Treating Panic Disorder in Veterans with PTSD

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Treating Panic Disorder in Veterans with PTSD

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

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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

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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

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Background (contd)

• 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).

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Background (contd)

• So whats 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)

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Background (contd)

• 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)

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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

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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.

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Method

• Participants
• 49 outpatients from the Trauma Recovery Program
• Overall Sample Characteristics
• Age M52 years, SD8.44
• 14 women 86 men
• 43 African American
• 43 Caucasian
• 14 Hispanic

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Method

• Inclusion Criteria current PTSD diagnosis gt 1
  PA in past month
• IQ gt 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

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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

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Results

• Primary Analyses
• A higher of patients in PCT (63, n10) was
  panic-free at the 3-month follow-up than the SUP
  group (19, n3), ?2 (1, N32) 6.35, p.01)

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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

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Discussion (contd)

• 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

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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)

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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