Clinical Experiences in using Cognitive-Behavior Therapy to Treat Panic
Disorder

Abraham W. Wolf, Marvin R. Goldfried

PII: S0005-7894(13)00096-8
DOI: doi: 10.1016/j.beth.2013.10.002
Reference: BETH 438

To appear in: Behavior Therapy

Received date: 29 June 2013

Accepted date: 10 October 2013

Please cite this article as: Wolf, A.W. & Goldfried, M.R., Clinical Experiences in using
Cognitive-Behavior Therapy to Treat Panic Disorder, Behavior Therapy (2013), doi:
10.1016/j.beth.2013.10.002

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CBT FOR PANIC DISORDER 1

Running head: CBT FOR PANIC DISORDER

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Clinical Experiences in using Cognitive-Behavior Therapy to Treat Panic Disorder

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Abraham W. Wolf and Marvin R. Goldfried

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Case Western Reserve University Stony Brook University
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Key words: empirically supported treatment, evidence-based treatment, panic disorder, agoraphobia,
therapeutic alliance, motivational interviewing
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CBT FOR PANIC DISORDER 2

Abstract

Although there is a growing body of research to support the use of psychological treatments for

specific disorders, there has been no way for practitioners to provide feedback to researchers on the

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barriers they encounter in implementing these treatments in their day-to-day clinical work. In order to

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provide practitioners a means to give researchers information about their clinical experience, the

Society of Clinical Psychology and the Division of Psychotherapy of the American Psychological

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Association collaborated on an initiative to build a two-way bridge between practice and research. A

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questionnaire was developed on the therapist, patient, and contextual variables that undermine the

effective use of CBT in reducing the symptoms of panic disorder, a clinical problem that occurs
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frequently in clinical practice and has an extensive research base. An Internet-based survey was

advertised internationally in listservs and professional newsletters, asking clinicians to indicate all
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aspects of CBT that they used in treating panic disorder, and to respond to a series of questions with
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variables that presumably limited successful symptom reduction in clinical work using CBT to treat
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panic disorder,. The final database included responses from 338 participants who varied in experience
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in applying CBT to the treatment of panic disorders. Participants identified a wide range of patient
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factors that were barriers to symptom reduction including symptoms related to panic, motivation,

social system, and the psychotherapy relationship in addition to in addition to specific problems with

implementing CBT for the treatment of panic disorder.

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CBT FOR PANIC DISORDER 3

Panic disorder, which can be seriously disabling by virtue of the distress involved as well as

the possibility of agoraphobic avoidance limiting one’s functioning, is one of the more frequent

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anxiety disorders one is likely to encounter clinically. According to findings from the National

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Comorbidity Survey, panic disorder has lifetime prevalence of 3.5%, and is twice as likely to occur

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among women as men (Eaton, Kessler, Wittchen, and Magee, 1994). Panic attacks themselves are

readily diagnosable, and are characterized by a sudden and intense fear that involves both

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physiological and subjective symptoms, including increased heart rate, sweating, chest pains,
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dizziness, palpitations, as well as fears of going crazy, losing control, and dying. This can often result

in fear-related behavioral avoidance, as such as the fear of crowded places, the use of public
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transportation, being home alone, and fear of traveling. Because the symptoms often occur “out of the
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blue,” the unexpected and seemingly uncontrollable nature of this severe physical and emotional

reaction--as well as the fear that something life-threatening may be occurring--can in and of itself
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enhance the distress.

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Notwithstanding the highly distressing and impairing nature of panic disorder, we have

nonetheless been able to develop interventions over the past few decades that have shown to be

efficacious (Mitte, 2005; Westen & Morrison, 2001). Much of the work on developing treatment

procedures began in the early 1980s and was derived from direct clinical experience, which may be

thought of as the context of discovery (e.g., Chambless & Goldstein, 1982; Fishman, 1980). For

example, the work of Fishman in 1980 presented the field with a treatment package to deal with

agoraphobia, which had been the primary diagnosis at the time, with panic existing as a secondary

symptomotology. Based on his years of practice with cognitive-behavior therapy, Fishman developed

a multifaceted intervention to deal with the symptoms of agoraphobia, panic, and anxiety, which

consisted of applied relaxation, breathing retraining, prolonged imaginal exposure, interoceptive

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CBT FOR PANIC DISORDER 4

exposure, and in vivo behavioral exposure to deal with the agoraphobic avoidance. Depending upon

the individual case at hand, other cognitive-behavioral interventions were used as well, such as

assertion training and encouragement of independent functioning.

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Although there are some variations among cognitive-behavior therapists regarding how to

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intervene with panic, most approaches involve a common set of procedures. It typically begins with a

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psychoeducational phase, which helps the patient better understand and become less fearful of what

they are experiencing physiologically and emotionally. They are then encouraged to self monitor

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those situations in which they experience panic attacks, and eventually learn to cope with them, either
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with or without breathing retraining and relaxation. A good deal of emphasis is placed on cognitive

restructuring, whereby catastrophic interpretations of bodily sensations are placed within a normal
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context of heightened arousal, and not a signal of an impending serious crisis. Some therapists make
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use of interoceptive exposure, whereby patients are encouraged to create the symptoms they

experience during panic attacks during the session by means of exercise or hyperventilation. In
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addition to viewing interoceptive exposure as a means of desensitizing patients, it may also serve the

function of providing them with experiences that can correct their conceptualization of panic as
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“coming out of the blue” and being uncontrollable. Moreover, with the use of slow, deep breathing

and/or applied relaxation, patients can also learn that they can reduce these symptoms. To the extent

that there is agoraphobic avoidance, graduated exposure is used as well, the goal being to encourage

such avoided behaviors as traveling, the use of public transportation, being away from home, or being

alone.

