A pilot study of two-day cognitive-behavioral therapy for panic disorder

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Abstract

The present study investigated the short-term efficacy of brief, intensive cognitive-behavioral therapy (CBT) for panic disorder (PD). The treatment involved 9 h of therapist contact over two consecutive days and was developed for the purpose of delivering CBT for PD to a largely rural patient population that must travel long distances to find a treatment provider. Ten patients who elected to participate in brief, intensive CBT instead of weekly CBT were recruited from routine clinical practice in a hospital-based anxiety disorders clinic. Patients were not excluded based on the presence of agoraphobia, diagnostic comorbidity, concurrent use of PRN benzodiazepine medications, or previous nonresponse to psychotherapy for PD. Assessments conducted at pre-treatment and 1-month follow-up revealed large, clinically significant reductions in PD symptoms, anxiety sensitivity, body vigilance, and anxiety and depressive symptoms. Most patients (60%) were panic-free after treatment and evidenced normative levels of symptomatology at follow-up. The present study suggests that brief, intensive treatment may be an effective means of delivering CBT for PD.

Introduction

Cognitive-behavioral therapy (CBT) involving interoceptive exposure is the psychological treatment of choice for panic disorder (PD) (Barlow, 2002). This treatment, when delivered in 12–15 weekly sessions, produces substantial and durable reductions in PD symptoms (Addis et al., 2004; Barlow, Gorman, Shear, & Woods, 2000) and, relative to pharmacotherapy, appears more cost-effective (Heuzenroeder et al., 2004), acceptable and preferable to patients (Deacon & Abramowitz, in press), and less likely to result in attrition (Hofmann et al., 1998). Despite the established efficacy and effectiveness of CBT, many patients with PD are unable to benefit from this treatment; for example, individuals living in underserved rural settings who must commute long distances for weekly appointments. This extra travel time can create a strain on time and financial resources, leading to treatment refusal. In the present study, we examined the effectiveness of a brief (2-day), intensive variant of CBT for PD that might be well suited for patients and treatment providers in settings where the aforementioned barriers to obtaining effective treatment exist.

A growing body of research has examined the efficacy of various methods for abbreviating standard treatment. Studies examining bibliotherapy (e.g., Gould, Clum, & Shapiro, 1993), computer-guided self-exposure (Marks, Kenwright, McDonough, Whittaker, & Mataix-Cols, 2004), internet-based treatment (e.g., Carlbring, Westling, Ljungstrand, Ekselius, & Andersson, 2001), and teletherapy (e.g., Swinson, Fergus, Cox, & Wickwire, 1995) indicate that reduced therapist contact interventions may be viable options for many individuals with PD. These studies highlight the possibility raised by stepped care models (Newman, 2000) that brief CBT might serve as a first-line treatment for patients who are likely to benefit from minimal interventions.

Although reducing therapist contact makes therapy more affordable and minimizes the inconveniences associated with frequent office visits, the duration of these interventions does not differ appreciably from that of standard CBT in most studies (e.g., Cote, Gauthier, Cormier, & Plamondon, 1994). As a result, such interventions might not make treatment more accessible to patients who lack sufficient time or who desire more immediate symptom reduction. Few studies have examined brief CBT approaches that include the essential features of CBT for PD: (a) education, (b) cognitive restructuring, (c) therapist-assisted interoceptive exposure, and (d) therapist-supervised in vivo exposure (e.g., Schmidt, 1999). Fewer still have compared reduced therapist contact interventions to this “gold standard” CBT. Perhaps not surprisingly, the most consistently effective brief treatments for PD are those that emphasize these procedures (e.g., Clark et al., 1999). Notably, several studies indicate that very brief, intensive, exposure-based interventions produce outcomes comparable to standard CBT in a matter of weeks (Westling & Ost, 1999) or even days (Evans, Holt, & Oei, 1991).

In the present study, we describe a novel, 2-day, therapist-directed exposure-based CBT approach for PD that was developed to serve a largely rural patient population. Pilot efficacy data are presented from a sample of PD patients treated in routine clinical practice. Although this study was exploratory in nature, based on previous research we hypothesized that brief CBT would produce clinically significant reductions in PD symptoms from pre-treatment to 1-month follow-up.

Section snippets

Participants

Ten adults (eight women and two men, all of whom were Caucasian; mean age=38.4 years; SD=11.5; range=26–62) meeting DSM-IV-TR criteria for PD with agoraphobia (n=5) and PD without agoraphobia (n=5) were recruited from a multidisciplinary anxiety disorders clinic within a large academic medical center. The sample was well-educated: four participants had attended some college and five had earned at least a bachelor's degree. Median annual family income was between $50,000 and $60,000 per year.

Changes from pre-treatment to 1-month follow-up

Table 1 presents means, standard deviations, paired samples t-test results, and effect sizes (Cohen's d) for each outcome measure at pre-treatment and 1-month follow-up. Statistically significant reductions and large within-group effect sizes (Cohen, 1988) were observed for each variable. Patients experienced substantial reductions following brief, intensive CBT in each dimension of PD symptoms assessed by the PDSS. Four patients experienced a single panic attack and six patients were

Discussion

The present pilot study was conducted to examine the efficacy of brief, intensive CBT for PD. This treatment involves 9 h of therapist contact over two consecutive days and was developed to facilitate the delivery of effective psychological treatment to a largely rural patient population that cannot conveniently attend weekly therapy sessions. Brief, intensive CBT includes the essential procedures of standard-length CBT and emphasizes therapist-assisted exposure to interoceptive and external

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