Panic Disorder and Agoraphobia: Randi E. Mccabe Martin M. Antony

This is a chapter excerpt from Guilford Publications.
Improving Outcomes and Preventing Relapse in Cognitive-Behavioral Therapy,

Martin M. Antony, Deborah Roth Ledley, an Richard G. Heimberg, Eds. Copyright © 2006.
McCABE
Panic Disorder
and ANTONY
and Agoraphobia
Panic Disorder
and Agoraphobia
RANDI E. McCABE
MARTIN M. ANTONY
OVERVIEW OF THE DISORDER
Although panic attacks may occur in the context of any anxiety disorder,
unexpected or “out of the blue” panic attacks are the central feature of panic
disorder. Panic disorder is characterized by recurrent unexpected panic
attacks involving a sudden onset of intense fear or discomfort that is accom-
panied by physical symptoms (e.g., palpitations, sweating, and shaking), cog-
nitive symptoms (i.e., fear of dying, losing control, or going crazy), or both.
These unexpected episodes of panic are associated with persistent concern
about future attacks and worry about the meaning or consequences of attacks
(that the panic may lead to a “catastrophic” outcome such as having a heart
attack, fainting, loss of bowel control, etc.). In addition, panic attacks are
often accompanied by behavioral change in response to the attacks such as
avoiding certain activities or places or engaging in safety behaviors (e.g., only
going out when accompanied or when carrying certain objects such as a
mobile phone, water, or medication) (American Psychiatric Association,
2000). Data from the National Comorbidity Survey indicate a lifetime preva-
lence of 3.5% for panic disorder (Eaton, Kessler, Wittchen, & Magee, 1994).
Panic disorder is often accompanied by agoraphobia, which refers to
anxiety about, or avoidance of, situations in which it may not be easy to
escape or get help in the event of experiencing panic symptoms (American
Psychiatric Association, 2000). Data from the National Comorbidity Survey
indicate a lifetime prevalence of 1.5% for panic disorder with agoraphobia
(Eaton et al., 1994). Typical situations that individuals with panic disorder
fear or avoid include crowded places, grocery stores and shopping malls, pub-
lic transportation, being home alone, driving in heavy traffic or on highways,
1
2 McCABE and ANTONY
movie theatres and arenas, airplanes, waiting in line, taking walks, restau-
rants, enclosed places (e.g., elevators), and open spaces (e.g., parks). Patterns
of avoidance associated with agoraphobia are variable. Some individuals
avoid just a few situations such as crowds and flying, whereas others avoid a
much wider range of situations. It is common for individuals with moderate to
severe agoraphobia to describe a “safe zone” or a certain radius around their
home in which they feel comfortable. Travel outside this “safe zone” is partic-
ularly difficult if not completely avoided, especially if unaccompanied. Most
individuals with panic disorder also report symptoms of agoraphobia (Eaton
et al., 1994).
Panic disorder is more common in females than in males. For example,
one study based on the National Comorbidity Survey found the lifetime
occurrence of panic disorder was roughly two and one half times higher in
females than in males (Eaton et al., 1994). Compared to men, women tend to
have more severe and chronic forms of panic disorder with agoraphobia (Yon-
kers et al., 1998), increased agoraphobic avoidance symptoms (Turgeon,
Marchand, & Dupuis, 1998), and increased respiration-related symptoms
(difficulty breathing, feeling faint, and feeling smothered) during panic attacks
(Sheikh, Leskin, & Klein, 2002).
Panic disorder is often a chronic condition (Keller et al., 1994) that is associated
with significantly reduced quality of life (Keller et al., 1994), increased health
care utilization (Klerman, Weissman, Ouellette, Johnson, & Greenwald,
1991), and high social and economic costs (Hofmann & Barlow, 1999).
Although there are a number of empirically supported treatment options
for panic disorder, some individuals do not respond to treatment and for oth-
ers, treatment leads only to a partial response (Rosenbaum, Pollack, & Pol-
lack, 1996). Thus, we are challenged to continue to improve our current treat-
ments and to further our understanding of the mechanisms underlying
suboptimal treatment response and relapse following treatment. In the first
part of this chapter, we provide an overview of empirically supported treat-
ments, focusing specifically on cognitive-behavioral therapy and pharmaco-
therapy. We then review predictors of treatment outcome and relapse, high-
lighting barriers to successful treatment, and providing practical clinical
strategies for improving response to cognitive-behavioral treatment and pre-
venting recurrence of symptoms. In the final part of the chapter, we present a
case to illustrate specific treatment challenges that often arise and how to
overcome these obstacles to recovery.
OVERVIEW OF EMPIRICALLY
SUPPORTED TREATMENTS
Cognitive-behavioral therapy and pharmacotherapy are the only approaches to

treating panic disorder that are well established, based on a large number of
controlled studies.
Panic Disorder and Agoraphobia 3
Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) is an empirically supported psycho-
therapeutic intervention for panic disorder and is listed as a first-line treat-
ment in practice guidelines for the treatment of panic disorder (e.g., American
Psychiatric Association, 1998; Anxiety Review Panel, 2000). CBT approaches
have tended to include various combinations of strategies, such as psycho-
education, cognitive restructuring, interoceptive exposure (i.e., exposure to
feared symptoms), in vivo exposure (i.e., exposure to feared situations), and
relaxation-based strategies (e.g., breathing retraining). Combined in any of a
number of different ways, these strategies tend to be useful for reducing the
frequency of panic, agoraphobic avoidance, and other features of panic disor-
der (for detailed review, see Antony & Swinson, 2000; Taylor, 2000).
There are a number of different CBT approaches to treating panic disor-
der that have been developed (for a review, see Margraf, Barlow, Clark, &
Telch, 1993). For example, Clark et al. (1994, 1999) developed a cognitive-
behavioral approach that focuses on cognitive restructuring and behavioral
experiments to challenge catastrophic beliefs about physical sensations and
phobic situations. In contrast, panic control treatment (PCT; Barlow &
Craske, 2000) combines psychoeducation, breathing retraining, cognitive re-
structuring, interoceptive exposure, and in vivo exposure to the extent that
agoraphobic avoidance is a problem (for a review, see Antony & McCabe,
2002). Sensation-focused intensive therapy (S-FIT; Heinrichs, Spiegel, &
Hofmann, 2002) combines the active ingredients of PCT with exposure tech-
niques for agoraphobia and relapse prevention strategies, along with a self-
study workbook that may be applied in an intensive treatment format over 8
days or in a group over 3 months.
Regardless of the specific packaging of treatment strategies, CBT for panic
disorder has demonstrated efficacy in research settings (e.g., Barlow, Gorman,
Shear, & Woods, 2000). Although there is less known about the effectiveness of
CBT for panic disorder outside the research setting, initial findings indicate a
comparable treatment response in community mental health and other service-
oriented settings (e.g., Wade, Treat, & Stuart, 1998). The length of treatment is
typically 10–12 sessions. CBT leads to reductions in anxiety symptoms, anxious
cognitions, agoraphobic avoidance, and depressive symptoms (e.g., Hahlweg,
Fiegenbaum, Frank, Schroeder, & von Witzleben, 2001). CBT for panic disorder
has also been found to improve physical health symptom ratings, independent
from its impact on anxiety symptoms (Schmidt et al., 2003).
Pharmacotherapy
With respect to pharmacotherapy, treatment options include antidepressants,
anxiolytics, and combined treatments (most commonly medication plus
CBT). Selective serotonin reuptake inhibitors (SSRIs) are effective treatments
for panic disorder and are also likely to help with certain comorbid disor-
4 McCABE and ANTONY
ders such as depression (den Boer & Slaap, 1998). SSRIs are recommended
as drugs of first choice with a treatment period of 12–24 months and a
slow discontinuation over a period of 4–6 months (Ballenger et al., 1998).
Other medication options include certain tricyclic antidepressants (TCAs),
other antidepressants (e.g., venlafaxine; Pollack et al., 1996), and high-potency
benzodiazepines (for reviews, see Antony & Swinson, 2000; Roy-Byrne &
Cowley, 2002; Weissman, 2002). A recent study comparing SSRIs to TCAs
using an effect-size analysis indicated no significant differences with regard
to efficacy or tolerability in short-term trials (Otto, Tuby, Gould, McLean,
& Pollack, 2001).
Despite the number of medications that have demonstrated antipanic
efficacy, relapse rates upon discontinuation are high (Ballenger, 1993; Toni
et al., 2000), and between 20 and 40% of individuals do not respond to
treatment (Slaap & den Boer, 2001). Predictors of nonresponse include lon-
ger duration of illness, greater pretreatment severity (e.g., more severe
agoraphobic avoidance, higher panic frequency, and certain comorbid disor-
ders), and personality disorders (for a review, see Slaap & den Boer, 2001).
The physician’s level of experience has also been associated with outcome
(Gorman et al., 2003).
Cognitive-Behavioral Therapy versus Pharmacotherapy