The results of randomized clinical trials (RCTs) in using CBT to treat panic have been very

encouraging. For example, meta-analyses have found that the effect sizes to range from .90 to 1.55

(Mitte, 2005; Westen & Morrison, 2001). Findings have also revealed and that somewhere between

70% and 80% of individuals undergoing CBT for panic disorder are able to achieve significant
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CBT FOR PANIC DISORDER 5

symptom reduction (Craske & Barlow, 2008). Despite these favorable results, there nonetheless

remain several factors that undermine the efficacy of the treatment.

For example, although research findings have indicated meaningful reductions in

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symptomotology, not all patients are panic free. Indeed, it is been found that roughly 50% remain

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somewhat symptomatic at the end of treatment (Arch & Craske, 2011). In treating panic disorder with

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agoraphobia, the average dropout rate has been found to be 19%, with a range between 0% and 54%.

Longitudinal studies have found that to be a relatively high recurrence rate of symptomotology (Arch

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& Craske, 2011). Moreover, the question of the extent to which the findings from RCTs are able to
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generalize to clinical settings has been questioned. As noted by Craske and Barlow (2008):

Most of the outcome studies to date are conducted in a university or research settings, with
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select samples (although fewer exclusionary criteria are used in more recent studies).
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Consequently, of major concern is the degree to which these treatment methods and outcomes
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are transportable to nonresearch settings, with more severe or otherwise different populations
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and with less experienced or trained clinicians (Craske & Barlow, 2008, P. 33).
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The issue of whether empirically supported treatments derived from RCTs can generalize to

actual clinical settings has been much debated (e.g., Goldfried & Wolfe, 1996, 1998). In the attempt to

delineate those treatments having a stronger empirical foundation, the APA Division of Clinical

Psychology Task Force on Promotion and Dissemination of Psychological Procedures (1995) was

formed "to consider methods for educating clinical psychologists, third party payers, and the public

about effective psychotherapies" (p. 3). After reviewing the outcome research literature the task force

came up with a list of "empirically validated” treatment, which was later referred to as “empirically

supported” treatments.
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As a result of the lively controversy over empirically supported treatments in the literature,

there has been a greater recognition that there exist other forms of evidence that can inform clinical

practice. In broadening the concept of empirical evidence, the APA Presidential Task Force on

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Evidence-Based Practice (American Psychological Association Presidential Task Force on Evidence-

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Based Practice, 2006) made it clear that RCTs represent only one approach for providing empirical

evidence that can inform clinical practice. Findings from other forms of research, such as research on

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clinical disorders, client characteristics and contextual variables, therapist competence, basic research

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on psychological processes, as well as the findings on the process of change, are all most relevant for

the practicing clinician.

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As we have noted earlier, clinical observation and experience may be thought of a providing us
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with the context of discovery—a setting in which important mediating and moderating variables in
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need of investigation may be discovered. The contribution of practicing clinicians can not only help us

develop intervention methods that are subsequently investigated empirically, but can also help us fine
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tune those empirically supported interventions so as to enhance their clinical effectiveness. Thus,

Sanderson and Bruce (2007) surveyed a group of expert CBT therapists about what they observed to
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be associated with treatment-resistant panic disorder, finding such factors as noncompliance,

secondary gains, and therapy relationship problems to play a role. Acknowledging the existence of our

clinical limitations in the treatment of panic disorder, McCabe and Antony (2005) emphasize that this

information can serve “to improve our current treatments and to further our understanding of the

mechanisms underlying suboptimal response and relapse following treatment” (p. 2).

Another way to think about the need to obtain practitioners’ feedback on how well an

empirically supported treatment like CBT for panic disorder works in the actual clinical application is

in terms of what happens after the Food and Drug Administration (FDA) has approved a drug for

clinical use on the basis on randomized clinical trials. Once a drug is approved, a mechanism exists for
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CBT FOR PANIC DISORDER 7

providing feedback about how well it fares in the real clinical setting. Thus practitioners can file

incident reports to the FDA when they encounter problems in the use of any given drug in clinical

practice.

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As noted elsewhere (Goldfried, Newman, Castonguay, Fuertes, Magnavita, Sobell, & Wolf, in

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press), such a mechanism has recently been developed within psychotherapy, whereby practitioners

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can readily provide the results of their clinical experiences to researchers. A collaborative effort

between the Society of Clinical Psychology, Division 12 of the APA and Division 29 (the Division of

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Psychotherapy), this initiative is an attempt to build a two-way bridge between research and practice.
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Much has been said about the dissemination of research findings to the practicing clinician, and the

assumption behind this initiative is to provide practicing therapists with a way of disseminating their
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clinical experiences in using empirically supported treatments to the research community—as well as
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to other practitioners.
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Panic disorder was selected as the clinical problem on which to begin this two-way bridge
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initiative, as it is a clinical problem that has received favorable research evidence, one that occurs
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frequently in clinical practice and, although there has been extensive research to confirm its efficacy,

there is still much that can be learned from clinicians treating such patients. Although all therapists

who have experience with this clinical problem would have much to offer, we decided to focus on the

only current intervention that is an empirically supported treatment--CBT. The survey was broadly

conceived, asking respondents (1) to indicate all aspects of CBT that they used in treating panic

disorder, (2) to respond to a series of questions with variables that presumably limited successful

symptom reduction in clinical work using CBT to treat panic disorder, and (3) to provide identifying

information.
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Method

Instruments

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The following group of clinicians experienced in using CBT clinically participated in

extensive, one-hour open-ended interviews that were used to develop specific questionnaire items:

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Dianne Chambless, Steven Fishman, Joann Galst, Alan Goldstein, Steven Gordon, Steven Holland,

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Philip Levendusky, Barry Lubetkin, Charles Mansuto, Cory Newman, Bethany Teachman, Dina

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Vivian, and Barry Wolfe. Based on these interviews, a survey questionnaire was developed, which

included items that reflected potential treatment, therapist, patient, and contextual variables that might
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undermine the successful use of CBT in reducing the symptoms of panic disorder. The survey asked

clinicians to respond to the following classes of variables that they found to limit symptom reduction:
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(1) patient’s symptoms related to panic; (2) other patient problems or characteristics; (3) patient
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expectations; (4) patient beliefs about panic; (5) patient motivation; (6) social system (home, work,
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other); (7) problems/limitations associated with the CBT intervention method; and (8) therapy
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relationship issues. A pilot version of the instrument was tested on a sample of cognitive behavioral
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therapists and graduate students in clinical psychology and their feedback was used to revise

questionnaire items.

