlow et al., 1989; Klosko et al, 1995; Telch et al., 1993).

## Background (cont’d)

- So what’s the problem?
- Treatment is less effective with significant psychiatric comorbidity
- Complications from comorbidity & using manualized therapy
- Increase in attrition & relapse rates
- Comorbidity rate of 27% for PD & PTSD based on data from National Comorbidity Study (Leskin & Sheikh, 2002)

## Background (cont’d)

- Why do PD and PTSD co-occur so frequently?
- Trauma related cues can trigger a panic attack (Sheikh et al., 1994)
- Experience of uncued panic attacks can lead to full-blown PD (Resnick et al., 1994)
- Shared symptoms-chronic hyperarousal, hypervigilance, somatic reactivity, anxiety sensitivity (Falsetti & Resnick, 2000; Jakupcak et al., 2006)

## Purpose

- To examine the effectiveness of Panic Control Therapy (PCT) in improving comorbid panic symptoms in veterans with a primary diagnosis of PTSD compared with a control therapy

## Hypotheses

- PCT would outperform a control therapy in reducing the frequency, severity, & fearfulness of panic attacks.
- PCT would result in a greater reduction in anxiety sensitivity and improve general anxiety & depression symptoms compared to the control therapy.
- No change in PTSD symptoms for patients receiving either therapy.

## Method

*Participants*
- 49 outpatients from the Trauma Recovery Program
- Overall Sample Characteristics
- Age: *M*=52 years, *SD*=8.44
- 14% women; 86% men
- 43% African American
- 43% Caucasian
- 14% Hispanic

## Method

*Inclusion Criteria: *current PTSD diagnosis; _>_ 1 PA in past month;
- IQ _>_ 80
*Exclusion Criteria*: current substance dependence, mania, psychosis; severe depression; PA exclusive to specific phobias; medical conditions that mimic anxiety symptoms
*Materials*
- Panic Control Treatment (PCT) manual
- Psychoeducational & Supportive Treatment (SUP) manual

## Slide 11

## Procedure

- _Design_
- Blocked randomization
- Assessed at pre-treatment, mid-treatment, post-treatment, and a 3-month follow-up
- Both treatments delivered in weekly, 1 hr, individual sessions over a 10-week period
- Treatments conducted by trained masters & doctoral level graduate students
- Treatment fidelity ratings completed by independent raters

## Results

- Primary Analyses
- A higher % of patients in PCT (63%, n=10) was panic-free at the 3-month follow-up than the SUP group (19%, n=3), ***2** (1, N=*32*) = *6.35*, p*=.01)

## Slide 14

| Means, Standard Deviations, and mixed ANOVA Source Tables Comparing Panic Control Treatment to Psychoeducational Supportive Treatment  for the Intent-to-Treat Sample |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- |
|  | Intervention |  |            Control |  | Repeated measures ANOVA tables |

| Time | M | SD |  | N |  | M | SD | N |    Source |  | dfs | f | p | η2 |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Panic Severity |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
| Pre | 58.33 | 18.34 | 18 |  |  | 51.71 | 14.11 | 17 |  | Time |    2, 66 | 6.45 |  .16 |   .003 |
| Post | 41.89 | 18.37 |  |  |  | 56.65 | 21.30 |  |  | Group | 1, 66 | 1.42 | .24 | .04 |
| Follow-up | 36.89 | 18.64 |  |  |  | 44.94 | 22.20 |  |  | Interaction | 2, 66 | 3.84 | .03 | .10 |
| Panic Fear |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
| Pre | 5.11 | 1.87 | 14 |  |  | 3.77 | 1.99 | 14 |  | Time | 2, 52 | 6.89 | .002 | .21 |
| Post | 2.79 | 3.26 |  |  |  | 2.73 | 2.43 |  |  | Group | 1, 52 | .006 | .94 | .00 |
| Follow-up | 2.32 | 3.24 |  |  |  | 3.90 | 2.36 |  |  | Interaction | 2, 52 | 4.67 | .01 | .15 |

