Cognitive Behavior Psychotherapy in Panic Disorder
Condition: Panic Disorder; Agoraphobia
MeSH terms: Panic Disorder; Agoraphobia
Study type: Interventional

Summary: 
      The objective of this study in cognitive-behavioural therapy (CBT) was to demonstrate the
      preparation of the patient with panic disorder for agoraphobic exposures. The focus of the
      work consisted of interoceptive exposures, in vivo, of body sensations themselves, to feared
      places and situations. The sample consisted of 50 individuals. Group 1 undertook 10 weekly,
      individual sessions of CBT of one hour duration. Group 2, control, was just follow-up with
      supportive therapy. The procedures used for the exposures, especially for induction symptom
      exercises, were considered essential in the preparation of patients with panic disorder, to
      be able to face up to panic attacks and subsequent agoraphobic situations.
    

Detailed description: 
      The patients with PDA were diagnosed by medical psychiatrists from the team at the
      Respiration and Panic Laboratory of Instituto de Psiquiatria da Universidade Federal do Rio
      de Janeiro (IPUB/UFRJ), INCT Translational Medicine, according to the criteria of diagnostic
      of the Manual of Diagnostic and Statistics of Mental Disorder (DSM-IV-TR, 2002b) and
      according to the evaluation instrument SCID-I (Structured Clinical Interview Diagnostic)
      (First et al, 1997). The sample consisted of 50 voluntary patients divided in two Groups. The
      1st Group, made up of 25 individuals, received 10 sessions of CBT. The 2nd Group, "control",
      also consisted of 25 patients, who received just supportive psychotherapy.

      With a view to comparing the results of the Groups after the interventions, the following
      evaluation instruments were applied at the beginning and at the end of the research: Beck
      Anxiety Inventory (Beck et al, 1998a); State-Trait Anxiety Inventory (Spielberg et al, 1970);
      Sheehan Disability Scale (Sheeham, 1983a); Global Assessment of Functioning (AXIS V)
      (DSM-IV-TR, 2002c); questionnaire of fears and phobias (Mark & Mathews, 1979); questionnaire
      of cognitive agoraphobias( Chambless, 1984a); questionnaire of body sensations (Chambless,
      1984b) and Panic and Agoraphobia Scale (Bandelow, 1999a).

      The criteria for inclusion in the research was patients over 18 years old of both sexes with
      a diagnosis of PDA, with no serious comorbidities. The patients that presented alcohol or
      drug dependency, mental retardation or serious mental disorders were excluded from the
      research.

      The patients who agreed to participate in the study, signed a "Term of Free and Clarified
      Consent" and were made aware of all the procedures undertaken, approved by the Committee of
      Ethics for the research IPUB/UFRJ.

      In the evaluation of the tests the Chi-square tests ( χ2 ) or ANOVA, depending on the type of
      variable measure, always with 95% of Confidence, or P-Value ≤ 0,05. In the characterization
      of the Groups, the tests were undertaken with the values identified at the beginning of the
      treatment. Thus, the efficiency of the initiatives undertaken could be perceived. The
      objective was to identify the significant statistical differences, between the initial and
      final results of the tests.

      The 10 CBT sessions were based on the previous study (King et al, 2007a), with some
      modifications and adaptations appropriate to the characteristics of the sample of the
      patients under study. The content of the sessions were distributed in the following way: PD
      education (including the educational concepts of anxiety, agoraphobia, panic,
      hyperventilation, respiratory re-education exercises (RR exercises), progressive muscular
      relaxation exercises (PMR exercises), preparation of a scale of "patient fears" from the
      smallest to greatest to cause anxiety, identification of cognitive distortions, cognitive
      restructuring (CR), symptom induction exercises (SIE), IE, IVE, reinforcement of conquests,
      observation of the difficulties in the procedures and maintenance of treatment gains.

      The patients were encouraged to apply cognitive strategies at home, such as expose themselves
      to changes of temperature, physical exercise, amongst others, several times, with the purpose
      of inducing and tolerating the sensations with no therapeutic assistance.

      The learning in the first phase of the treatment that BS related to panic are not really
      dangerous is essential to overcoming of agoraphobia and for the control of panic.

      Standard model of the 10 CBT sessions:

        1. st. Session: Education concerning the trajectory of PD and the preparation of a priority
           list of feared situations by the patient. Instructions to the patient of relaxation
           techniques, repeated whenever necessary. RR exercise: Placing ones hand above ones
           stomach, feeling the air passing through the diaphragm, perception of the abdominal
           movement at each respiration. Slow inspiration through the nose counting up to three,
           holding the respiration, counting up to three, and releasing the air slowly through the
           mouth counting up to six. Repetition of the exercise several times in a row. In
           continuity, Progressive Muscular Relaxation (PMR) (Jacobson, 1938) is undertaken with
           the individual, whereby the instructor seeks to exercise by tensioning four Groups of
           muscles for ten seconds and immediately after relaxing for another ten seconds. The
           latter are: 1st face; 2nd arms, shoulders, chest and neck; 3rd abdomen, spine, genital
           organs and 4th legs and feet.

        2. nd. Session: explanation concerning the physiological mechanism of "fight and flight"
           (Barlow, 1988b), verification of the similarity between the sensation originating from
           this mechanism, compared with BS that emerge from panic. Undertake RR exercise, used
           constantly during the sessions. When one manages to alter the thoughts referring to the
           capacity to deal with feared situations, one is capable of controlling the physical
           symptoms.