Procedure

An Internet-based survey was advertised internationally on listservs and newsletters of

professional organizations between December 2009 and December 2010 inviting practicing clinicians

with experience in using CBT for the treatment of panic to respond. The request for participants was

posted on the following listservs and Internet Web sites: Association for Behavioral and Cognitive

Therapies, Society for Psychotherapy Research, Siciety for the Exploration of Psychotherapy

Integration, and the American Psychological Association Society of Clinical Psychology (Division
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12), the Society of Counseling Psychology (Division 17), the Division of Psychotherapy (Division 29),

and Psychologists in Independent Practice (Division 42). In addition, requests were made on several

English-speaking listservs throughout the world (e.g. the United Kingdom, Canada, and Australia).

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The survey took approximately 10 minutes to complete. In addition to demographic information,

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educational background, and the nature of their clinical practice, respondents were asked about their

clinical experiences in those areas specified above. Specifically, they were given the following

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instructions:

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Clinical Experiences in Conducting Empirically Supported Treatments: Panic Disorder
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Once a drug has been approved by the Federal Drug Administration (FDA) as a result of
clinical trials, practitioners have the opportunity to offer feedback to the FDA on any
shortcomings in the use of the drug in clinical practice. The Society of Clinical Psychology,
Division 12 of the American Psychological Association, is in the process of establishing a
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mechanism whereby practicing psychotherapists can report their clinical experiences using
empirically supported treatments (ESTs).
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This is not only an opportunity for clinicians to share their experiences with other therapists,
but also to offer information that can encourage researchers to investigate ways of
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overcoming these limitations. We are starting with the treatment of panic disorder, but will
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extend our efforts to the treatment of other problems at a later time. This questionnaire
provides the opportunity for therapists using cognitive-behavior therapy (CBT) in treating
panic to share their clinical experiences about those variables they have found to limit the
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successful reduction of symptomatology. Although research is underway to determine if other

therapies can successfully treat panic, CBT is the only approach at present that is an EST.
However, in order for the field to move from an EST to an evidence-based treatment that
works well in practice settings, we need to know more about the clinical experience of
therapists who make use of these supported interventions in actual clinical practice. By
identifying the obstacles to successful treatment, we can then take steps to overcome these
shortcomings.

Your responses, which will be anonymous, will be tallied with those of other therapists and
posted on the Division 12 Web site at a later time—with links made to it from other relevant
Web sites. The results of the feedback we receive from clinicians will be provided to
researchers, in the hope they can investigate ways of overcoming these obstacles.

It should take you only 10 minutes to complete this.

Participants
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A total of 439 participants responded to the Internet survey. The survey was organized to that

respondents were first queried about content areas and then about demographic information. The final

database included responses from 338 participants who completed the entire survey, including

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demographic information regarding gender, age, and ethnicity, in addition to information on their

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education, training, and experience. (Subsequent interviews in this research program first queried

respondents about demographic information and then on content areas. This sequencing allowed those

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studies to compare respondents who completed the interview from those who did not on demographic

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variables. Since this survey queried for demographic information at the end of the interview, non-

completers were defined as those who failed to provide demographic information.)

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The percent of individuals who endorsed at least one item in each content area question ranged

from 58% for the question about the therapeutic alliance to 100% on most demographic variables.
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Since the response rate for the questions was over 90%, the low response rate to the question regarding

the therapeutic alliance may mean that respondents did not see the alliance as a problematic issue.
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Participants’ median age was 45-years (range 25 to 81 years), 52% were female, and 86% were
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Caucasian. Most respondents had a Ph.D. in clinical psychology (56%), and many obtained CBT
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training in graduate school (65%), internship (39%), post-doctoral experience (38%), or peer

supervision (27%), although others were self-taught through books, journals, or videos (59%), or

trained in workshops (47%). (Since participants may have obtained CBT training in more than one

modality, percentages do not total 100 %.) While most identified themselves as having a cognitive

(42%) or behavioral (38%) orientation, individual participants also endorsed other theoretical

orientations such as psychodynamic, experiential/humanistic, and family systems. The majority were

employed in outpatient treatment centers (59%) and/or in private practices (54%). Information about

respondents’ level of education, experience practicing psychotherapy and treating panic disorder is

presented in Table 1.
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Results

Techniques Typically used in Conducting CBT for Panic Disorder

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Table 2 lists the proportion of CBT techniques respondents endorsed to treat panic disorder.

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Most (84%-99%) indicated using patient education and cognitive restructuring or labeling of affect. A

majority (54%-75%) indicated using behaviorally oriented techniques such as in vivo exposure,

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simulation of panic sensations, and relaxation, in addition to resolution of conflict situations and an

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understanding of developmental roots of panic. Finally, from 10% to 31% used specific forms of

training to treat panic (e.g., assertiveness training, communication training).

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Barriers to Treatment Progress due to Symptoms Related to Panic Disorder

Table 3 reports the frequencies of responses to patient symptoms that limited symptom
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reduction. The majority of respondents indicated that the chronicity of the panic symptoms (57%), but
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also the severity of the symptoms (36%), and how the symptoms impaired the patient’s ability to
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function at home or work (39%). Comorbid disorders such as Post-traumatic stress disorder (39%),
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and symptoms such as the tendency to dissociate (39%) and a history of fainting (16%) were barriers
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to successful treatment.