Meta-analytic studies comparing treatment approaches indicate that phar-
macological treatments, CBT, and combinations of these approaches are ef-
fective for reducing the symptoms of panic disorder both in the short term
(van Balkom et al., 1997) and at follow-up (ranging from 1 month to 8
years) (Bakker, van Balkom, Spinhoven, Blaauw, & van Dyck, 1998).
These studies also indicate greater dropout associated with pharmacotherapy
than CBT (Bakker et al., 1998). For example, attrition rates in one meta-
analytic study were 5.6%, 19.8%, and 22.0% for cognitive-behavioral
treatments, pharmacological treatments, and combined cognitive-behavioral
and pharmacological treatment, respectively (Gould, Otto, & Pollack,
1995).
Findings from meta-analytic studies comparing the relative and combined
efficacy of pharmacological and cognitive-behavioral treatments for panic dis-
order are mixed. Some research indicates that antidepressants combined with
in vivo exposure are more effective than cognitive-behavioral interventions
alone for short-term (van Balkom et al. 1997) and long-term (Bakker et al.,
1998) outcome, particularly for agoraphobic avoidance. Other studies indicate
relatively few differences between CBT, medication, and their combination in
acute treatment outcome (Barlow et al., 2000). However, in the long-term,
cognitive-behavioral treatments appear to be more effective in maintaining
treatment gains and preventing relapse than pharmacological treatments
(Barlow et al., 2000; Gould et al., 1995).
Need for Strategies to Improve Treatment Response

and Prevent Relapse
Despite the demonstrated efficacy of CBT interventions for panic disorder,
there is still a need to improve treatment response, particularly in the long
term, for a number of reasons.
Poor Initial Response to Treatment

Some treatment completers do not respond to CBT. For example, in one effec-
tiveness trial, 87% of participants were panic-free at the end of treatment
(Wade et al., 1998), indicating that more than 1 in 10 patients did not respond
optimally. Furthermore, many people who are panic-free may continue to
have significant agoraphobic avoidance, and indeed, this may be why they are
panic-free (i.e., they do not have panic attacks because they avoid panic-
related situations). In one study, 89% of treatment completers were identified
as being panic-free at 1-year follow-up, although 28% continued to report sig-
nificant agoraphobic concerns (Stuart, Treat, & Wade, 2000). The issue of
what qualifies as good treatment response is particularly relevant for patients
with moderate to severe agoraphobia. For example, Clark et al. (1994) found
that 30% of patients who had received cognitive-behavioral therapy did not
meet criteria for high end-state functioning (defined as zero panic attacks in
the month preceding assessment and a clinical severity rating of less than or
equal to 2 on scale from 0 to 8 or “very severely disturbing-disabling”) at 15-
month follow-up. Thus, additional treatment strategies are needed to target
this group of patients.
Occurrence of Residual Symptoms during Follow-Up

Even if a good response to treatment is achieved, residual symptoms are com-
mon. In one study, one-third of a sample that had achieved a good response to
treatment experienced persistent residual anxiety and somatic symptoms at 1-
year follow-up (Corominas, Guerrero, & Vallejo, 2002). In addition, across a
number of studies, a sizable percentage of individuals continue to report panic
attacks at follow-up assessments: 17% at 6-month follow-up (Telch et al.,
1993); 11% at 1-year follow-up (Stuart et al., 2000); and 13% at 2-year follow-
up (Craske, Brown, & Barlow, 1991). Follow-up data beyond 2 years are
almost nonexistent.
Fluctuating Course of Panic Disorder

The fluctuating course of panic disorder is not necessarily reflected in typical
measures of outcome, as evidenced by the discrepancy between the percentage
of panic-free patients (usually measured in the month preceding the assessment)
6 McCABE and ANTONY
and the percentage of patients meeting high end-state functioning criteria (e.g.,
Clark et al., 1994; Craske et al., 1991). For example, T. Brown and Barlow
(1995) reported that 74.6% of their sample was panic-free 2 years after com-
pleting CBT, but only 57% met high end-state functioning criteria. This discrep-
ancy may be due to the fact that most studies use cross-sectional methods that do
not capture the fluctuating course of panic symptoms experienced by many pa-
tients following CBT for panic disorder (T. Brown & Barlow, 1995). For exam-
ple, more than one-third of the sample classified as panic-free at 2-year follow-
up reported experiencing panic attacks in the year preceding assessment (T.
Brown & Barlow, 1995). In addition, 27% of participants who had completed a
course of CBT for panic disorder sought out further treatment, although further
treatment did not confer additional improvement (T. Brown & Barlow, 1995).
Attrition
A sizable proportion of individuals drop out of treatment. For example, Wade et
al. (1998) reported a dropout rate of 26% among patients receiving treatment in
a community mental health center. High rates of attrition may be particularly
problematic in clinical service settings, compared to those in clinical research
settings. Recall that Gould et al. (1995), in their meta-analysis of studies of the
efficacy of CBT, reported that the average rate of attrition was only 5.6%.
Outcome Study Exclusion Criteria

Many patients who are characteristic of those seen in clinical settings are ex-
cluded from randomized controlled trials because of the presence of psychotic
symptoms, bipolar disorder, organic conditions, substance use disorders, mod-
erate to severe agoraphobic avoidance, concurrent or recent treatment,
suicidality, or additional diagnoses in need of immediate treatment (e.g., de-
pression). For example, in one review, the average inclusion rate for studies of
the treatment of panic disorder was 36% (Westen & Morrison, 2001). These
high exclusion rates may inflate the efficacy of CBT for panic disorder, raising
questions about how well findings can be generalized to real-life treatment set-
tings. In support of this view, Westen and Morrison (2001) found that exclu-
sion rates were positively correlated with the percentage of patients included
in the study who showed improvement (Westen & Morrison, 2001). However,
a benchmarking study conducted in a community mental health clinic and us-
ing less stringent exclusion criteria yielded results similar to those obtained in
research settings (Wade et al., 1998).
PREDICTORS OF TREATMENT OUTCOME
After a quarter century of research on predictors of response to CBT for panic

disorder, findings are largely mixed, and there are few clear prognostic indica-
tors. Different methodologies (e.g., different predictor variables and measure-

ment tools), variations across studies in the CBT components used, and lim-
ited sample sizes make it difficult to draw consistent conclusions. This section
reviews factors that have been investigated as possible predictors of outcome,
both in the short and the long term.
Demographic Characteristics
Studies indicate that demographic variables are generally not predictive of
treatment outcome (e.g., Sharp & Power, 1999). CBT for panic disorder ap-
pears to be effective regardless of age or gender. However, other important de-
mographic variables such as cultural and ethnic background have yet to be ad-
equately examined.
Personality and Personality Disorders