        3. rd. Session: model of hyperventilation that delineated by the rhythm and depth of the
           exaggerated respiration for the needs of the body at a specific given moment. The latter
           was undertaken with a patient sitting in a position of SIE hyperventilation: patient
           inspires and expires deeply for 90 seconds, observation of patient reactions and
           explanation of the reason for the emerging symptoms. Undertaking of RR exercise. The
           patient should understand that anticipated anxiety is characterized by anticipated
           thought processes, generally negative, of feared situations. Even in a secure situation
           if the mind interprets it as insecure, the body will react with a message of danger
           producing symptoms.

        4. th. Session: SIE: -sitting, look fixedly at a light for a minute and afterwards standing
           up quickly and trying to read something. Analysis with the patient of the sensations
           present and the levels of negative, catastrophic and repetitive thoughts that have
           occurred. The patient begins to understand the origin of the symptoms and to perceive
           that they are inoffensive, learning to deal with them. In continuity, RR exercise is
           administered.

        5. th. Session: explanation of the concepts of BS that can be accentuated due to a
           situation or to substances. Examples: exercising oneself or moving oneself quickly,
           brusque changes of temperature, bright light, use of caffeine, alcohol, medicines and
           irregular levels of respiration. Panic has it root in the fear of physical sensations
           (Rangé, 2001b).

           A patient was submitted to SIE: turning around in circles for a minute, afterwards
           stopping, understanding and giving a new positive significance to the reactions
           verified.

           Immediately after, RR exercise is administered.

        6. th. Session: in PA some of the patient complaints were: ex: "I cannot breathe", or "I am
           going to suffocate". It was explained that it is natural to breathe excessively when one
           is anxious. The body seeks more energy in the form of oxygen to prepare itself to deal
           with danger. When the oxygen is not used in the same proportion in which it is consumed,
           the result is hyperventilation. The concepts of hyperventilation are remembered and SIE
           of the 4th session is repeated, followed by RR exercise.

        7. th. Session: education concerning CR - The way events are interpreted is what determines
           the nature of the resulting emotional reactions (Rangé, 2001c). The patient should try
           to identify and give a new significance to the specific badly-adapted cognations. The
           concepts of Anticipated Anxiety (AA) and agoraphobic avoidance (PA-aa) (Beck, 1994) were
           clarified. Patients have the custom of myths in relation to PA: "I think I am going to
           lose control", "I think I am going to die", "I think I am going to have a heart attack",
           I think I am going mad", amongst others. The patient is instructed to question and
           contest his or her conjectures and beliefs concentrating on the realistic probabilities
           and gather evidence and forms to deal with the events.

        8. th.Session: The IE refers to the fear learnt of internal state. Certain sensations of
           terror, similar to fear previously experienced, have the custom of indicating new
           possible PA (Muotri et al, 2007c). The automatic stimulus generated intensifies the
           feared sensations, creating a vicious circle. Undertake two SIE: Sitting down, place the
           patient's head between his or her legs for 30 seconds, afterwards sit up quickly and
           look to the ceiling. And other exercise: the patient holds his or her respiration until
           it can no longer be held while turning round in circles for 30 seconds. In continuity,
           analysis of the symptoms and trying to understand the originating causes. RR exercise is
           undertaken.

        9. th. Session: Undertake three SIE: repeat the exercise of the 5th session and the two of
           the 8th session with subsequent administration of RR exercise. The purpose being for the
           individual to associate the symptom with the cause, explain that the symptoms emerge
           from physiological alterations triggered for some reason, differently from what one
           thought that BS emerged from nowhere, with no apparent reason. Previously, the patient
           would make a distorted association of the facts, interpreting tachycardia, perspiration,
           lack of breath, among others, as a sign of imminent death or loss of control and not as
           resulting from specific triggering factors.

       10. th. Session: one SIE: the patient standing up turns his or her head from one side to the
           other for 30 seconds, stops and tries to fix his or her eyes on a spot on the wall.
           Repeat this exercise after SIE of the 3rd session, in continuity; recover the patient's
           physical balance and respiration with RR or PMR exercises. Evaluate the IVE concept
           regarding confronting the patient with agoraphobic situations or locations. Explain that
           agoraphobia is maintained by the fear of panicking or the experience of certain BS.

      Real confrontation with the feared situation is repeated with each item of the priority list
      of the patient's fears, beginning with the least anxiety provocative, until reaching the most
      feared. Ask the patient to practise IVE whenever there is an opportunity.

      Review the IVEs undertaken, encourage the practical repetitions, and discuss the difficulties
      in the procedures. The behaviour of exceeding oneself should be encouraged instead of
      unnecessary over precautions. Remind the patient that to run away from the IVE reinforces the
      maintenance of fear. The therapist stimulates thoughts concerning the avoided tasks and helps
      the patient with CR. The fact that the additional diagnostics have the tendency to decline
      after PD treatment should be commented. Ex: comorbidities such as depression, generalized
      anxiety and social phobia. Reaffirm that the fear response is inoffensive, passing and
      controllable, the BS appear and disappear, without the need of being avoided.

      After the end of all the stages of the research, the two Groups were re-evaluated with same
      initial instruments. The Groups were compared, observing the changes that had occurred, the
      benefits, the losses and differences that had occurred because Group 1 had received
      accompaniment with CBT and medication, compared to Group 2 control that had only made use of
      medication with no CBT.
    

Intervention name(s): Psychotherapy; Supportative psychotherapy
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Cognitive Behavioral Therapy; Supportative psychotherapy
Other intervention name(s): Cognitive Behavior psychotherapy; non-specific psychotherapy
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: psychotherapy; panic disorder; anxiety; behavior; cognition