Barriers to Treatment Progress due to other Patient Characteristics

Table 4 reports responses to a list of patient characteristics that limit symptom reduction.

Patients’ lack of adherence to treatment in the form of inability to work between sessions (70%),

unwillingness to give up safety behaviors (for example, objects or people believed to prevent panic

attacks; 63%), a reliance on psychotropic medication (52%), fear of exposure and associated emotional

reactions (46%), and resistance to directedness of treatment (37%) were all reported to have interfered

with the implementation of CBT. Comorbid disorders such as personality disorders (55%), substance

abuse (49%), intellectual limitations (34%), and depressed mood and mood disorders (32%) similarly

complicated treatment. Finally, patients’ chaotic lifestyle (55%), limited premorbid functioning (46%),
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and personality characteristics such as dependency and endorsements of lack or assertiveness (33%)

and a perfectionistic or obsessive style (30%) were identified as problematic.

Barriers to Treatment Progress Due to Patient Expectations

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Patient’s unrealistic expectations about the process and outcome of treatment mitigated the

successful implementation of CBT. Frequencies of participant’s endorsements as reported in Table 5

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indicate that patients expected that they would be free of all anxiety following treatment (54%),

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successful exposure would mean not having any panic or anxiety (41%), and that more than reduction

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of panic symptoms were needed in treatment (20%). In addition, patients’ beliefs that therapists would

do all the work to make things better (53%), disappointments with past therapists (33%) and expecting
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that treatment would be brief and easy (28%) were problems. Patients’ belief that they need

medication to reduce panic (49%) also interfered with CBT. Finally, 20% of respondents indicated that
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their patients believed that reduction of panic symptoms was not enough.

Barriers to Treatment Progress due to Patient Beliefs

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Patients’ beliefs’ about their panic symptoms also interfered with CBT’s ability to reduce
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symptoms. Table 6 reports that many respondents indicated that their patients believed their fears were
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realistic, for example, that they may really have a heart attack (57%), that their problems were due to

external factors (40%), and that being anxious was abnormal and dangerous (38%). Problematic

patient beliefs also included the notion that panic was biologically based (26%), and that symptom

reduction could have a negative impact on their relationships (12%).

Barriers to Treatment Progress due to Patient Motivation

Frequencies of responses associated with problems due to patient motivation are reported in

Table 7, and indicate that premature termination (60%),minimal motivation at the beginning of

treatment (60%), and decreased motivation with some symptom reduction (31%) all interfered with

treatment.
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Barriers to Treatment Progress due to Patient’s Social System

Table 8 reports elements in patients’ social system that respondents identified as interfering

with the effectiveness of CBT. Most respondents identified that patient’s symptoms were reinforced

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and supported by their social network (61%) and that their patients were trapped in a dysfunctional

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environment (57%). Other mitigating factors included high levels of stress at home or work (48%),

lack of family support for treatment (43%), social isolation (39%) and family members who were

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controlling or critical (34%) or themselves very anxious (32%).

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Barriers to Treatment Progress due to Problems/Limitations associated with the CBT

Intervention
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Table 9 lists problems and limitations associated with CBT that respondents endorsed as

limiting symptom reduction. These include patients’ reluctance to eliminate safety behaviors (56%),
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logistical problems with in vivo exposure (44%), the fact that CBT does not offer guidelines for

dealing with comorbid problems and symptoms (34%), and difficulty in simulating panic symptoms in
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session (33%). Respondents also identified how triggers to panic were not evident (27%), overly strict
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adherence to CBT protocols (26%), and how relaxation either does not work or causes anxiety (25%)
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as limiting CBT.

Barriers to Treatment Progress due to Therapy Relationship Issues

Respondents were asked about factors in the therapy relationship that were barriers in

implementing CBT, and the report of their responses are summarized in Table 10. A little over one

third of the respondents (36%) indicated that the therapy alliance not being strong enough, 33%

reported that the patient did not feel that his/her distress was insufficiently understood or validated,

17% confessed that their own negative feelings toward the patient was problematic, and that their

frustration with progress interfered with symptom reduction.

Other Survey Findings

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Survey respondents reported an average success rate of 78% in reducing panic symptoms using

CBT. Respondents also indicated that 55% of their patients were prescribed some form of

psychotropic medication.

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Discussion

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This study is the first of a series of surveys that are part of a collaborative effort between

Division 12 (Society of Clinical Psychology) and Division 29 (Psychotherapy) of the APA, the goal of

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which is to build a two-way bridge between research and practice. In much the same way that the

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FDA has a mechanism for practicing physicians to provide feedback on the use of a clinically

approved drug, the goal here is to obtain feedback from practicing therapists on their use of an
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empirically supported treatment for panic disorder. Having information on those mediating and

moderating variables that may undermine the clinical effectiveness of an intervention provides
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important information on potential areas in need of research. Moreover, it also offers important

information to clinicians about some of the limitations in using an empirically supported treatment in
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actual clinical practice.

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This study focused solely on the use of CBT in the treatment of panic disorder, as at present it
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is the only intervention that clearly meets criteria for an empirically supported treatment. Although

there is much to be said for the contributions of RCTs in determining the efficacy of CBT in treating

panic disorder, the goal here is to learn about those variables that can further enhance clinical

effectiveness. Indeed, Dimidjian and Hollon (2011) have argued that there is much to be learned by

investigating those variables that contribute to clinical failure in the use of empirically supported

treatments in actual practice--including such variables as client factors, treatment variables,

intervention limitations, working alliance, and motivation. And while there is considerable evidence

from RCTs for the efficacy of CBT in the treatment of panic disorder, there nonetheless is

considerable room for clinical improvement (Arch & Craske, 2011; McCabe & Antony, 2005;

Sanderson & Bruce, 2007).