Although there are a few studies suggesting that personality variables are not
predictive of treatment outcome (e.g., Massion et al., 2002), the majority indi-
cate that personality pathology has a negative impact on the outcome of CBT
for panic disorder (for a review, see Mennin & Heimberg, 2000). The pres-
ence of personality disorders has been associated with poorer outcome and
slower progress in CBT for panic disorder (e.g., Keijsers, Hoogduin, &
Schaap, 1994; Marchand, Goyer, Dupuis, & Mainguy, 1998). With regard to
broad personality dimensions, higher levels of extraversion have been associ-
ated with improved outcome (Sharp & Power, 1999), and lower levels of
extraversion predict higher rates of residual symptoms following successful
treatment (Corominas et al., 2002).
Symptom Severity
The severity of the core features of panic disorder appears to be a strong prog-
nostic indicator of outcome. Severity of agoraphobic complaints and cata-
strophic agoraphobic cognitions were both found to be significant predictors
of poor treatment outcome (Keijsers et al., 1994). Lower levels of self-rated
anxiety, lower panic frequency, lower levels of agoraphobic avoidance, and
higher levels of social and occupational functioning at pretreatment have been
related to improved treatment outcome (with CBT or fluvoxamine; Sharp &
Power, 1999). In addition, change in anxiety sensitivity (particularly the physi-
cal concerns subscale of the Anxiety Sensitivity Index; Peterson & Reiss,
1993) is a significant predictor of symptom change following CBT treatment
(Schmidt & Bates, 2003). Severity of symptoms is also a significant predictor
of long-term outcome following CBT for panic disorder. Increased panic fre-
quency, increased agoraphobic avoidance, and social maladjustment have
been related to outcome at 6-month follow-up (Sharp & Power, 1999).
Pretreatment severity of panic disorder has also been related to end-state func-
8 McCABE and ANTONY
tioning and panic-free status at 24-month follow-up after CBT for panic dis-
order (T. Brown & Barlow, 1995).
Therapist Qualities
Although therapist characteristics have been associated with treatment out-
come (Huppert et al., 2001; Williams & Chambless, 1990), neither the quality
of the therapeutic relationship (Keijsers et al., 1994) nor the patient’s percep-
tion of the therapist (de Beurs, van Dyck, Lange, & van Balkom, 1995)
appears to be a significant factor in treatment outcome. Evidence is mixed for
the relationship of therapist experience and outcome, with some studies show-
ing that therapist experience is related to outcome (Huppert et al., 2001) and
other studies suggesting that it is not (Halhweg et al., 2001).
Depression
Evaluation of the impact of major depressive disorder on the outcome of CBT
for panic disorder has been equivocal (for a review, see Mennin & Heimberg,
2000). Some studies indicate that depression has an adverse impact on out-
come (e.g., Laberge, Gauthier, Côté, Plamondon, & Cormier, 1993). Comor-
bid major depression was associated with lower end-state functioning (Rief,
Trenkamp, Auer, & Fichter, 2000) and poorer outcome 6 months following
CBT (Sharp & Power, 1999). However, other studies indicate that individuals
with major depressive disorder may be less likely to be panic-free immediately
after treatment but not at follow-up (e.g., T. Brown, Antony, & Barlow,
1995). In addition, the response to treatment of individuals with panic disor-
der and depression is comparable to individuals with panic disorder without
comorbid depression (Chudzik, McCabe, Antony, & Swinson, 2001; McLean,
Woody, Taylor, & Koch, 1998; Rief et al., 2000).
Other Factors
Although pain symptoms are associated with higher levels of anxiety and mood
symptoms in individuals with panic disorder, they have not been found to signif-
icantly affect response to CBT (Schmidt, Santiago, Trakowski, & Kendren,
2002). Other factors that do not appear to affect treatment outcome include the
duration of the disorder (T. Brown & Barlow, 1995; Hahlweg et al., 2001), num-
ber of treatment sessions (Halhweg et al., 2001), marital dissatisfaction (Keijsers
et al., 1994), perceived parental upbringing (de Beurs et al., 1995), and co-
morbidity with other anxiety disorders (T. Brown et al., 1995).
Other factors associated with treatment outcome include motivation for
treatment (Keijsers et al., 1994), chronic life stress (Wade, Monroe, &
Michelson, 1993), and expressed emotion among family members, such as
emotional overinvolvement or hostility (Chambless & Steketee, 1999). Use of
psychotropic medication during treatment (primarily benzodiazepines) has
been associated with poorer outcome at 24-month follow-up (T. Brown &
Barlow, 1995). However, recent evidence suggests that discontinuation of
medication does not affect outcome following cognitive-behavioral therapy
for panic disorder; nor does it lead to greater likelihood of relapse at 1-year
follow-up (G. Brown, Bieling, Beck, Newman, & Levy, 2001).
Evidence for homework compliance as a predictor of treatment outcome
is mixed. Some studies indicate a relationship between homework compliance
and treatment outcome (e.g., Edelman & Chambless, 1993) and others do not
(e.g., Woods, Chambless, & Steketee, 2002).
Predictors of Dropout
Initial studies examining motivation for change based on Prochaska and col-
leagues’ continuum of readiness for therapeutic change, the stages-of-change
model (Prochaska & DiClemente, 1992; Prochaska & Norcross, 1994),
indicate that stage of change is a predictor of whether individuals complete
treatment. In a preliminary study examining stages of change as predictors of
response to CBT for panic disorder, individuals classified as being in one of
the preaction stages (precontemplation, contemplation) were more likely to
drop out of treatment than those in the action stage (Dozois, Westra, Collins,
Fung, & Garry, 2004). Other research has found that level of motivation and
level of education have small, yet significant, associations with dropout from
CBT for panic disorder (Keijsers, Kampman, & Hoogduin, 2001).
Personality psychopathology and initial symptom severity do not appear to
be associated with dropout from CBT (Keijsers et al., 2001). In a randomized
controlled trial of panic disorder conducted by Grilo et al. (1998), dropout was
associated with household income, negative treatment attitudes, less education,
shorter length of previous treatment, increased anxiety sensitivity, decreased
agoraphobic avoidance, and a coping style of seeking social support. Psychiatric
comorbidity and personality style were not related to dropout.
COMMON TREATMENT OBSTACLES AND PRACTICAL

STRATEGIES FOR IMPROVING OUTCOME
Based on our review of predictors of treatment outcome, this next section

presents useful strategies for enhancing treatment success. Treatment strate-
gies are organized around common obstacles that arise in the various stages of
readiness to change (Prochaska & DiClemente, 1992) and when implementing
the different treatment components.
Motivation
CBT strategies for panic disorder are based on the assumption that an individ-
ual is ready for change and willing to actively work in therapy. However, not
10 McCABE and ANTONY
all individuals who present for treatment are ready to actively engage in the
therapy process. There may be a number of reasons for resistance to change
including fear of change, fear of treatment strategies, and secondary benefits
derived from symptoms (e.g., attention from family and decreased responsibil-
ity). Prochaska and DiClemente (1992) have articulated a series of stages of
change based on their transtheoretical model: precontemplation, contempla-
tion, preparation, action, and maintenance. Although this model was origi-
nally applied in the addictions field, it has proven to be useful in conceptualiz-
ing resistance to treatment and treatment failure in other areas as well (e.g.,
Dozois et al., 2004; Hasler, Delsignore, Milos, Buddeberg, & Schnyder, 2004).
Applying this model to panic disorder may be useful for selecting appropriate
treatment strategies and for working with the patient at his or her stage of
change using motivational enhancement techniques (Miller & Rollnick, 2002)
prior to CBT. Motivational enhancement techniques include validation of the
patient’s particular stage of change through expression of empathy, identifying
discrepancies between the patient’s goals and problem behaviors (e.g., avoid-
ance), “rolling with resistance” by emphasizing personal control and ap-
proaching treatment as an experiment, and supporting self-efficacy by focus-
ing on personal strengths and highlighting positives (for a review, see Miller &
Rollnick, 2002).
In the precontemplation stage, an individual does not yet acknowledge
that there is a problem. Although most individuals with panic disorder will ac-
knowledge that they have a problem, they may not view the problem as hav-
ing a psychological basis and, therefore, they may be unwilling to engage in
psychotherapeutic interventions. Given that 10 of the 13 panic attack symp-
toms (e.g., heart palpitations, sweating, and dizziness) are physical in nature,
it is not surprising that a number of individuals with panic disorder continue
to believe that their symptoms have a physiological basis, despite medical tests
to the contrary. Treatment strategies for individuals in the precontemplation
stage of change include building a therapeutic alliance and raising awareness
about the nature of anxiety and panic through psychoeducation and reflection
on the individual’s own personal experiences with panic.
In the contemplation stage, an individual is aware that there is a problem
but is not ready to complete the steps necessary for treating the problem. A
number of individuals with panic disorder who present for treatment may not
be ready to engage in CBT for a variety of reasons, including fear of the treat-
ment strategies (e.g., exposure to panic symptoms and to situations that the
individual avoids), lack of time or commitment to treatment due to other pri-
orities or stressors, and possible benefits of not changing (e.g., spouse does all
the driving and manages the household). Treatment strategies for individuals
in the contemplation stage of change include psychoeducation regarding the
nature of anxiety and panic, exploration of the benefits and costs of engaging
in treatment, and a thorough explanation of the treatment and how it works.
In the preparation stage, an individual is ready for action and is taking
the initial steps necessary for change. At this point, treatment strategies in-
clude setting realistic goals and discussion of the treatment process and under-
lying rationale. In the action stage, an individual is ready to engage in active
treatment strategies for symptom control, and this may be the best time to
proceed with CBT for panic disorder. Once symptom control is achieved, a
person may enter the maintenance stage. At this point, treatment strategies
should focus on relapse prevention and preparing for potential setbacks or re-
currence of anxiety and panic.
To assess motivation for treatment and to determine an individual’s cur-
rent stage of change, the University of Rhode Island Change Assessment Scale
(URICA; McConnaughy, Prochaska, & Velicer, 1983) is a useful tool. The
URICA is a brief, 32-item scale that assesses attitudes toward changing
problem behaviors and four stages of change: precontemplation, contempla-
tion, action, and maintenance. URICA scores may be used to select treatment
strategies and also to measure outcome. Although the URICA has demon-
strated reliability and validity in an alcoholism treatment population, re-
searchers have only just begun to examine responses to this measure in
anxiety-disordered individuals (e.g., Dozois et al., 2004).
Therapy Rationale
Explaining the rationale for CBT for panic disorder is a very important and
critical activity at the initiation of therapy. It is at this point that the individual
is first engaged in active treatment. It is important to explain the treatment
procedures in a way that makes sense to the individual so that the active stage
of treatment can begin. For treatment to be successful, the patient must “buy
into” treatment. Explaining the treatment rationale using simple language to
which he or she can relate is imperative. If the individual has doubts about the
therapist, the treatment, or his or her ability to complete the treatment, ther-
apy may end before it begins.
A number of obstacles may arise when explaining the therapy rationale.
A common reaction that occurs when people are given information on the
effectiveness of CBT for panic disorder is one of disbelief in the treatment
strategies (e.g., “I know this works for others, but I really don’t think it will
work for me,” or “I have lived with this so long and tried everything, so I
don’t see how this is going to be any different”). One intervention for address-
ing this obstacle follows Miller and Rollnick’s (2002) “roll with resistance”
strategy. Instead of engaging in a debate about the effectiveness of CBT, it is
more useful to agree with the individual and normalize the ambivalent reac-
tion (e.g., “I am not surprised that you feel that way. It is common for people
to have difficulty believing that these strategies will be helpful”) and then to
roll with the resistance (e.g., “I realize that it is hard to imagine that this treat-
ment approach will be helpful to you; the best thing to do is to keep an open
mind and try the strategies as an experiment. In this way, you can see if they
are helpful based on your own experience. When you think about how much
your panic has interfered in your life, what do you have to lose by trying this
approach? What do you possibly have to gain?”) (for further strategies relat-
ing to the treatment rationale, see Addis & Carpenter, 2000).
If the patient raises doubts about the benefits of a psychological interven-
tion for a problem that he or she perceives as being primarily biological (ge-
netics, chemical imbalance in the brain, etc.), it can be useful to acknowledge
the role that biology plays in the etiology and maintenance of panic disorder.
In addition, the therapist can take this opportunity to discuss the interactions
between biological and psychological functions and ways in which psycholog-
ical interventions can influence biological processes. A useful analogy is that
of weight control. Although weight and physical fitness are influenced by ge-
netics and other biological processes, they can also be influenced by behavior.
People who have a genetic predisposition to be anxious may have to work
harder at managing their anxiety than people who are genetically predisposed
to be calm, but that does not mean it cannot be done. In fact, the long-term
data support psychological interventions for panic disorder over medication
treatments, despite evidence supporting the contributions of biological factors
to the disorder.
If an individual does not express reservations about the treatment, it does
not mean that he or she does not have any. Often, individuals have doubts
about the treatment but are hesitant to express them. Thus, it is important to
specifically ask the individual about his or her understanding of the treatment
rationale and whether there are any questions, concerns, or reservations (e.g.,
“Does this treatment make sense to you?” “How do you think this treatment
applies to you? Can you tell me about any doubts or concerns that you may
have about this treatment?” “Do you have any questions about anything that
we have covered regarding the treatment and how it works?”).
A major emphasis in CBT for panic disorder is on exposure to one’s fears.
This treatment component is typically scary for patients and may cause them
to have second thoughts about engaging in treatment. A useful intervention
for addressing patients’ concerns about exposure is to normalize the concerns
and to emphasize the gradual pace of treatment and the patient’s personal
control (e.g., “It makes sense that hearing about exposure sounds very scary
for you. Before coming to treatment, most people cope with their anxiety by
avoiding situations, and here I am suggesting that you do the opposite of
avoid. Avoidance is a strategy that seems to work in the short term. However,
avoidance does not work in the long term, or you would not be here today.
Avoidance provides “short-term gain” for “long-term pain,” whereas expo-
sure involves learning to tolerate “short-term pain” for “long-term gain.”
Considering all the reasons that brought you in for help right now, do you
think you might be willing to try this treatment?”).
Treatment Goals
The next step in CBT for panic disorder is to establish realistic treatment
goals. Although patients with panic disorder often express the desire for com-
plete symptom elimination, such a goal is usually not realistic. Anxiety and
fear are part of normal human experience, and most patients obtain only par-
tial symptom relief following treatment. Thus, it is essential to have a discus-
sion regarding what the patient will realistically get out of therapy. This may
take place in the context of a discussion about the important roles that anxiety
and fear play in our lives. Realistic therapy goals include learning new ways of
responding to anxiety and panic (e.g., as uncomfortable physical sensations
rather than harbingers of danger or catastrophe), developing a set of skills to
manage symptoms, increasing one’s tolerance of discomfort, and taking back
control of one’s life.
Psychoeducation
Psychoeducation in CBT for panic disorder involves increasing the patient’s
level of knowledge and awareness of the nature of anxiety and panic. One
common risk associated with this treatment component is the therapist being
drawn into doing all the talking, making it difficult to tell whether the patient
fully understands the information provided. Thus the therapist should strive
to:
• Make the psychoeducational portion of treatment more interactive and