## Slide 15

| Anxiety Sensitivity Index |  |  |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Pre | 41.83 | 11.78 | 18 |  | 42.47 | 9.53 | 17 |  | Time | 2, 66 | 8.36 | .001 | .20 |
| Post | 29.61 | 14.48 |  |  | 40.53 | 13.44 |  |  | Group | 1, 66 | 3.64 | .07 | .10 |
| Follow-up | 31.50 | 14.94 |  |  | 40.65 | 10.87 |  |  | Interaction | 2, 66 | 4.30 | .02 | .12 |

| Hamilton Anxiety Rating Scale |  |  |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Pre | 25.50 | 9.34 | 18 |  | 24.24 | 7.16 | 17 |  | Time | 2, 66 | 12.87 | .28 | < .001 |
| Post | 19.94 | 8.48 |  |  | 23.24 | 9.83 |  |  | Group | 1, 66 | 0.63 | .43 | .02 |

| Follow-up | 15.83 | 9.02 |  |  | 19.82 | 8.91 |  |  | Interaction | 2, 66 | 2.11 | .13 | .06 |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |

| Beck Anxiety Inventory |  |  |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Pre | 37.33 | 10.32 | 18 |  | 30.35 | 10.48 | 17 |  | Time | 2, 66 | 1.33 | .27 | .04 |
| Post | 29.61 | 14.89 |  |  | 31.71 | 15.02 |  |  | Group | 1, 66 | 0.26 | .61 | .008 |
| Follow-up | 30.94 | 15.39 |  |  | 30.29 | 11.47 |  |  | Interaction | 2, 66 | 2.11 | .13 | .06 |

|  | Intervention |  |            Control |  | Repeated measures ANOVA tables |
| --- | --- | --- | --- | --- | --- |

| Time | M | SD | N |  | M | SD | N |    Source | dfs | f | p | η2 |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |

## Slide 16

| Hamilton Rating Scale for Depression |  |  |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Pre | 18.44 | 4.38 | 18 |  | 18.35 | 5.77 | 17 |  | Time | 2, 66 | 5.36 | .007 | .14 |
| Post | 15.06 | 4.95 |  |  | 17.47 | 9.33 |  |  | Group | 1, 66 | 1.39 | .25 | .04 |
| Follow-up | 12.78 | 5.87 |  |  | 16.41 | 6.90 |  |  | Interaction | 2, 66 | 1.33 | .27 | .04 |
| Beck Depression Inventory-II |  |  |  |  |  |  |  |  |  |  |  |  |  |
| Pre | 35.78 | 8.40 | 18 |  | 30.65 | 12.75 | 17 |  | Time | 2, 66 | 6.22 | .003 | .16 |
| Post | 29.50 | 13.52 |  |  | 25.47 | 12.46 |  |  | Group | 1, 66 | 0.83 | .37 | .03 |
| Follow-up | 27.78 | 14.51 |  |  | 27.29 | 10.76 |  |  | Interaction | 2, 66 | 0.85 | .43 | .03 |
| Posttraumatic Stress Disorders Checklist |  |  |  |  |  |  |  |  |  |  |  |  |  |
| Pre | 69.33 | 7.76 | 18 |  | 67.29 | 9.77 | 17 |  | Time | 2, 66 | 2.11 | .13 | .06 |
| Post | 64.56 | 13.37 |  |  | 65.41 | 10.94 |  |  | Group | 1, 66 | 0.01 | .92 | .00 |
| Follow-up | 64.06 | 10.98 |  |  | 66.12 | 12.06 |  |  | Interaction | 2, 66 | 0.65 | .52 | .02 |

|  | Intervention |  |            Control |  | Repeated measures ANOVA tables |
| --- | --- | --- | --- | --- | --- |

| Time | M | SD | N |  | M | SD | N |    Source | dfs | f | p | η2 |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |