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In order to obtain feedback from clinicians using CBT in the treatment of panic disorder, an

on-line survey was constructed with the assistance of a group of clinicians who were experienced in

using CBT clinically, and included treatment, therapist, patient and contextual variables. The survey

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itself, which took approximately 10 minutes to complete, was advertised internationally to practicing

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clinicians using CBT to treat panic. The following categories were included in the survey, where

clinicians indicated which specific variables in each category they found to limit the successful use of

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CBT in treating the symptoms of panic: patient’s symptoms related to panic; other patient problems or

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characteristics; patient expectations; patient beliefs about panic; patient motivation; social system

(home, work, other); problems/limitations associated with the CBT intervention; and therapy
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relationships issues.

Most of the participants who responded to the survey had their degrees in clinical psychology.
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Their median age was 45, with a range of 25 to 81 years of age. In line with this wide age range,

approximately 1/3 participants had less than 10 years of clinical experience, and another third 20 or
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more years of experience. With regard to the length of therapy, most indicated that their intervention
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lasted between three and six months. However, there was a substantial number that saw patients six
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months to a year. This is consistent with the clinical survey findings of Westen and colleagues (2004),

who found that interventions in naturalistic settings often lasted longer than the duration reported in

the research literature.

With regard to the CBT procedures used, virtually all respondents made use of

psychoeducation as part of their intervention. Inasmuch as panic patients typically misinterpret the

origins and significance of their symptoms (e.g., “I don’t know why this is happening,” “I’m going to

die”), the psychoeducational component of the intervention plays a particularly important therapeutic

function. As an extension of psychoeducation, the typical intervention reported by respondents also

included cognitive restructuring of patients’ beliefs and their feared outcomes, relabeling of the

sensations associated with panic, and identification of their emotional reactions to current life
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CBT FOR PANIC DISORDER 16

situations. Exposure to agoraphobic situations is also typical, as is simulation of panic sensations

within the session and breathing retraining. Although not usually part of the CBT intervention for the

treatment of panic disorder, more than half report having worked on helping patients to resolve

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conflicts that were causing stress in their lives, and also explored the developmental roots of some of

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their fears. Further, more than half of the participants made use of relaxation training which, like

breathing retraining, has been somewhat controversial in the literature (Teachman, Goldfried, &

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Clerkin, in press). Although some therapists view these interventions as providing the patient with a

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coping skill, others have expressed the concern that they might serve as safety behaviors, causing the

patient to avoid, rather than confront their anxiety. The research findings on whether to include
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breathing retraining and applied relaxation are mixed (Craske & Barlow, 2008), and further work to

clarify this issue is clearly in order.

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When asked about panic-related symptoms they have found to undermine treatment

effectiveness, more than half of the respondents indicated that chronicity played a major role. This is
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consistent with the findings of a meta-analysis of 42 studies published between 1980 and 2006, which
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found that the shorter the duration of the disorder, the more effective the intervention (Sanchez-Meca,
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Rosa-Alcazar, A. I., Marin-Martinez, F., & Gomez-Conesa, A., 2008). As reported by more than a

third of the respondents in the current survey, other symptom characteristics that make treatment less

than effective included the presence of PTSD, the tendency to dissociate, functional impairment, and

severity. With regard to other patient characteristics that created difficulties, the two most typical

patient problems consisted of their inability to work between sessions and their reluctance to give up

safety behaviors, both of which reflect between-session aspects of treatment over which therapists

have little control. There were also a number of other patient problems reported that make symptom

reduction more difficult (e.g., personality disorders, chaotic life style, substance abuse). This is

consistent with an observation made by Chambless and Goldstein several years ago (Chambless &

Goldstein, 1982) that prognosis in the treatment of agoraphobia with panic varied according to the
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“complexity” of the case. Thus they maintained that panic attacks that were the result of a focal

situational event (e.g., speaking in public) were easier to treat than those that were a function of other

psychological problems (e.g., general anxiety disorder) or a difficult and stressful life circumstance

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(e.g., a bad marriage).

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Of those patient expectations about the treatment that limited clinical effectiveness, the most

typical problem reported by respondents were that patients expected that they will be free of all

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anxiety, that the therapist would do all the work to make things better, and that medication was needed

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in order to reduce their panic symptoms. Thus despite the fact that virtually all therapists included a

psychoeducation component to the intervention, a certain percentage of patients nonetheless continued

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to hold anti-therapeutic expectations about the therapy. Extending the early work on the importance of

therapy expectations by Borkovec (1972), Constantino (2012) and his colleagues have recently
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conducted research on the parameters of this important variable that can contribute to successful

treatment. Of the most problematic beliefs about panic itself that limited clinical effectiveness was the
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thought on the part of patients that their fears were actually realistic (e.g. that they would have a heart
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attack), that their problems were due to realistic external factors, and that it was dangerous to
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experience anxiety). Interestingly enough, relatively few therapists reported clinical limitations

resulting from patients’ beliefs that symptom reduction would have a negative impact on their

relationships with others. The question of whether the reduction of panic symptoms and agoraphobic

avoidance would have an adverse affect on the patients’ relationship with significant others has been

debated over the years (Craske & Barlow, 2008), and the findings of this survey would suggest that it

might not be as serious a problem as some have suggested.

Not surprisingly, the role of patient motivation was highlighted as significant to therapeutic

progress, with half of the therapists noting this as a problem at the outset of therapy, and that

insufficient motivation contributed to premature termination. In many respects, this is not surprising,

as willingness to comply with the therapy procedure that requires them to experience anxiety depends
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CBT FOR PANIC DISORDER 18

on a certain level of motivation to change. In light of this, it would be important for therapists to

consider the use of motivational interviewing as an adjunct to the treatment of panic disorder (Miller

& Rollnick, 1991).

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A large percentage of therapists pointed to the patient’s social system as an important factor

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that could potentially undermine clinical effectiveness, such as the environment at home and at work.