less didactic.
• Use a whiteboard, chalkboard, or easel to illustrate the CBT model of
panic in a visual way.
• Ask frequent questions to assess the patient’s level of understanding.
• Ask the patient for examples based on his or her personal experience
that illustrate the concepts under discussion.
• Use in-session experiments.
Cognitive Strategies
Cognitive strategies for panic focus on examining the evidence for anxious
thoughts with an emphasis toward shifting to more realistic ways of interpret-
ing or perceiving triggers of anxiety and panic. A number of obstacles are
commonly associated with this treatment component.
It is common for patients to view being anxious or having a panic attack
as a defeat or failure. This response results in reduced motivation for treat-
ment. To overcome this obstacle, episodes of anxiety or panic should be
reframed as opportunities to learn and to practice newly acquired skills rather
than as signs of defect or failure. The therapist should encourage patients to
focus on what they did behaviorally in the situation (e.g., stayed in the mall
despite feeling anxious) rather than on how they felt (e.g., whether they had a
panic attack).
Another common obstacle is for patients to report that they do not have
any thoughts (e.g., “The panic comes on so quick that I don’t know what my
thoughts are.”). One strategy to overcome this challenge is to educate the pa-
tient on the automaticity of thoughts (e.g., “It is common for people to feel
like they don’t have any thoughts because emotional reactions can happen so
quickly that they feel automatic”) and then to focus on slowing things down
the next time that the patient feels anxious to examine what triggered the
anxious feelings and how he or she responded to them. Instead of reacting
automatically, encourage the patient to practice taking a step back from the
emotion and to observe feelings, thoughts, and behaviors in an analytical way.
Have patients ask themselves questions to elicit their thoughts (e.g., “What
was going through my mind right before I started feeling panicky?” “What
am I afraid might happen?”). If the patient is having difficulty eliciting
cognitions while sitting in the therapist’s office, exposure to the feared situa-
tion may increase awareness of his or her anxious thoughts. If these sugges-
tions are ineffective, it may be useful for the therapist to list some of the com-
mon thoughts that often arise among people with panic disorder to see
whether any of these ring true for the patient.
For some people, the cognitive work may be difficult. Patients may con-
tinue to report that they have no thoughts despite repeated attempts to elicit
them. Other people may be less cognitively minded. If this is the case, therapy
should emphasize more simple, straightforward cognitive strategies (e.g.,
focusing on a small number of cognitive distortions, repeating key concepts
within and between sessions, providing examples to illustrate important con-
cepts, and using cue cards to counter common anxious thoughts). If the indi-
vidual continues to have difficulty using the cognitive strategies, therapy
should focus more on behavioral strategies, such as exposure. Behavioral
strategies are powerful methods for changing cognitions.
Another common obstacle associated with cognitive techniques is that
patients have difficulty believing the alternative, more realistic ways of think-
ing. It is common to hear, “I know rationally that my feared outcome will not
happen but I still really feel that it will.” One strategy to address this problem
is to have patients externalize their anxiety. Rather than seeing anxiety as a
sign of true danger that requires a response, anxiety can be conceptualized as
stemming from “sneaky thoughts that try to trick you.” It may also be helpful
to have patients rate the level of their belief in the likelihood of the feared out-
come on a 0–100 scale, based on how they feel. For example, an individual
may know realistically that the chance of vomiting during a panic attack is
about 0% based on his or her own experience (i.e., having had hundreds of
panic attacks but not having vomited) but may still view the likelihood of
vomiting as high based on the intensity of his or her fear. In these cases, behav-
ioral strategies (e.g., exposure) are often useful for challenging patients’ anx-
ious predictions as well as illustrating that thoughts (i.e., “I could vomit”) do
not equal behavior (i.e., vomiting).
It may also complicate cognitive work if the patient describes thoughts in
vague and general terms. A practical strategy to deal with this problem is to
help patients articulate their thoughts in a very specific and precise manner.
For example, thoughts such as “I will panic” and “I need to get out of here”
are vague, as the specific meaning of these thoughts to the individual (e.g., the
feared consequence) is not clear. Thoughts should be elaborated so that the
therapist is able to perceive the precise meaning of the thought for the patient
(e.g., “I will panic and pass out in front of everyone” or “I need to get out of
here or else I will lose control of my bowels and have an accident”).
Given that one predictor of poorer treatment outcome is a tendency to
have more severe catastrophic agoraphobic cognitions, improved response
may depend on developing more realistic patterns of thinking. If an individual
has trouble countering his or her anxious thoughts in a specific situation, it
may be useful to develop a cue card with questions that he or she can ask to
elicit evidence (e.g., “What is the worst thing that can happen in this situa-
tion?”).
It is also helpful to emphasize that developing more realistic thinking
does not happen overnight. Rather, it is a skill that takes repeated practice to
build. In any situation, there are always a number of appraisals that can be
made. It is an important goal of treatment to increase the patient’s awareness
of other appraisals beyond anxiety-based interpretations. Over time, these al-
ternate appraisals will become easier to generate. As alternate appraisals are
made, the anxious appraisal becomes less powerful.
Exposure Strategies
Situational and interoceptive exposure are central components of CBT for
panic disorder. One obstacle that often arises in the context of exposure is pa-
tients’ reluctance to confront feared situations and sensations. Presenting the
rationale for exposure in a credible way is a critical first step for overcoming
this obstacle. In addition, it is often useful to deal with anxiety about exposure
exercises by breaking them down into more manageable tasks and taking
steps more gradually (e.g., riding a bus with a friend before riding a bus
alone). Huppert and Baker-Morissette (2003) emphasize the notion of avoid-
ance as a choice. In this way, the patient’s response can be reframed with an
emphasis on personal control instead of being controlled by anxiety (e.g., “I
can’t take the bus” vs. “I am anxious about taking the bus and choose not to
do so”).
Despite repeated exposure practice, some patients may report that their
fear does not decrease. This may be due to heightened stress in the person’s
life, practices that are too brief or too infrequent, catastrophic thinking that
does not change as a result of exposure alone, or the presence of subtle safety
behaviors (e.g., distraction) that prevent extinction of the fear. If a person’s
fear does not decrease over the course of treatment, these issues should be
evaluated and addressed directly if they appear to be affecting the individual’s
progress.
In addition to distraction, subtle safety behaviors include carrying safe
objects (e.g., medication, gum, water, and a paper bag to breathe into), seek-
ing reassurance (e.g., about personal safety or the meaning of physical symp-
toms), checking (e.g., monitoring physical symptoms), maintaining contact
with others (e.g., being accompanied by a safe person or carrying a mobile
phone or pager), staying near exits or bathrooms, using alcohol or drugs, or
controlling the environment (e.g., wearing short sleeve shirts in winter or not
using the heater to control physical symptoms). Ideally, safety behaviors
should be identified during the initial assessment. However, it is common for
some behaviors to go undetected until part way through treatment because the
patient is unaware of the behavior or the function of the behavior and how it
may affect treatment. The therapist should be vigilant for any safety behaviors
when reviewing exposure practices. Once identified, safety behaviors should
be incorporated as therapy targets during exposure.
Breathing Retraining
One obstacle that sometimes arises with breathing retraining is that it can be-
come relied on as a subtle avoidance strategy, thus interfering with the course
of treatment. For example, a patient may use diaphragmatic breathing to
avoid feeling anxious and thus perpetuate catastrophic thoughts about the
consequences of anxiety and the need to engage in safety behaviors to reduce
discomfort. Unless a patient clearly has a tendency to hyperventilate, breath-
ing retraining is not considered a necessary therapeutic ingredient and can be
excluded (Antony & Swinson, 2000; Schmidt et al., 2000). If breathing re-
training is used, it should be in the context of reducing initial physical symp-
toms of hyperventilation, or as a way of managing general feelings of stress
and anxiety, rather than to avoid experiencing anxiety or panic. If breathing
retraining appears to be serving the latter function, it should be discontinued.
Homework Compliance
Homework is essential for transferring skills learned in treatment to real-life
situations that the patient encounters and for ensuring successful treatment
outcome. Predictors of homework compliance include age and employment
status, with older and unemployed individuals complying more with home-
work (Schmidt & Woolaway-Bickel, 2000). Therapist ratings of homework
compliance have been found to be significantly related to treatment outcome
(Schmidt & Woolaway-Bickel, 2000). Homework noncompliance is an obsta-
cle that may arise for many reasons. As illustrated in Table 1.1, troubleshoot-
ing strategies should be chosen according to the underlying reason for
incompletion of homework.
With regard to CBT outcome for panic disorder, evidence suggests that it
is more important to focus on homework quality versus quantity (Schmidt &
Woolaway-Bickel, 2000). Thus, the therapist should emphasize the need to do
homework following the recommended guidelines (e.g., completing the same
prolonged exposure practice repeatedly, ideally until one’s fear has decreased)
TABLE 1.1. Troubleshooting Strategies for Managing Homework Noncompliance