## Slide 17

|  | Panic 
Control Treatment |  | Psychoeducational
Supportive Treatment |  |  |
| --- | --- | --- | --- | --- | --- |
|  | ______________________ |  | _____________________ |  |  |
| Period |           n | % | n | % | Fisher’s Exact p |

| Intent-to-Treat Sample (N=35) |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- |
| 1-week post |  |  |  |  |  |
| ASI | 7 | 38.9 | 1 | 5.9 | .04 |
| BAI | 5 | 27.8 | 1 | 5.9 | .06 |
| BDI | 8 | 44.4 | 6 | 35.3 | .69 |
| HARS | 7 | 38.9 | 6 | 37.5 | .64 |
| HRSD | 8 | 44.4 | 4 | 25.0 | .45 |
| PCL | 7 | 38.9 | 7 | 41.2 | .38 |
| 3-month follow-up |  |  |  |  |  |
| ASI | 5 | 27.7 | 2 | 11.8 | .40 |
| BAI | 4 | 22.2 | 2 | 11.8 | .86 |
| BDI | 7 | 38.9 | 5 | 29.4 | .86 |
| HARS | 10 | 55.6 | 10 | 62.5 | .44 |
| HRSD | 9 | 50.0 | 5 | 31.3 | .23 |
| PCL | 6 | 33.3 | 7 | 41.2 | .06 |

| Percentage of Participants with Clinically Significant Improvement at Each Follow-up Period |
| --- |

## Slide 18

| Percentage of Participants with Clinically Significant Improvement at Each Follow-up Period

                                                      Panic                       Psychoeducational               
                                          Control Treatment            Supportive Treatment

Period                                   n                 %                    n                   %              Fisher’s Exact  p

Treatment Completers (n=26)
1-week post |
| --- |

|  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- |
|  |  |  |  |  |  |
|  |  |  |  |  |  |
|  |  |  |  |  |  |
|  |  |  |  |  |  |
|  |  |  |  |  |  |
|  |  |  |  |  |  |

| 3-month follow-up |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- |
| ASI | 7 | 58.3 | 1 | 7.1 | .009 |
| BAI | 4 | 33.3 | 2 | 14.3 | .63 |
| BDI | 7 | 58.3 | 4 | 28.6 | .31 |
| HARS | 11 | 91.7 | 9 | 64.3 | .28 |
| HRSD | 9 | 75.0 | 5 | 35.7 | .03 |
| PCL | 6 | 50.0 | 6 | 42.9 | .34 |

| ASI | 8 | 66.7 | 1 | 7.1 | .003 |
| --- | --- | --- | --- | --- | --- |
| BAI | 4 | 33.3 | 1 | 7.1 | .13 |
| BDI | 8 | 66.7 | 5 | 35.7 | .09 |
| HARS | 8 | 66.7 | 5 | 35.7 | .39 |
| HRSD | 8 | 66.7 | 4 | 28.6 | .17 |
| PCL | 7 | 58.3 | 6 | 42.9 | .88 |

## Discussion

- PCT effectively reduced severity and fear of panic symptoms compared with SUP
- PCT reduced the frequency of panic attacks by the 3-month follow-up
- PCT produced significant reductions in anxiety sensitivity at post- and follow-up periods

## Discussion (cont’d)

- Clinician & Self-Report Ratings
- Anxiety symptoms: both groups improved at post and follow-up (patient self-report indicated no improvement at either period)
- Depression symptoms: both groups improved at 3-month follow-up (consistent with patient self-report)
- By the follow-up period, 59% of both groups showed improvement in anxiety symptoms and 41% in depressive symptoms

## Limitations

- Small sample size
- Service connection for PTSD may be related to disparity between self-report & clinician ratings
- Sessions were unevenly dispersed
- Drop-out rate was double for PCT (33%) compared with SUP (12%)

## Future Directions

- Need to understand better the mechanisms leading to the development & maintenance of comorbid PTSD and PD
- Compare the effectiveness of integrated treatment approaches vs. sequential ones
- Develop briefer interventions to increase treatment acceptability and adherence for patients