This is consistent with the observation made by Chambless and Goldstein (1982) noted above and the

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more recent findings that criticism and control in close relationships can exacerbate panic symptoms

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(Steketee, Lam, Chambless, Rodebaugh, & McCullouch, 2007). These findings, taken together,

underscores the need for research to assess and modify relevant environmental antecedents and
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consequences of panic, as well as the role that significant others play in either supporting or

sabotaging the therapy.

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When asked about the problems and limitations associated with the CBT intervention itself,

close to one half of the participants indicated that it did not provide sufficient guidelines for dealing
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with patients’ reluctance to eliminate safety behaviors. Other limitations of the treatment protocol
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involved its inability to deal with comorbid problems, the difficulty in simulating panic symptoms in
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the session, and the logistical problems associated with in vivo exposure. In addressing the exposure

problem, Botella and colleagues (Botella et al., 2007) have found virtual reality exposure to be

efficacious in the treatment of panic with agoraphobia. An interesting finding in the survey was that

16% of the therapists reported that the current CBT protocol is limited in that it does not deal with

instances where the patient’s anger contributed to the panic attacks. In light of the fact that there have

been scattered reports in the literature on the link between anger and panic (e.g., Chambless &

Goldstein, 1982; Hinton, Hsia, Um, & Otto, 2003; Moscovitch, McCabe, Antony, Rocca, & Swinson,

2008), these finding suggest that the option for treating anger (which has many of the same

physiological correlates as anxiety) may be an important addition to the CBT protocol.

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CBT FOR PANIC DISORDER 19

Therapy relationship issues were highlighted by survey respondents as contributing to clinical

difficulties. More than one third of the respondents indicated that the therapy alliance was not strong

enough to bring about change, and one third admitted that their patients did not feel that their distress

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was sufficiently understood or validated by the therapist. Of particular significance was that 17 percent

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close to a third of the respondents acknowledged that their own frustration with progress and their

negative feelings for the patient created difficulties. Although therapist frustration with patients have

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been found to adversely affect therapeutic progress (Henry, Schacht, & Strupp, 1986), it is often

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unrecognized or unacknowledged by therapists, despite the fact that there exist methods (e.g.,

reattribution of motive) for reducing such negative feelings toward the patient (Wolf, Goldfried, &
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Muran, 2013). Indeed, research findings by Williams and Chambless (1990) found that agoraphobic

patients that perceived their therapists as more caring and involved were more likely to benefit from
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treatment.

The results of this survey have important implications for training new psychotherapists.
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Training in cognitive behavioral therapy typically starts a manual that trainees are expected to master.
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An inherent problem with manuals is how they decontextualize the process of therapy by emphasizing
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adherence to accomplishing specific goals in a specific order. A trainee faced with a challenging

patient who does not refuses to cooperate with the manual may become frustrated, blaming themselves

for lack of clinical skill or worse, blaming the patient. By specifying patient variable that are known to

interfere with the successful implementation of CBT, new therapists are prepared for challenging

patients and may be less inclined to rigid adherence to a treatment manual.

There are a number of limitations of this study. One of the obvious limitations of this study is

that it involves reports of what therapists say they do and what they’ve observed, and not what they

actually did or what actually occurred. With no check on fidelity or competence, we have no way of

knowing the extent to which therapists made use of the CBT intervention for threatening panic

disorder or how well they implemented the intervention. Many reported making use of procedures
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CBT FOR PANIC DISORDER 20

that were not part of the empirically supported protocol, and it is possible that had they adhered to the

clinical procedures used in the research, they may have had different experiences. Future studies will

need to more closely securitize the endorsement of items by respondents for reliability and validity.

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Second, given the nature of Internet surveys, there are serious concerns about the representativeness of

the sample. Respondents were primarily Ph.D.’s in Clinical Psychology. Only four identified

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themselves as social workers. Future studies will need to make more of an effort to sample from the

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different professional groups practicing CBT. A related issue is how respondents identified themselves

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as cognitive behavioral therapists. Future studies will need to question respondents about specific

assessment and treatment procedures in order to obtain a more functional identification of the practice
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of CBT. Third, the yes/no format of responses to specific items do not differentiate whether a specific

variable is a barrier to treatment that a clinician encounters only once or whether it is a recurrent
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problem. For example, although 57% of respondents endorsed the chronicity of panic symptoms as a

barrier, there is no way to determine if this occurred in only one patient or in multiple patients. The
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answer to these questions is beyond the scope of a 10-minute Internet survey, and future studies using
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more sophisticated and detailed questions are required to obtain this level of detail. occurs only This
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is clearly a question that merits empirical investigation. Finally, not all the therapists that began the

survey completed it, and the absence of demographic data on these non-completers makes it difficult

to determine the characteristics of these participants.

Although there are limitations associated with internal validity, a strength of the current study

is that is has external validity, in that it is a report of therapists’ clinical experiences. Interestingly

enough, their report of having 78% percent success in symptom parallels the success rate found in

controlled clinical trials (Teachman et al., in press). Although the focus of their work with panic

patients consisted of symptom reduction, it is also of particular interest that a little over two thirds of

the participants indicated that they believed that more than symptom reduction was required in their
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CBT FOR PANIC DISORDER 21

clinical work with these patients, no doubt to deal with many of those variables that they observed

were contributing to the panic symptoms.

The survey findings are intriguing and, in many ways, raise more questions than they answer.

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However, this is precisely the purpose of this initiative, namely to provide the researcher with

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clinically derived directions for future investigation. Moreover, it offers a compendium of shared

clinical experiences than can alert the practitioner to potential difficulties in treating panic patients.

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Finally, it is also a step in the direction of closing the gap between research and practice. The

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objective is to give clinicians a voice in the research agenda; hopefully, this may encourage them to

become more willing to reap the benefits of research findings, and point to research findings that bear
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directly on their clinical experience.
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References

American Psychological Association Presidential Task Force on Evidence-Based Practice (2006).

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Evidence-based practice in psychology. American Psychologist, 61, 271-285.

