When it comes to cognitive behavior therapy (CBT) and most psychiatrists, a little knowledge is a troubling thing. We know that CBT is effective, but we don’t know how to practice it. We know that a lot of patients ask us about it, but we don’t know enough to confidently describe to them what it entails.

You may be one of the few who has sought out the training and experience to gain proficiency in CBT. But for those others who are mystified by terms such as “interoceptive exposure” and “catastrophic cognitions”, this article is a primer for you.

To begin, how effective is CBT for panic disorder? The typical treatment protocol in CBT studies entails 12 weekly 50-minute sessions over a 3 month period. In such studies, response rates (usually defined as panic-free rates) are in the 80% range (1). This compares favorably to data reported in studies of antidepressants and benzodiazepines, in which panic-free rates range from 50% to 85% (2).

Good head-to-head comparisons of cognitive therapy and pharmacotherapy are rare, but a recent landmark study published in JAMA (3) compared CBT with imipramine in 312 patients with panic disorder. At 3 months, both treatments produced response rates of about 70% (significantly better than the 40% response rate produced by placebo). After 6 months of further maintenance treatment (monthly therapy in the CBT arm), responders discontinued treatment, and were assessed 6 months later. Relapse rates were 25% in the imipramine group vs. only 4% in the CBT group. The bottom line is that while CBT and imipramine were equivalent in terms of response rate, CBT led to more durable responses after treatment discontinuation. This makes sense, since one goal of CBT is to teach techniques that patients can deploy throughout their lives when anxiety hits them hard.

The glaring deficiency of the JAMA study, of course, is that the comparator drug was not an SSRI, and we’re still waiting for such a study to be reported. In the meantime, the weight of the evidence is that CBT is at least as effective as medications for panic disorder, and that the response may be more durable.

Does this mean that we should all immediately rush out to our nearest cognitive therapy training center? Perhaps, but few of us will. More realistically, we can fold some CBT techniques into our pharmacotherapy sessions. While studies combining full scale CBT with medication treatment have yielded mixed results (1,4), adding smaller components of CBT to pharmacotherapy has been shown to enhance treatment response, especially in patients with agoraphobia (5). In consultation with Newburyport cognitive behavior therapist Robert Safion, TCR recommends the following approach for what has been termed “Cognitive Behaviorally Informed Pharmacotherapy”.

1. Teach your patient a brief CBT model of panic disorder. This will help make a very scary experience comprehensible, and most patients will feel significantly better after this piece of psychoeducation alone. The best way to do this is by working from an example of a recent panic attack.
   
   Guide your patient through the panic experience, starting with the trigger (e.g., driving toward the highway), proceeding to the sensations (e.g., shortness of breath, pounding heart), then to catastrophic cognitions (“I’m going to pass out”, “I’m going to crash”), then to increased fear in response to the thoughts, resulting in a full blown panic attack. Reassure your patient with something like: “A panic attack happens because you interpret your initial sensations as meaning that terrible, catastrophic things are going to happen. Medication and therapy will help you to gain control of your thinking, so that you can just watch those sensations come and go, without getting into panic mode, and without feeling the need to escape.”

Psychiatrists should incorporate four CBT techniques in panic disorder treatment:

• Psychoeducation


• Exposure training


• Breathing exercises


• Bibliotherapy

2. Encourage exposure. Explain: “When you engage in safety-seeking behaviors, like getting off the highway or avoiding it, you get some temporary relief, but this reinforces your underlying belief that the only way to relieve your anxiety is to avoid the situation. This is escaping your symptoms rather than dealing with them head on.” You understand that this can be a terrifying prospect right away, and this is why you are starting medication first. But you will expect your patient to push him or herself over the course of treatment: “I expect you to continue driving; and in fact the worse thing you can do for your treatment is to avoid driving. Week after week, as you feel the meds kicking in more and more, I will encourage you to push yourself. You can start with surface streets, then move on to larger boulevards, then to frontage roads paralleling the highway, then onto the highway and getting off at the next exit, and so on until you feel comfortable with highway driving again.”The key thing is to ask about your patient’s success with exposure during follow-up medication visits. If you do not, she may all too happily assume that you have decided that this exercise doesn’t really matter. It does.

3. Teach a breathing/relaxation exercise. While there are many different relaxation exercises available, one of the most useful and easiest to learn is breathing retraining , which is especially important for “respiratory panickers”— patients who describe hyperventilation as a prominent symptom. To teach breathing retraining, say: “I’m going to teach you a simple breathing technique that will help you when you feel a panic attack beginning. Sit comfortably, and count to one with each inhalation, then count to two with each exhalation. If you prefer, you can count to 3 when you inhale and 6 when you exhale. The key thing is to maintain a 1 to 2, inhalation to exhalation ratio. If you do this exercise diligently, it is almost impossible to hyperventilate or to have the sensation of losing control.”


4. Assign reading. The fancy name for this is “bibliotherapy,” and studies have shown it to be effective treatment for panic disorder (6). Several good books are available (7). As with exposure therapy, the crucial thing about bibliotherapy is to ask patients if they are practicing it when you see them for med checks. This therapeutic “nudging” provides needed motivation.

Bring some or all of these techniques into your pharmacotherapy with anxiety patients, and you’ll likely see them becoming more functional over time. And you’ll make Aaron Beck (the father of CBT) proud!

TCR VERDICT:
CBT: Ignore it at your patient’s peril!

<sub>1.Otto MW and Deckersback T. Cognitive Behavior Therapy for Panic Disorder. In Panic Disorder and Its Treatment, Ed. Rosenbaum JF and Pollack MH, 1998, Marcel Dekker, New York.
2. den Boer JA. Pharmacotherapy of Panic Disorder: Differential Efficacy from a clinical viewpoint. J Clin Psychiatry 1998:59[suppl 8]:30-36.
3. Barlow DH, Gorman JM, Shear MK, Woods SW. Cognitivebehavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. JAMA 2000;283:2529-2536.
4. 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.
5. Zitrin CM, Klein DF, Woerner MG: Treatment of agoraphobia with group exposure in vivo and imipramine. Arch Gen Psychiatry 1980; 37:63-72.
6. Wright J, Clum GA, Roodman A, et. al: A bibliotherapy approach to relapse prevention in individuals with panic attacks. J Anxiety Disord 2000; 14(5):483-99.
7. Coping with Panic: A Drug-Free Approach to Dealing with Anxiety Attacks, by George Clum (Brooks/Cole, 1990), and Stopping Anxiety Medication: Panic Control Therapy for Benzodiazepine Discontinuation Patient Workbook, by David Barlow, Mark Pollack, and Michael Otto (Psychological Corp, 2000).</sub>