Reason for homework noncompliance Troubleshooting strategy
The patient does not understand • Review homework task including specific
the homework task. details. Complete a practice exercise or exam-
ple monitoring form during the session.
• Provide homework assignments in writing.
Exposure practice is too difficult. • Break down practice into more manageable
tasks.
• Conduct therapist-assisted exposures.
• Use a family member or friend as a helper.
There is no time to practice. • Schedule practices during normal activities

(e.g., drive to work instead of being driven by
someone else).
• Take a week off work to practice exposure
full time.
• Hire a babysitter to care for the children,
thereby freeing up time for exposure practices.
• Discuss priorities and motivation for treatment.
There is no opportunity to practice. • Plan out homework practices in session. Have

a backup plan in case the original plan falls
through.
The patient lacks motivation to • Use motivational enhancement strategies.

complete homework assignments. Review benefits and costs of continuing with
treatment vs. putting treatment on hold.
The assigned homework seems • Review connection of homework to therapy

irrelevant. goals. Have patient (rather than the therapist)
generate homework task (for exposure).
rather than simply completing a large quantity of homework (e.g., completing

seven brief exposures, each in a different situation).
Other Strategies for Improving Treatment Outcome

The outcome of CBT for panic disorder may be improved by increasing the
length of treatment as well as the frequency of sessions. Including a family
member may also be useful in treatment, particularly for exposures. It is also
helpful to include a psychoeducation session for family members so they can
learn to take a supportive role without accommodating or reinforcing symp-
toms or dependence. This session can also prepare family members for the
change in roles within the family that may occur as the patient develops
greater independence.
When panic disorder is complicated by the presence of medical condi-
tions, treatment may need to be adapted accordingly. For individuals with

medical conditions (asthma, diabetes, etc.) that produce symptoms that are
similar to those associated with panic, therapy should help the patient to dif-
ferentiate between the symptoms of panic and those of the complicating con-
dition. Interoceptive exposures may also need to be modified depending on
the medical condition. For example, an individual with panic disorder and
emphysema will not be able to engage in hyperventilation, and it may not be
advisable for a woman who is in the latter stages of pregnancy to jog vigor-
ously on the spot to raise her heart rate. A team approach is required, in
which the physician treating the medical condition is consulted to determine
the safety and appropriateness of various interoceptive exposure exercises.
Treatment may also need to be adapted for particular presentations of
symptoms. For example, for individuals with moderate to severe agoraphobia,
the intensity or length of exposure sessions should be increased, in vivo therapist-
assisted exposure should be utilized, and additional exposure sessions offered
as needed (Stuart et al., 2000). If patients have severe agoraphobia to the
point that they are housebound, initial treatment sessions may need to be
done in the patient’s home.
The presence of comorbid conditions (mood disorders, substance abuse,
psychosis, personality disorders, etc.) may also require treatment modifica-
tion. For example, preliminary findings indicate that a modified CBT protocol
for treating panic disorder in patients with schizophrenia is effective (Hof-
mann, Bufka, Brady, Du Rand, & Goff, 2000). Hofmann and colleagues
described a number of modifications made to enhance treatment outcome in
schizophrenic patients, including repetition and simplification of the psycho-
education component of treatment, the use of “catch phrases” or coping
statements during the cognitive restructuring component, simplification of
monitoring forms, and frequent review of the instructions for completing
monitoring forms. Additional modifications included simplifying multistep in-
structions into simple, single steps that were repeatedly reviewed and using
simple questions about the material being covered to engage the patient’s at-
tention and to keep the patient on task. Finally, more time within sessions and
an increased number of sessions were required to cover the basic components
of CBT treatment, particularly when active psychotic processes were present.
In general, the inclusion of CBT strategies to target the comorbid disorder
may be necessary and relevant. In addition, it may be helpful to spend some
time at the outset of treatment differentiating panic symptoms from symptoms
related to comorbid disorders.
Comorbidity can also complicate the decision of which problem to focus
on first during treatment. Typically, treatment initially targets the problem
that is most impairing or distressing to the patient. However, if one problem
appears to be causing the other (e.g., impairment from panic disorder leading
to symptoms of depression), there is good reason to think that engaging the
patient in treatment of the panic disorder symptoms will also lead to improve-
ments in the secondary problems. If the comorbid condition is likely to inter-
fere with the treatment of panic disorder, it should be the initial target of clini-
cal attention. For example, for an individual who manages anxiety by
drinking six to eight beers per day and who has on occasion come to treat-
ment sessions intoxicated, a detoxification program may be needed prior to
initiating treatment for panic disorder. Once the drinking is under control and
CBT for panic disorder is initiated, monitoring of alcohol use should be incor-
porated into the treatment sessions. To our knowledge, there are no published
studies examining unified CBT protocols designed to target both panic disor-
der and comorbid conditions, although research is currently under way (e.g.,
Barlow, Allen, & Choate, 2004; McCabe, Chudzik, Antony, Bieling, &
Swinson, 2003).
CBT may also be combined with other treatments (e.g., medications) to
augment treatment response. For example, combining medication with CBT is
recommended if response to CBT is not optimal (Otto, Gould, & Pollack,
1994) or in the case of severe agoraphobia (van Balkom et al., 1997). Cur-
rently, there are no studies that address the best ways in which to sequence
treatments. In other words, little is known about whether it is best to start
with CBT, start with medication, or begin both treatments concurrently. Given
the long-term advantages of CBT over medication, we typically recommend
starting with CBT and later adding medication if needed.
In some cases, CBT is administered with another concurrent psychologi-
cal treatment. For example, an individual with early abuse issues who attends
supportive therapy may be referred by his family doctor to receive CBT for
panic disorder. In such a case, it is important for both therapists to work as a
team to avoid any conflicts that may arise between the different therapeutic
approaches. For example, the supportive psychotherapist may recommend
that the patient minimize anxiety-provoking exposures if he or she believes
that the patient is not ready to confront feared situations. The supportive psy-
chotherapist may inadvertently encourage the patient to avoid experiences
that arouse anxiety or discomfort, and this may contradict the approach of
the cognitive-behavioral therapist.
In some cases, medications may interfere with CBT. For example,
benzodiazepines may interfere with exposure practices by reducing situational
anxiety (BaêoÈlu, Marks, Kilic, Brewin, & Swinson, 1994). In such instances,
it may be necessary to use interoceptive exposure to bring on anxiety symp-
toms or incorporate into the treatment a schedule for reducing the use of
benzodiazepines. The latter option should be coordinated with the physician
prescribing the medication. In the case of multiple treating professionals, a
coordinated team approach to treatment is best. If a patient is too distressed
to engage in CBT, and symptoms are too severe, short-term use of a benzo-
diazepine may be warranted until other therapies take effect (Sturpe &
Weissman, 2002).
Treatment may also be optimized by using assessment tools to identify
targets for treatment and residual symptoms. There are a variety of validated
measures for assessing the core features of panic. Some of the common mea-
sures include the Panic Disorder Severity Scale (PDSS; Shear et al., 1997), the
Mobility Inventory for Agoraphobia (MI; Chambless, Caputo, Jasin, Gracely,
& Williams, 1985), the Agoraphobic Cognitions Questionnaire (ACQ; Cham-
bless, Caputo, Bright, & Gallagher, 1984), and the Anxiety Sensitivity Index
(ASI; Peterson & Reiss, 1993). These scales, and others, can be found in a
sourcebook compiled by Antony, Orsillo, and Roemer (2001).
In addition to these standard panic measures, having patients rate their
anxiety and avoidance levels on their exposure hierarchy (i.e., list of 10–15
feared situations rank-ordered in terms of difficulty) at the beginning of each
therapy session is a useful tool for guiding treatment and for monitoring prog-
ress. Exposure hierarchy ratings have been shown to be sensitive to change
following CBT for panic disorder and to correlate with clinical improvement
assessed by standard panic measures (McCabe, Rowa, Antony, Swinson, &
Ladak, 2001). Individualized hierarchies offer more detailed information
about specific areas requiring further follow-up and form a basis for identify-
ing posttreatment goals for maintenance and continuation of treatment gains.
Finally, treatment may need to be adapted for the age and developmental
stage of the patient. Specifically designed CBT protocols for treating panic disor-
der in children, adolescents, and older adults should be used (for a review, see
Taylor, 2000). In children, the clinical expression of panic disorder features may
vary from that seen in adolescents and adults (for a review, see Ollendick, 1998).
In addition, including the family in treatment is a major component in the treat-
ment of children and younger adolescents (Craske, 1997).
PREDICTORS OF RELAPSE
Panic disorder with or without agoraphobia is characterized by a chronic

