Treatment Of PTSD With Comorbid Panic Attacks
By Sherry A. Falsetti, Ph.D.
NCP Clinical Quarterly 7(3): Summer 1997
My interest in comorbid PTSD and panic attacks first began several years ago when I treated a patient who had comorbid PTSD and panic disorder. I was a psychology intern at the National Crime Victims Research and Treatment Center and was working with Dr. Heidi Resnick. She suggested that the panic attacks of my patient may be a conditioned response related to his past trauma history and that I first treat his panic disorder using Barlow and Craske’s panic control treatment (1) and then use Resick’s cognitive processing therapy for PTSD (2). The treatment of this patient was successful and led us to wonder how common comorbid panic attacks were in patients with PTSD. Thus, a new line of research was born. We found that over 60% of patients seeking treatment for crime related PTSD also were suffering from panic attacks (3).
Over the past six years I have worked in collaboration with Dr. Resnick to develop a treatment for comorbid PTSD and panic disorder by combining Dr. Resick’s cognitive processing therapy (CPT) with Drs. Barlow and Craske’s panic control treatment (PCT). The course of these treatments are 12 weeks and 15 weeks, respectively. I did not want a treatment that took 27 weeks to complete, so I have worked on modifying and combining these treatments in such a way as to have a 12 week treatment that does not lose the essential components of each treatment. These efforts have resulted in Multiple Channel Exposure Therapy (MCET), which I am currently testing in the first randomized trial with funding from the National Institute of Mental Health.
The grant to study this treatment is a three year grant. The first year of the grant was devoted to writing two manuals: a therapist and a patient manual. The remaining two years will be used to test the treatment in a randomized study against a minimal attention control group. Treatment will be conducted in a group format for twelve weekly sessions and patients will be assessed pretreatment, posttreatment, and at three and six months posttreatment. Patients assigned to the minimal attention control group will be assessed pretreatment and posttreatment and will be offered MCET free of charge at the conclusion of the post assessment.
The theoretical underpinnings of this treatment are based on a combination of Barlow’s model for panic disorder (4) and Foa’s information processing theory for PTSD (5). Our model of the development of panic attacks or panic disorder for individuals who have experienced a traumatic event (6) posits that, initially, panic represents an unconditioned response to a traumatic event. Through classical conditioning, panic attacks become a conditioned response to trauma-related cues in the environment. Furthermore, the reexperiencing of physiological panic symptoms may trigger thoughts that accompanied these symptoms at the time of the trauma (e.g., "I am in danger" or " I’m going to die"), which may induce fear of the symptoms themselves. Fear of the intense physiological arousal may lead to further avoidance of trauma-related cues that trigger panic attacks in patients with PTSD. Thus, these patients may be more fearful of exposure based treatment due to fear of the memory of the traumatic event, as well as fear of the physiological symptoms experienced when recalling the memory of the event.
Based on this model, we developed a treatment program in which fear of physiological symptoms is reduced prior to implementing trauma related exposure techniques. This treatment also has a cognitive exposure component, as well as an in vivo exposure component. In addition, it includes psychoeducation about panic attacks and PTSD, and a cognitive restructuring component that addresses distorted thinking that may be trauma or panic related. This treatment is the first to target PTSD patients who also experience panic attacks.
The first session of treatment is designed to provide education about traumatic events and reactions to trauma including education about posttraumatic stress disorder, panic attacks, depression, and increased drug and alcohol use. Patients are also provided with a treatment
rationale using learning and information processing theories. The remainder of the first session is used to discuss what the patient can expect from treatment, the importance of attending sessions and completing homework, and the importance of monitoring symptoms. Homework is assigned to complete monitoring forms for PTSD symptoms and panic attacks (these assignments are given throughout treatment), to write about the meaning of the traumatic event, and to complete a worksheet that assists in identifying conditioned cues.
Session Two begins with reviewing the homework. This review emphasizes the importance of homework. PTSD and panic symptoms are reviewed and any questions about the readings are addressed. This activity emphasizes the importance of the readings as homework and assists in refreshing the patient’s memory about how her symptoms may be trauma related. Also in Session Two, education about the connection of breathing, panic attacks, and the traumatic event(s) is provided. This interaction lays the groundwork for breathing retraining. The main points here are how hyperventilation may lead to panic attacks and how the first panic attack may have occurred when experiencing a traumatic event. In addition, patients are asked to complete a brief questionnaire about over-breathing in the Patient Manual. The results of this questionnaire help the therapist to determine if over-breathing is in fact playing a role in the patient’s panic attacks and if the over-breathing may be trauma related. Finally, patients are taught how to breathe diaphragmatically. This exercise gives each patient a useful skill that can reduce physiological arousal and gives a sense of control over her body. Homework for this session includes monitoring of PTSD and panic symptoms, and practicing breathing retraining exercises.