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Arch, J. J., & Craske, M. G. (2011). Addressing relapse in cognitive behavioral therapy for panic

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Disorder: Methods for optimizing long-term treatment outcomes. Cognitive and Behavior

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Practice, 18, 306-315.
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Botella, C., Garcia-Palacious, A., Villa, H., Banos, R. M., Quero, S., Alcaniz-M., & Riva, G. (2007).

Virtual reality exposure in the treatment of panic disorder and agoraphobia: A controlled study.
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Clinical Psychology and Psychotherapy, 14, 164-175.

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Borkovec, T. D. (1972). Effect of expectancy on outcome of systematic desensitization and implosive

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treatment for analogue anxiety. Behavior Therapy, 3, 29-40.

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Chambless, D. L., & Goldstein, A. J. (Eds.). (1982). Agoraphobia: Multiple perspectives on theory
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and treatment. New York: Wiley-Interscience.

Constantino, M. J. (2012). Believing is seeing: An evolving research program on patients’

psychotherapy expectations. Psychotherapy Research, 22, 127-138.

Craske, M. G., & Barlow, D. H. (2008). Panic disorder and Agoraphobia. In D. H. Barlow (Ed.)

Clinical handbook of psychological disorders (4th ed.).(pp. 1-64). New York: Guilford.

Dimidjian, S. & Hollon, S. H. (2011). What can be learned when empirically supported treatments

fail? Cognitive and Behavioral Practice, 18, 303-305.

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Eaton, W.W., Kessler, R.C., Wittchen, H.U., & Magee, W.J. (1994). Panic and panic disorder in the

United States. American Journal of Psychiatry, 151(3), 413-420.

Fishman, S. T. (1980). Agoraphobia: Multiform treatment (audio tape). New York: Guilford.

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Goldfried, M. R., Newman, M., Castonguay, L. G., Fuertes. J. N., Magnavita, J. J., Sobell, L. C., &

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Wolf, A. W. (in press). On the dissemination of clinical experiences in using empirically

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supported treatments. Behavior Therapy.

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Goldfried, M. R., & Wolfe, B. E. (1996). Psychotherapy practice and research: Repairing a strained

alliance. American Psychologist, 51, 1007-1016.

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Goldfried, M. R., & Wolfe, B. E. (1998). Toward a more clinically valid approach to therapy research.
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Journal of Consulting and Clinical Psychology, 66, 143-150.

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Hinton, D., Hsia, C., Um, K., & Otto, M. W. (2003). Anger-associated panic attacks in Cambodian
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refugees with PTSD: A multiple baseline examination of clinical data. Behaviour Research and
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Therapy, 41, 647-654.

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Henry, W. P., Schacht, T. E., & Strupp, H. H. (1986). Structural analysis of social behavior:

Application to a study of interpersonal processes in differential psychotherapeutic outcome.

Journal of Consulting and Clinical Psychology, 54, 27-31.

McCabe, R. E., & Antony, M. M. (2005). Panic disorder and agoraphobia. In M. M. Antony, D. R.

Ledley, & R. G. Heimberg (Eds.). Improving outcomes and preventing relapse in cognitive

behavioral therapy. New York: Guilford.

Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. New

York: Guilford.
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Mitte, K. A. (2005). Meta-analysis of the efficacy of psycho- and pharmacotherapy in panic disorder

with and without agoraphobia. Journal of Affective Disorders, 88, 27-45.

Moscovitch, D. A. , McCabe, R. E., Antony, M. M., Rocca, L., Swinson, R. P. (2008). Anger

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experience and expression across the anxiety disorders. Depression and Anxiety, 25, 107-113.

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Sanchez-Meca, J., Rosa-Alcazar, A. I., Marin-Martinez, F., & Gomez-Conesa, A. (2010).

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Psychological treatment of panic disorder with or without agoraphobia: A meta-analysis.

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Clinical Psychology Review,30, 37-50.

Sanderson, W. C., & Bruce, T. J. (2007). Causes and management of treatment-resistant panic disorder
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and agoraphobia: A survey of expert therapists. Cognitive and Behavioral Practice, 14, 26-35.
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Steketee, G., Lam, J. N., Chambless, D. L., Rodebaugh, T. L. & McCullouch, C. E. (2007). Effects of
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perceived criticism on anxiety and depression during behavioral treatment of anxiety disorders.
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Behaviour Research and Therapy, 45, 11-19.

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Task Force on Promotion and Dissemination of Psychological Procedures (1995). Training in and
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dissemination of empirically-validated psychological treatment: Report and

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Teachman, B. A., Goldfried, M., R., & Clerkin, E. M. (in press). Panic and phobias. In L. G.

Castonguay and T. F. Oltmanns (Eds.), Psychopathology: Bridging the gap between basic

empirical findings and clinical practice. New York: Guilford Press.

Westen, D., & Morrison, K. (2001). A multidimensional meta-analysis of treatment for depression,

panic and generalized anxiety disorder: An empirical examination of the status of empirically

supported therapies. Journal of Consulting and Clinical Psychology, 59, 875-899.

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Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). The empirical status of empirically

supported psychotherapies: Assumptions, findings, and reporting in controlled clinical trials.

Psychological Bulletin, 130, 631-663.

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Williams, K. E., & Chambless, D. L. (1990). The relationship between therapist characteristics and

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outcome of an in vivo exposure treatment of agoraphobia. Behavior Therapy, 21, 111-116.

Wolf, A., Goldfried, M. R., & Muran, J. C. (Eds.). (2013). Transforming negative reactions to clients:

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From frustration to compassion. Washington, DC: American Psychological Association.

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Table 1. Therapist Education and Experience.