course, with symptoms often remaining after treatment has ended (Weisberg,
Machan, Dyck, & Keller, 2002), and with a significant risk of relapse
(Faravelli, Paterniti, & Scarpato, 1995; Pollack & Smoller, 1995). For our
purposes, relapse is defined as the return of symptoms of panic disorder fol-
lowing a period of remission such that full criteria for the disorder are once
again met. Additional treatment seeking during follow-up among patients
who initially responded well to treatment may also be seen as a marker of re-
lapse. From a research perspective, relapse is operationalized in a variety of
ways. For example, one study defined relapse as a return of panic attacks and
an increase in the severity of the core symptoms of panic disorder such that
they were clinically significant as indicated by a specific clinical severity rating
(e.g., T. Brown & Barlow, 1995).
A number of factors have been investigated as possible predictors of
relapse. In a study by Fava et al. (2001), patients with panic disorder and ago-
raphobia (n = 132) who were panic-free following 12 sessions of exposure
therapy were assessed at posttreatment intervals ranging from 2 to 14 years
(median was 8 years). Approximately a quarter of the sample (23%) had a
relapse during the follow-up period, with 62.1% of patients remaining in

remission after 10 years. Higher rates of relapse were predicted by a younger
age, high pretreatment depression scores, residual agoraphobic avoidance fol-
lowing treatment, and concurrent use of medication (including benzodiaze-
pines and antidepressants).
Despite the results from the Fava et al. (2001) study, findings regarding
the use of medication during CBT treatment have been inconsistent. There is
evidence that among those who are successfully treated with both a psycho-
logical treatment (CBT or relaxation training) and a pill (either alprazolam or
placebo), attribution of outcome to the pill versus the psychological treatment
is associated with increased risk of relapse (BaêoÈlu et al., 1994). In addition,
research on combining CBT and imipramine for panic disorder indicates that
combined CBT and medication does not significantly improve long-term out-
come for panic disorder and may contribute to relapse when medication is dis-
continued (Barlow et al., 2000), relative to CBT plus placebo. However, there
is also preliminary evidence that medication discontinuation does not contrib-
ute to relapse or reduce the effectiveness of cognitive strategies for panic disor-
der (G. Brown et al., 2001).
A number of other factors have also been investigated as possible predic-
tors of relapse. Changes in anxiety sensitivity (i.e., the extent to which an indi-
vidual is fearful of the sensations associated with panic attacks, as measured
by the ASI physical concerns factor) was a significant predictor of outcome 6
months after group CBT, with a smaller degree of change associated with in-
creased likelihood of relapse (Schmidt & Bates, 2003). This study replicated
earlier findings regarding the relationship between anxiety sensitivity and
relapse (Ehlers, 1995). In addition, Ehlers (1995) found that heightened heart-
beat perception, which tends to be associated with panic disorder (van der
Does, Antony, Barsky, & Ehlers, 2000), predicted relapse during the first year
following treatment. Finally, T. Brown et al. (1995) found that individuals
with comorbid diagnoses at 3-month follow-up were more likely to seek addi-
tional treatment in the 24-month period after CBT, compared to individuals
with panic disorder without comorbid diagnoses (50% vs. 21.7%).
PRACTICAL STRATEGIES FOR PREVENTING RELAPSE
Based on the predictors of long-term outcome and relapse, there are a number
of clinical interventions that may be useful for preventing relapse:
• Psychoeducation regarding relapse and the episodic nature of panic dis-

order should be incorporated in treatment (preparing the patient for possible
setbacks) and combined with relapse prevention strategies aimed specifically
at detailing an action plan for managing recurrence of symptoms.
• Additional treatment to eliminate residual agoraphobic avoidance may
be useful. Strategies may include increasing the number of therapist-assisted
exposures or including a family member as a coach. It may also be helpful to

explore the benefits (comfort) and costs (increased risk of relapse) of ending
treatment when the patient continues to experience residual avoidance.
• Teach the patient how to identify and manage episodes of symptom re-
currence. Early identification is key in controlling the magnitude of a setback.
• Prepare the patient for the possible recurrence of symptoms during
times of stress. During these periods, it is important not to resume avoidance
behaviors. A few booster sessions during times of stress may be useful if the
patient’s panic symptoms appear to be worsening.
• Schedule occasional follow-up visits to monitor panic disorder symp-
toms using a psychometrically sound measure (e.g., the PDSS; Shear et al.,
1997), so any recurrence of symptoms is identified and targeted accordingly
(Shear, Clark, & Feske, 1998).
• Discuss lifestyle factors that may increase vulnerability for relapse (e.g.,
diet, sleep, exercise, and stress management) and plan changes accordingly.
For example, individuals with panic disorder often report that a lack of sleep
or stress at work increases their susceptibility to anxiety and panic. Thus, en-
suring good sleep hygiene and managing one’s workload may be important
protective factors.
• Create a plan for long-term use of CBT strategies (including self-help
strategies).
• If a patient is receiving combined medication and CBT, incorporate dis-
cussion that promotes internal attribution for treatment gains (e.g., “The
medication can’t be doing everything or else it wouldn’t be so hard to do ex-
posures! Therefore, you are doing the real work—the medication just makes it
a bit more manageable”).
• Use CBT to assist in the discontinuation of medications (rather than
trying to discontinue them without CBT). Research indicates that discontinua-
tion from benzodiazepines and antidepressants results in a significant increase
in anxiety symptoms (Rickels, Schweizer, Weiss, & Zavodnick, 1993). CBT
facilitates benzodiazepine discontinuation (Otto et al., 1993), and preliminary
data suggest that CBT may also help a patient to stop taking antidepressants
(Schmidt, Woolaway-Bickel, Trakowski, Santiago, & Vasey, 2002).
• Incorporate booster sessions or a more structured form of continuation
therapy following acute treatment. For example, one study found that an ad-
ditional eight treatment sessions focusing on Safety Behavior Fading (educa-
tion regarding safety behaviors, continued elimination of safety behaviors,
and problem solving for overcoming safety behaviors) led to additional treat-
ment gains compared to therapy that did not include continuation treatment
(Telch, Smits, Sloan, & Powers, 2002).
CASE EXAMPLE
In this section, a case is presented of an individual with panic disorder who