Session Three, like all sessions, begins with a review of the homework assigned in the previous session. In addition, patients are asked to work further on breathing retraining skills by slowing down the rate of breathing. In this session the connection of events, thoughts, feelings, and behaviors is introduced and over-estimation thinking errors regarding the traumatic event and panic attacks, and the resulting consequences of panic attacks, such as over-estimates of the likelihood of going crazy or having a heart attack are discussed. For homework, patients are asked to continue with monitoring of PTSD and panic symptoms, to practice breathing retraining and slowing down breathing, and to complete worksheets for trauma and panic related thoughts.
At Session Four, after reviewing homework, the patient and therapist discuss catastrophic thinking, which means jumping to the worst possible conclusion. Catastrophic thoughts can be about panic attacks, can be related to PTSD symptoms, or can be a result of the traumatic event. A series of questions are introduced in worksheet format to assist patients in challenging distorted thinking. Each patient can usually relate to a particular type of cognitive distortion, for instance having a tendency to overestimate the probability of something bad happening, or to disregard important aspects of the situation. The therapist should assist each patient in identifying if she has a particular way of distorting that seems to be habitual, so she can pay particular attention to this question on the worksheet as she completes her homework for the week. For homework, patients are asked to complete worksheets for catastrophic thoughts and to continue to practice breathing retraining.
Session Five is devoted primarily to interoceptive exposure exercises aimed at desensitizing patients to the physiological panic sensations. Exercises from Barlow and Craske’s PCT are practiced in the session and ratings regarding the intensity of the sensations, the similarity to panic, and anxiety at the sensations are elicited to develop a hierarchy for homework exercises. Interoceptive exercises include hyperventilating, breath holding, tensing muscles, spinning in a chair, breathing through a straw, and stair stepping. Further cognitive restructuring work to help patients identify overestimations, catastrophic thinking, and other cognitive distortions is also completed. Lastly, patients are instructed to begin applying breathing retraining in anxiety provoking situations. Homework includes continuing to complete worksheets for cognitive restructuring, applying breathing when feeling anxious, and practicing interoceptive exposure exercises.
At Session Six, work is continued with interoceptive exposure exercises and cognitive exposure is introduced. We have found that patients with PTSD and comorbid panic attacks are generally successful in quickly reducing their fear to the physiological symptoms of panic attacks. If the patient was successful in decreasing fear to initial two interoceptive exercises on the hierarchy, then we move on to the next two exercises. It is helpful to practice these in session in case the patient has forgotten how to perform exercises. To begin the cognitive exposure component, patients are asked to write about the traumatic event. The rationale for exposure to the traumatic memory is very important in motivating the patient to complete this assignment. The first writing of the traumatic event is often the most difficult therapy assignment. We encourage the patient to begin this assignment as soon as possible, to read the account at least once a day, and record her anxiety after the writing and each reading of the account.
Session Seven focuses on the traumatic event writing homework. If treatment is conducted in a group format we do not have the patients read their assignments in session because of the possibility of secondary victimization of hearing the details of other victim’s stories. If the patient is being treated individually, the patient reads the assignment aloud in the session. In both group and individual treatment, it is important to discuss the writing homework and identify what parts of the event are most painful to recall. It is also important to identify any cognitive distortions that may interfere with processing the memory accurately (i.e., "I must have done something to deserve to have been raped. I should have never gone on a date with him".) The therapist then assists the patient in using cognitive restructuring skills to examine the evidence, challenge, and correct distortions. This session is also used to review any remaining interoceptive exposure exercises that need to be completed. If the patient has completed these exercises, the therapist should provide reinforcement for completing this phase of treatment and note any decreases in panic attacks and avoidance behaviors that are associated with this. For homework, patients are asked to write about the traumatic event a second time. It is helpful for the therapist to predict that writing about the event a second time will not be as difficult as writing about the event was the first time, although it will not be easy and to note any decreases in anxiety that took place the first week from reading the account.