% n

Highest degree completed

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Ph.D. in Clinical Psychology 56% 190
Ph.D. in Counseling Psychology 5% 17
Ph.D. in Educational Psychology 1% 4

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Psy..D. 7% 24
Ed.D. 1% 2

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Graduate Student 3% 11
MSW 1% 4
Masters in Clinical Psychology 6% 21

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Masters in Counseling Psychology 5% 16
Masters in Psychology - Other 4% 14
Post Graduate Certificate in CBT 5% 16
M.D. 2% 8
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RN 1% 2
Other 3% 9

Number of panic patients treated

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Less than 10 18% 59

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10 to 20 17% 57
21 to 30 12% 40
31 to 40 9% 30
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41 to 50 7% 24
51 to 100 14% 47
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Over 100 23% 76

Years of experience conducting psychotherapy

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Less than 10 36% 120

10 to 20 28% 96
21 to 30 22% 75
31 to 40 10% 33
Over 40 3% 10
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Table 2. Techniques Typically used in Conducting CBT for Panic Disorder

% n

Psychoeducation about nature of panic 99% 333

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Cognitive restructuring of general beliefs associated with panic 92% 312

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Cognitive restructuring of feared outcomes associated with panic attacks 88% 339

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Identification of emotional reactions to situations associated with panic 85% 228

Cognitive relabeling of sensations triggering panic 84% 285

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In vivo exposure to travel, open spaces and other agoraphobic situations 75% 255

Breathing retraining 68% 228

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Simulation of panic sensations within the session 65% 220

Resolution of stressful conflicts leading to panic e.g., relationships, work 57% 192
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Relaxation training
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54% 182

Helping patient understand developmental roots of fears 53% 178

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Mindfulness 48% 161

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Motivational enhancement 31% 103

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Assertiveness training 25% 86

Communication training 18% 60

Independence training 10% 32

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Table 3. Barriers to Treatment Progress due to Symptoms Related to Panic

Disorder

% n

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Chronicity 57% 194

Tendency to dissociate 39% 132

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Functional impairment travel, work, social 39% 130

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Post-traumatic stress disorder 39% 133

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Severity 36% 121

Fainting history MA 16% 55

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Table 4. Barriers to Treatment Progress due to Other Patient Characteristics.

% n

Inability to work independently between sessions 70% 235

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Unwillingness to give up safety behaviors
e.g., objects/people believed to prevent panic 63% 214

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Personality disorder s 55% 186

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Chaotic life style 55% 186

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Reliance on psychotropic medication 52% 175

Substance abuse MA 49% 165

Premorbid functioning is limited 46% 157

Fear of exposure and associated emotional reactions 46% 156

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Resistance to directiveness of treatment 37% 124

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Intellectual/cognitive/introspective ability is limited 34% 116

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Dependency/unassertiveness 33% 112

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Depressed mood/mood disorder 32% 108

Perfectionistic/obsessive style 30% 100

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Low self-esteem/self-efficacy 22% 73

Negative emotions not recognized 21% 71

Poor interpersonal skills 19% 64

Physical problems 16% 55

Low socioeconomic status 7% 23

Diversity issues associated with ethnicity/race/sexual orientation 3% 9

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Table 5. Barriers to Treatment Progress due to Patient Expectations.

% n

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They will be free of all anxiety 54% 184

Therapist will do all the work to make things better 53% 179

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They need medication to reduce panic 49% 164

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Successful exposure means not having panic/anxiety 41% 139

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Pessimism due to disappointment with past therapy 33% 110

Treatment will be brief and easy MA 28% 94

Symptom reduction is not enough 20% 67

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Table 6. Barriers to Treatment Progress due to Patient Beliefs.

% n

Belief that their fears are realistic e.g. they may have a heart attack 57% 193

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Their problems are due to external factors e.g., situation, other people 40% 135

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Being anxious is abnormal/dangerous 38% 128

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Panic is biologically based 26% 88

Belief that symptom reduction will have negative impact on relationships 12% 39

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Table 7. Barriers to Treatment Progress due to Patient Motivation.

% n

Premature termination 60% 203

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Minimal motivation at outset 60% 202

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Motivation decreased as some improvement occurs 31% 105

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Motivation decreased when patient learns reasons for having panic 10% 33

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Table 8. Barriers to Treatment Progress due to Patient’s Social System.

% n

Symptoms/dependency is reinforced/supported 61% 205

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Trapped in a dysfunctional home, work, or social situation 57% 194

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Stress very high at home, work, or socially 48% 162

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Family does not support treatment 43% 144

Social isolation of patient 39% 132

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Family is controlling and critical 34% 116

Family members are very anxious 32% 107

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Loss of family member, partner, employment 18% 62
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Table 9. Barriers to Treatment Progress due to Problems/Limitations Associated with CBT Intervention.

% n

Patient’s reluctance to eliminate safety behaviors

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e.g. carrying meds, being with others 56% 189

Exposure in vivo has logistical problems 44% 150

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Doesn’t deal with comorbid problems/symptoms 34% 116

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Simulating panic in session is difficult 33% 113

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Triggers to panic not evident 27% 92

Strict adherence to CBT protocol MA 26% 87

Relaxation doesn’t work or causes anxiety 25% 85

Absence of guidelines for dealing with resistance/noncompliance 17% 58

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Doesn’t deal with patient’s anger 16% 55

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Doesn’t deal with fear of interpersonal loss 14% 46

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Triggers for panic are not linked to client's past history 10% 33
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Doesn't deal with comprehensive or lasting change 9% 29

Current coping skills are not linked to past 7% 25

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Table 10. Barriers to Treatment Progress due to Therapy Relationship Issues.

% n

Therapy alliance not strong enough 36% 121

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Patient doesn’t feel his/her distress is sufficiently understood/validated 33% 111

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Therapist’s negative feelings toward patient 17% 57

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Therapist’s frustration with progress 17% 56

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Highlights

 Survey data collected from a group of cognitive behavioral therapists

 Determined variables that limit symptom reduction using CBT for panic disorders

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 Wide range of patient factors identified

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 Implications for communication between researchers and practitioners

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