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Treatment of Panic Disorder

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A Critical Evaluation of Three Different Methods for
Treating Panic Disorder

A Critical Evaluation of Three Different Methods for
Treating Panic Disorder Australia and New Zealand Journal of Psychiatry (2003) described panic disorder (PD) as an anxiety disorder in people that are characterised by intense fear within discrete periods, with the symptoms of ‘flight or fight’ response. Symptoms commonly associated with PD are: palpitations, accelerated heart rate, sweating, trembling and shaking, fear of losing control, abdominal distress and fear of dying. Studies across the developed world have shown that PD prevalence is between 1.4% and 2.9%, with more women being affected by PD (Australia & New Zealand Journal of Psychiatry, 2003). PD can lead to serious consequences which can result in recurrent panic attacks, alcohol and drug abuse or risk of attempting suicide, if not treated (Bouton, Mineka, & Barlow, 2001). The three treatment methods that will be assessed are: Cognitive behaviour therapy (CBT) augmented by panic surfing, a combination of CBT and pharmacotherapy using serotonin selective reuptake inhibitors (SSRI) and short term psychodynamic psychotherapy (STPP). It will be argued that a combination of CBT and SSRI is the best treatment for PD. CBT is a method that involves a paradigm of a fight or flight response and the role of bodily hyper-vigilance. Panic surfing is used to reduce anxiety by ‘riding out the wave of anxiety’ instead of trying to control the symptoms. (Lamplugh, Berle, Milicevic, & Starcevic, 2008). In Lamplugh et al. study there were eighteen participants in the study, fifteen of which were women who attended the anxiety clinic. Their mean age was 35.6 years. Of the eighteen, 10 participants (55.6 %) were married, 4 participants (22.2%) had post secondary qualifications and 10 were in paid employment. Participants attended a 5 day group therapy programme. Participants were educated about anxiety and the fight/ flight response to threat. During group therapy patients were instructed to try and surf out the feeling when they were to experience a panic attack. Group sessions were conducted by well trained clinical psychologists. The study was evaluated with questionnaires. Results from Lampugh et al. (2008) study showed that CBT augmented by panic surfing is an effective short term treatment for panic disorder. Pre and post-treatments showed statistically significant improvements on all measures except the mobility inventory (MI). Scores on questionnaires such as the MI did not conform to a normal distribution. Favourable outcomes of Lampugh’s study were: the study was delivered in a very intense, structured and condensed manner; the study incorporated approaches that were proved to be effective by previous studies; the study approach presented complex ideas in a format that was simple and easy to understand, therefore contributing to the good acceptance by the participants. In contrast for patients to benefit from CBT with panic surfing, they need to be accepting of anxiety and be able to understand the principles. Patients with overwhelming symptoms found it difficult to learn and apply the principles of this approach. The Lampugh et al. (2008) study has a number of limitations. Firstly participants were not followed up over longer periods of time and it is not known how long the observed treatment gains were maintained. Secondly the study relied on self report instruments and did not have an index to measure the intensity and frequency of panic attacks. Thirdly a small sample size was used for the study and is not representative of the total population. Fourthly a control group of participants for comparison was not present and therefore could not ascertain whether non-specific factors might have played a role in affecting the results. Generalisabilty of the findings were difficult to establish as referrals to the clinic were screened for suitability, before clinic attendees were considered for inclusion into the study. The results should be generalised to other age groups and to the opposite gender group i.e. men. CBT is an exposure-based approach aimed at helping patients re-acquire a sense of safety around cues associated with anxiety disorders. Education and the provision of skills to deal with anxiety reduce the probability of relapse (Australian and New Zealand Journal of Psychiatry, 2003). In contrast to CBT, pharmacological interventions aim to directly target biochemical pathways underlying the anxiety elicited by disorder-specific cues. Pharmacological agents that have demonstrated efficacy for a variety of anxiety disorders include SSRI. The successes of both psychological and pharmacology treatments, have led us to believe that two effective treatment modalities that target different mechanisms of treatment change should be more effective than either modality alone. (Van Apeldoorn et al., 2008). A study by Van Apeldoorn et al. (2008) had one hundred and fifty participants in the CBT and SSRI study, 54.7% were women. The mean age was 37.5years (18-61 years). Sixty three participants were treated at the university research and training centres, forty two participants were treated at the university research clinics and forty five participants at 7 regular mental health clinics. The sites were chosen so as to ensure naturalistic nature and to allow for control on external validity. Patients were not allowed to use psychotropic drugs except small doses of benzodiazepines. PD severity and degree of improvement were evaluated by both the patient and an independent rater. Treatment was administered according to the CBT and SSRI manuals. CBT was delivered by the CBT therapist and SSRI treatment was delivered by the pharmacologist (Van Apeldoorn et al., 2008). Findings in Van Apeldoorns et al. (2008) study showed that CBT and SSRI were superior to CBT on five outcome measures in both the completer analysis and the intent to treat (ITT) analysis. Completer and ITT analysis revealed that all patients showed significant improvements on all outcome measures, regardless of treatment received. The research done by van Apeldoorn was considered externally valid with regards to the selection of patients and type of treatment centres. CBT was found to improve maintenance of treatment effects in patients, before and during drug discontinuation (Australia and New Zealand Journal of Psychiatry, 2003). The degree of improvement in patients was evaluated by both patients and an independent rater, thus providing an unbiased measure of improvement in the study results. Treatments provided were found to be effective in a clinical practice. Van Apeldoorn et al. (2008) study had a number of methodological flaws. There was no significant difference in the patient dropout rate between treatment groups; however dropout rates were higher for SSRI treatments. The reason for drop out was due to side effects and ineffectiveness of the medication (Australia and New Zealand Journal of Psychiatry, 2003). Formal treatment checks were not applied to Van Apeldoorns study and therefore this could have affected internal validity. Another shortcoming of the Van Apeldoorns study was that patients were allowed to use benzodiazepines during treatment; its use could affect the effect of SSRI. Research also suggested that CBT and SSRI are effective treatments in clinical practice, but there is a high rate of relapse following the discontinuation of drugs. Short term psychodynamic psychotherapy was defined by Lewis, Dennerstein, and Gibbs (2008) as focused therapy that uses active techniques designed to focus, clarify, and intensify the therapeutic process. In a study conducted by Milrod et al. (2001) as cited in Lewis et al. (2008) it was found that there was significant improvements in the quality of life that were consistent across all measures. Twenty–one patients diagnosed with Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) were included in the study. Patients were eligible for inclusion if they were between the ages of 18 and 50 and met DSM-IV criteria for panic disorder. Participants were treated with panic focused psychodynamic psychotherapy. The treatment consisted of twenty-four, twice-weekly sessions (12 weeks). Follow-up assessments took place at treatment termination and at 6 months after treatment termination. Results of the Milrod et al study indicated that there were substantial reductions in panic attacks and symptoms of panic attacks. There were substantial improvements in quality of life, for the patients and gains were maintained six months after follow up. The therapists in the study were well trained, senior and experienced clinicians. The positive responses in the patients would not have been observed, if inexperienced therapists had delivered the manualised treatments. The study by Milrod et al. (2001) had some limitations, the study did not have a comparison treatment and therefore did not test efficacy of psychodynamic psychotherapy for panic disorder. The small sample size was a limiting factor and therefore not generalisable to the total population. The study lacked detail with regard to training even though training was considered important in the study. (Lewis et al., 2008). Milrod et al. (2001) study had no comparison of treatment and therefore did not test for efficacy of psychodynamic psychotherapy for PD. In conclusion, a combination of CBT and SSRI is an effective short term treatment for PD. In the short term SSRI in combination with CBT has demonstrated efficacy for anxiety disorder. All patients showed significant improvements from pre to post-test on all outcome measures. The study was externally valid due to the sites chosen for carrying out the study. Treatments were effective when carried out in clinical practice. In contrast STPP showed substantial reductions in panic attack and its symptoms. STPP may be effective over longer term for some patients. CBT augmented by panic surfing was effective when delivered in an intense, structured and condensed manner.