At Session Eight the second exposure writing assignment is discussed and patient and therapist further identify distortions and difficulties about the event, such as self-blame that she was unable to prevent the event or generalizations from this event to all situations or groups of people (i.e., all men are dangerous). The patient and therapist should also discuss interoceptive exposure exercises if any were assigned the previous week. At this point in treatment, the patient should be less fearful of the physical sensations, and as a result may also be experiencing a decrease in panic attacks. If the patient has successfully completed all interoceptive exposure exercises and has also experienced a decrease in panic attacks, the therapist should reinforce her progress in successfully completing the component of treatment that focuses on physical reactions. New material in this session includes how trauma may have affected the patient’s sense of safety. Pertinent to safety issues is discussion of conditioned cues, changes in thinking, and changes in the ability to recognize dangerous situations. Facts about rape and basic safety tips, if appropriate are also discussed. For homework, patients are asked to continue to monitor symptoms and to record panic attacks, apply breathing, read a handout on safety and a handout of crime facts and strategies for prevention and coping.
Sessions Nine, Ten, and Eleven focus primarily on in vivo exposure to trauma and panic related cues. Patients develop fear hierarchies for at least three in vivo target fears and work through these hierarchies as their homework. Session Twelve, which is the final session of treatment is devoted to reviewing treatment, discussing problems encountered in treatment, discussing relapse prevention, and making plans for what patients may want to continue working on independently.
The treatment format presented here is that of our manualized treatment that has been standardized for research purposes. Of course, therapists who are interested in using this treatment with their therapy patients have the flexibility to spend more or less time on particular topics that are relevant for each of their patients. In addition, patients with a history of multiple vicitimzations may need more time to complete treatment successfully.
Results from the pilot data for this study indicate that this combination of treatment may be a promising treatment for women with PTSD and comorbid panic attacks (7 ). Six patients were treated individually and four were treated in a group format. Within the
subsample of individually treated patients (n=6), at post-treatment assessment, none met diagnosis for PTSD and nor were they experiencing panic attacks. Within the group treatment subsample (n=4), two patients dropped out of treatment. Of the two patients who completed treatment, neither met diagnostic criteria for PTSD nor were experiencing panic attacks posttreatment. One of the patients who dropped out of treatment was assessed five months posttreatment and was found to meet diagnostic criteria for PTSD, but was no longer having panic attacks. For all patients who completed a posttreatment assessment, panic attacks had completed remitted by week 6, although PTSD symptomatology persisted until much later in treatment. This differential pattern of improvement was consistent with the order in which symptoms are addressed in the treatment protocol. Ongoing research will include a randomized trial of this treatment compared to a minimal attention control group for 48 women with comorbid PTSD and panic attacks.
References
1. Barlow, D.H., and Craske, M.G. (1989). Mastery of your anxiety and panic. Manual available from the Center for Stress and Anxiety Disorders, 1535 Western Avenue, Albany NY 12203.
2. Resick, P.A., & Schnicke, M.K. (1993). Cognitive processing therapy for rape victims: A treatment manual. Newbury Park, CA: Sage.
3. Falsetti, S.A., & Resnick, H.S. (in press). Frequency and severity of panic attack symptoms in a treatment seeking sample of trauma victims. Journal of Traumatic Stress.
4. Barlow, D.H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and panic. New York: The Guilford Press.
5. Foa E.B., Steketee G., Olasov-Rothbaum, B. (1989). Behavioral/cognitive conceptualizations of post-traumatic stress disorder. Behavior Therapy, 20, 155-176.
6. Falsetti, S.A., Resnick, H.S., Dansky, B.S., Lydiard, R.B., & Kilpatrick, D.G. (1995). The relationship of stress to panic disorder: Cause or effect? In C.M. Mazure (Ed.), Does stress cause psychiatric illness? (pp.111-147) Washington, DC: American Psychiatric Press, Inc.
7. Falsetti, S.A., Resnick, H.S. , & Gibbs, N.A. (1997). Treatment of posttraumatic stress disorder with panic attacks: Combining cognitive processing therapy with panic control techniques. Manuscript submitted for publication.
Sherry Falsetti is an Assistant Professor of Psychiatry and Behavioral Sciences and Director of Training for the National Crime Victims Research and Treatment Center at the Medical University of South Carolina. She is currently the principal investigator on a National Institute of Mental Health Grant to develop multiple channel exposure therapy and is a coprincipal investigator on a National Institute of Mental Heatlh Grant to investigate irritable bowel syndrome, victimization history, psychiatric disorders, and health care seeking behavior in a nationally representative sample.
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