was particularly challenging to treat and who benefited only partially from
treatment. This case description includes some discussion of the ways in which
treatment might have been improved, given the opportunity. Mr. Carr was a
50-year-old man who presented to a specialty treatment clinic for assessment
and treatment of his symptoms of anxiety.
Personal History
Mr. Carr lived with his wife of 20 years and two sons ages 15 and 17. He re-
ported being happily married. He described his wife as very supportive and in-
dicated having a good relationship with his children. He had been working as
an office administrator in a large manufacturing company until he took a
leave of absence due to bouts of dizziness. He had been off work for a year,
during which time he had undergone numerous physical examinations to de-
termine the cause of his dizzy spells. All physical findings were negative. His
doctor informed him that he was suffering from vertigo and that anxiety may
also be playing a role in his symptoms. Thus, he was referred for psychologi-
cal assessment.
Presenting Problem
Mr. Carr described episodes of dizziness that occurred “out of the blue” in
which the room would seem to spin around him and he had difficulty main-
taining his balance. During the assessment, it became evident that Mr. Carr
was experiencing unexpected panic attacks in addition to his vertigo. These
panic attacks began in his early 20s but did not become significantly impair-
ing or distressing until the past year, shortly after the onset of vertigo. Dur-
ing a panic attack, Mr. Carr would experience a racing heart, sweating,
shaking, shortness of breath, dizziness, and concerns that he would pass
out. In the past year, he had become increasingly worried about additional
panic attacks. He had recently started to avoid a wide range of situations
for fear of both a panic attack and vertigo, including driving more than 10
minutes from home, crowds, airplanes, and waiting in line. He stated that
he felt especially uncomfortable outside his “comfort zone”—within 10
miles of his house. He also reported that he felt more comfortable in a pub-
lic situation when accompanied by his wife, in case he needed help. Mr.
Carr’s symptoms were consistent with a diagnosis of panic disorder with ag-
oraphobia. Mr. Carr denied any history of mood disorder, additional anxi-
ety disorders, psychotic symptoms, somatoform disorder, eating disorder, or
substance use disorder. Apart from vertigo, Mr. Carr did not report any dif-
ficulties with his physical health.
Treatment Recommendations
Mr. Carr was offered individual CBT for his panic disorder with agoraphobia.
He was very interested and motivated for treatment. He was also offered a
psychiatric consultation to review medication options but declined as he did
not like the idea of taking medication. Mr. Carr had never received psycho-
therapy for his difficulties in the past.
Treatment Progress and Challenges

Over the course of treatment, a number of therapeutic challenges arose. As
treatment progress is described, these challenges are outlined, along with
strategies used to overcome them.
Session 1
The first session focused on discussing Mr. Carr’s experience with panic
attacks and vertigo including anxiety-provoking physical sensations, common
anxious thoughts and predictions, and behavioral reactions to anxiety includ-
ing escape, avoidance, and safety cues. The overlap of vertigo symptoms and
panic was also discussed. The cognitive-behavioral model of panic disorder
and agoraphobia was introduced, and an exposure hierarchy was developed.
Homework included monitoring the three components of anxiety (thoughts,
physical sensations, and behaviors) whenever he felt anxious or experienced
an episode of vertigo. Self-help readings were also assigned.
Session 2
The week was reviewed. Mr. Carr reported that most of the week went well,
until he had two panic attacks while shopping in the mall during the days pre-
ceding the second therapy session. Homework was reviewed, as was the mate-
rial covered in Session 1. Mr. Carr’s typical behavioral response to his panic
was to escape from the situation, and he left the mall in response to both panic
attacks. The role of cognitions in maintaining anxiety was reviewed (with a
focus on Mr. Carr’s two episodes of panic in the past week), and the concept
of cognitive distortions was introduced. Mr. Carr reported that his main con-
cern during his panic attacks was the possibility that he would be embarrassed
in front of others. Homework included monitoring his anxious thoughts dur-
ing episodes of anxiety or vertigo and identifying cognitive distortions. He
also agreed to stay in the situation if he felt anxious and monitor the three
components of his anxiety more closely.
Session 3
Mr. Carr reported two panic attacks over the week. In both instances, he
stayed in the situation and practiced observing the three components of anxi-
ety and focusing on his anxious thoughts. This session focused on strategies to
challenge anxious thoughts with the goal of more balanced or realistic think-
ing. Homework involved countering his anxious thoughts using cognitive
monitoring forms.
Session 4
Upon reviewing his homework, Mr. Carr reported that he had discovered that
his core fearful thought was of becoming dizzy. He found that he would moni-
tor his body for dizziness and distract himself if he felt dizzy. He also indicated
fearing an attack of vertigo. The session focused on exploring his fear of dizzi-
ness and examining his anxious predictions. Different countering strategies
were discussed. In addition, the short- versus long-term usefulness of distrac-
tion was reviewed.
The presence of a medical symptom (vertigo) with no known cause or
treatment presented a number of obstacles during the treatment. First, the
dizziness that was associated with Mr. Carr’s vertigo was similar to the diz-
ziness he experienced during his panic attacks. Second, the presence of a di-
agnosed medical condition contributed to Mr. Carr’s fears that something
must be physically wrong with him and his belief that physical sensations
are dangerous. To address these issues, the therapist also addressed Mr.
Carr’s beliefs about episodes of vertigo, emphasizing noncatastrophic inter-
pretations:
MR. CARR: When I become dizzy, it feels like I am going to pass out and I have
to sit down or else something bad could happen. How am I supposed to
do exposures if I have an episode of vertigo?
THERAPIST: Have you ever had something very bad happen during an episode
of vertigo?
MR. CARR: No, but almost. I always sit down so I don’t pass out.
THERAPIST: So it sounds like it feels like something really terrible is going to
happen, but based on your own experience it never has.
MR. CARR: Yes, but that is because I sit down.
THERAPIST: What do you think about trying an experiment where you don’t sit
down the next time that you feel dizzy? That way, you can test out your
prediction that something bad will happen?
MR. CARR: I don’t know . . . why would I want to do that?
THERAPIST: Although your strategy of sitting down each time you feel dizzy
may work in the short term, what effect do you think it has in the long
term? In other words, what is the long-term effect on your life of avoiding
situations that might actually provide you with an opportunity to find out
whether your dizziness is in fact dangerous?
MR. CARR: It is not working because I can no longer go anywhere or do any-
thing the way I used to.
THERAPIST: OK, so if it is not working for you, do you think it might be worth
trying the strategies that we are discussing here to see if they might work
better for you? What do you have to lose?
MR. CARR: Not much, I guess. But what if I pass out?
THERAPIST: Well, why don’t you try it first when you are at home? The next
time you are dizzy, don’t sit down. Instead, keep doing what you are do-
ing at the time. When you do experience vertigo, how long does it last?
MR. CARR: A few minutes.
THERAPIST: OK, so for a few minutes you may feel extremely dizzy. Do you
think you can manage that?
MR. CARR: I could try. But what if I pass out?
THERAPIST: Well, let’s say the worst case scenario happens and you do pass
out. What would happen?
MR. CARR: I would collapse.
THERAPIST: OK, and then what?
MR. CARR: I guess that eventually I would come to.
THERAPIST: And then what?
MR. CARR: I guess I would get up. I never really thought that far ahead.
THERAPIST: Good. Well, that is what I would like you to try. I want to examine
what your anxious predictions are and then really test them out. That
way, your predictions can be based on your own experience rather than
on what you feel might happen.
Session 5
Mr. Carr had done well practicing carrying on with his activities when he felt
dizzy. He stated that he did not pass out and, as he continued with a task de-
spite feeling dizzy, the dizziness usually decreased over time. The session fo-
cused on reviewing the rationale for planned exposures as well as guidelines
for their conduct. Mr. Carr planned to practice driving out of his “safe zone”
and to continue challenging his anxious thoughts.
Session 6
Mr. Carr experienced an episode of vertigo shortly after the last session, and
he decided not to do the driving exposures. He reported feeling discouraged
and more anxious throughout the week. He stated that he had woken up feel-
ing anxious almost every morning. The session focused on processing Mr.
Carr’s thoughts and feelings about how the week went and how therapy was
progressing. Mr. Carr realized that his negative thoughts about himself (e.g.,
seeing himself as a failure because he was too anxious to do the driving expo-
sure) were contributing to his feeling anxious and unsettled in the morning.
MR. CARR: I just couldn’t do the driving exposure as we planned. I feel like a
failure. Maybe this treatment won’t work. I was so hopeful.
THERAPIST: Exposures are a very challenging part of treatment. Is it possible