References

Australian and New Zealand clinical practice guidelines for the treatment of panic disorder and agoraphobia (2003). Australian and New Zealand Journal of Psychiatry, 37, 641-656.
Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory perspective on the etiology of panic disorder. Psychological Review, 108(1), 4-32. doi:10.1037//0033-295X.108.1.4
Lamplugh, C., Berle, D., Milicevic, D., & Starcevic, V. (2008). A pilot study of cognitive behaviour therapy for panic disorder augmented by panic surfing. Clinical Psychology and Psychotherapy, 15, 440-445. doi:10.1002/cpp.582
Lewis, J., Dennerstein, P., & Gibbs, M. (2008). Short term psychodynamic psychotherapy: review of recent process and out come studies. Australian and New Zealand Journal of Psychiatry, 42, 445-455.
Milrod, B., Busch, F., Leon, A.C., Leon, A. C., Aronson, A., Roiphe, J., Rudden, M., Singer, M., Shapiro, T., Goldman, H., Richter, D., & Shear, K. M. (2001). A pilot open trial of brief psychodynamic psychotherapy for panic disorder. J Psychother Pract Re, 10, 239-245.
Van Apeldoorn, F. J., Van Hout, W. J. P. J., Mersch, P. P. A., Huisman, M., Slaap, B. R., Hale III, W. W., Visser, S., Van Dyck, R., & Den Boer, J. A. (2008). Acta Psychiatr Scand, 117, 260-270. doi:10.1111/j.1600-0447.2008.01157.x

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