that the exposure we planned may have been too difficult, or do you re-
ally think that the difficulties you had are because you are a failure?
MR. CARR: Well, I do feel like a failure, but when you put it that way, I guess
that maybe this was too difficult for me right now.
THERAPIST: It seems like the episode of vertigo that you had also played a role
in making your planned exposure seem too challenging right now. What
sort of thoughts were you having?
MR. CARR: Well, after I had the vertigo, I started to worry that I might have an
episode when I was driving and I could get in an accident.
THERAPIST: So it sounds like the episode of vertigo triggered some powerful
anxious thoughts.
MR. CARR: Yes. I guess that played a major role in my decision to not do the
exposures.
THERAPIST: OK. So perhaps this week we should choose an exposure practice
that feels more manageable to you. We should also examine the anxious
predictions you were making. It sounds like you believe that it is pretty
dangerous for you to drive because of your vertigo.
MR. CARR: Well, it is dangerous. I could have an accident and hurt someone.
THERAPIST: Have you ever had an episode of vertigo when you were driving?
MR. CARR: Yes, just once. Although I have felt dizzy lots of times.
THERAPIST: OK, and what happened?
MR. CARR: Well I was driving down a narrow hill and I felt very dizzy. I
wanted to pull over but there was no shoulder to pull off on.
THERAPIST: So what did you do?
MR. CARR: Well, I had to keep driving, so I did. But it was terrible. I drove
right home after that.
THERAPIST: And did the vertigo last the whole time you were driving?
MR. CARR: No. It just lasted about a minute when I was driving on the hill.
THERAPIST: OK. Taking into account what we have covered so far in our sessions,
what do you think about this incident based on your own experience?
MR. CARR: Well, I guess I felt like something dangerous would happen. But
when I look at it realistically, nothing bad did happen.
THERAPIST: So you were able to drive, despite the vertigo, and despite the other
times when you felt dizzy.
MR. CARR: I guess that’s true.
THERAPIST: What do these experiences tell you about your ability to drive
when you are dizzy?
MR. CARR: Well, I guess I am able to drive safely. The dizziness did pass. But I
still feel like something bad could happen.
THERAPIST: That’s OK. Over time, and as you practice exposures, you will no-
tice that your level of belief in the realistic interpretation of events will in-
crease and your belief in the anxious interpretation of events will de-
crease. Let me ask you, what percentage of you believes that you can drive
safely despite feeling dizzy?
MR. CARR: 30%.
THERAPIST: OK. That gives us a starting point. When you think about it, it
makes sense that you feel anxious about driving if you believe that you
are 70% unsafe. Most people would feel very anxious if they felt 70% un-
safe about driving.
MR. CARR: I never thought about it that way, but that makes a lot of sense.
THERAPIST: So what do you think we will be working toward?
MR. CARR: I guess as I practice the exposures, the 30% belief I will be safe will
increase, and the 70% belief I will be unsafe will decrease.
THERAPIST: Exactly. So what exposure would you like to practice this week?
Session 7
Mr. Carr had practiced driving on some hills over the week as well as continu-
ing to walk when he had an episode of vertigo. He reported feeling quite ex-
hausted from the exposures. The session focused on reviewing how his expo-
sures went and reinforcing all the difficult work he was doing. His feelings of
exhaustion were normalized and strategies were discussed to deal with the ef-
fects of exposure (e.g., planning exposures when he did not have to do some-
thing right afterward, letting his family know that he might be more irritable
because of the exposures, and planning some fun activities to reward himself
after exposure practices).
Session 8
Mr. Carr practiced a number of driving exposures as well as starting to do
other activities he had previously avoided. The rationale for interoceptive
exposure was introduced and symptom testing was conducted. Mr. Carr’s
homework was to practice spinning in a chair to expose himself to feelings of
dizziness.
Session 9
Mr. Carr reported that his week was “terrible.” He had attempted to practice
the interoceptive exposure but it was too difficult. He felt discouraged and re-
ported that his anxiety over the week was heightened and he found the driving
exposures much more difficult than the previous week. The session focused on
discussing Mr. Carr’s expectations for recovery. He identified that one of his
expectations was that he should be able to “handle anything without stress.”
This belief was explored and Mr. Carr realized that he was placing a lot of
pressure on himself to do everything perfectly. Once these beliefs were exam-
ined, he indicated that he felt some relief. The difficulty of doing the
interoceptive exposure practices was discussed in the context of striking at the
core of his fear of physical sensations, and his feelings were normalized. He
was encouraged to reframe his experience the past week as a normal bump in
the recovery process rather than a treatment failure. An interoceptive expo-
sure practice was conducted in session (spinning in a chair), and Mr. Carr
agreed to practice the exercise in the coming week despite his anxiety.
Session 10
Mr. Carr reported that his week was much better. He practiced spinning in the
chair once a day and was able to practice identifying and countering his anxious
thoughts about dizziness. He also did a number of personal experiments to chal-
lenge his anxious thoughts. For example, he realized that he had been avoiding
bending over to pick things up and instead would keep his head upright, bend at
the knees, and lower himself slowly to prevent the onset of vertigo. Over the
week, he had practiced purposely bending over with his head upside down to
challenge these fears. However, Mr. Carr had not practiced the planned driving
exposures. He stated that it was too difficult to plan them as he never knew how
he would feel on the chosen day. If it was a “good day” he would be able to do
the exposure, but if it was a “bad day” he would not. The session focused on dis-
cussing what a “bad day” meant (for Mr. Carr it meant waking up feeling anx-
ious and dizzy) and why it is even more important to practice exposure on a
“bad day.” Mr. Carr stated firmly that he preferred to stick to just doing expo-
sures as they arose. He liked the cognitive strategies and found them very useful.
He did not wish to plan exposures in advance.
Session 11
Mr. Carr reported that his week went well. He had some episodes of anxiety
but persisted at whatever he was doing despite his feelings. The idea of com-
bining interoceptive exposure and situational exposure was introduced (e.g.,
making himself dizzy in a store). Mr. Carr agreed to try this over the week but
did not want to plan it in advance. His return to work was also discussed.
Session 12
In this final session, Mr. Carr’s gains in treatment were reviewed, with an em-
phasis on the obstacles he overcame, the goals he was able to reach, and the
goals that he still needed to work toward. His reluctance to plan exposures
was discussed in terms of increasing his vulnerability for relapse due to the
persistence of his beliefs about not planning things on a “bad day.” A plan
was put in place for how Mr. Carr could respond to future episodes of anxiety,
panic, or vertigo. A scheduled follow-up session was offered but Mr. Carr pre-
ferred not to schedule a session. Instead, he agreed to call if he needed a
booster session in the future.
Treatment Outcome
Although Mr. Carr did make some significant gains in treatment, including re-
duced episodes of anxiety, panic, and dizziness, decreased avoidance, and de-
creased impairment and distress, treatment was considered only partially suc-
cessful. Upon completion of treatment, Mr. Carr still had a significant level of
anxiety sensitivity and some agoraphobic avoidance, particularly on days
when he did not “feel well.” Further, Mr. Carr was resistant to the idea of
planned exposures and he declined a follow-up treatment session that would
have provided an opportunity to check on his progress and ensure that his
gains had been maintained.
Upon reviewing this case, a number of practical strategies emerged that
might have enhanced outcome:
• Incorporating additional sessions involving (1) therapist-assisted expo-

sure to driving situations and (2) combined interoceptive and situa-
tional exposure.
• Bringing Mr. Carr’s wife into session to educate her about the CBT
model of treatment, enlist her help as a coach during planned expo-
sures, and reduce her tendency to accommodate his symptoms (e.g.,
when Mr. Carr was having a “bad day,” his wife tended to do the driv-
ing).
• Once again, reviewing with Mr. Carr the possible benefits of adding in
a medication (e.g., an SSRI).
CONCLUSION
Despite the availability of empirically supported treatment options for panic

disorder, there are some individuals who not respond to treatment or who
drop out of treatment prematurely. There are also a significant number of in-
dividuals who experience residual symptoms and relapse following treatment.
Thus, the challenge is to continue to improve our current treatments and to
examine factors underlying suboptimal treatment response and relapse. This
chapter examined predictors of treatment response and relapse. Factors asso-
ciated with treatment response included personality variables, symptom sever-
ity, anxiety sensitivity, therapist characteristics, depression, motivation for
treatment, chronic life stress, expressed emotion in the family, and medication
discontinuation. Factors unrelated to response included demographic charac-
teristics, quality of the therapeutic relationship, perception of the therapist,
pain symptoms, duration of the disorder, the number of treatment sessions,
comorbid anxiety disorders, perceived parental upbringing, and marital dis-
satisfaction. Predictors of relapse included younger age, higher pretreatment
depression, residual posttreatment agoraphobic avoidance, concurrent use of
antidepressants, anxiety sensitivity, and heightened heartbeat awareness. In
consideration of these factors, practical strategies were outlined aimed at im-
proving outcome and preventing relapse. A case illustration was used to dem-
onstrate various therapeutic challenges and treatment strategies.
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Improving Outcomes and Preventing Relapse in Cognitive-Behavioral Therapy,

OVERVIEW OF THE DISORDER

Cognitive-behavioral therapy and pharmacotherapy are the only approaches to

Cognitive-Behavioral Therapy versus Pharmacotherapy

Need for Strategies to Improve Treatment Response

Poor Initial Response to Treatment

Occurrence of Residual Symptoms during Follow-Up

Fluctuating Course of Panic Disorder

Outcome Study Exclusion Criteria

PREDICTORS OF TREATMENT OUTCOME

After a quarter century of research on predictors of response to CBT for panic

tors. Different methodologies (e.g., different predictor variables and measure-

Personality and Personality Disorders

COMMON TREATMENT OBSTACLES AND PRACTICAL

Based on our review of predictors of treatment outcome, this next section

• Make the psychoeducational portion of treatment more interactive and

TABLE 1.1. Troubleshooting Strategies for Managing Homework Noncompliance

There is no time to practice. • Schedule practices during normal activities

There is no opportunity to practice. • Plan out homework practices in session. Have

The patient lacks motivation to • Use motivational enhancement strategies.

The assigned homework seems • Review connection of homework to therapy

rather than simply completing a large quantity of homework (e.g., completing

Other Strategies for Improving Treatment Outcome

tions, treatment may need to be adapted accordingly. For individuals with

Panic disorder with or without agoraphobia is characterized by a chronic

relapse during the follow-up period, with 62.1% of patients remaining in

PRACTICAL STRATEGIES FOR PREVENTING RELAPSE

• Psychoeducation regarding relapse and the episodic nature of panic dis-

exposures or including a family member as a coach. It may also be helpful to

In this section, a case is presented of an individual with panic disorder who

Treatment Progress and Challenges

THERAPIST: Exposures are a very challenging part of treatment. Is it possible

• Incorporating additional sessions involving (1) therapist-assisted expo-

Despite the availability of empirically supported treatment options for panic

and exposure for panic disorder with agoraphobia attribution of improvement to

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