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A pilot study of cognitive behaviour therapy for panic disorder augmented by panic surfing

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A pilot study of cognitive behaviour therapy for panic disorder augmented by panic surfing
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  Clinical Psychology and PsychotherapyClin. Psychol. Psychother.   15 , 440–445 (2008)Published online 10 October 2008 in Wiley InterScience (www.interscience.wiley.com). DOI : 10.1002/cpp.582 Copyright © 2008 John Wiley & Sons, Ltd.  A Pilot Study of Cognitive Behaviour Therapy for Panic Disorder Augmented by Panic Surfing  Claire Lamplugh, 1  David Berle, 1 * Denise Milicevic 1  and Vladan Starcevic 2 1  Nepean Anxiety Disorders Clinic, Sydney West Area Health Service, Penrith, NSW, Australia 2  University of Sydney, Discipline of Psychological Medicine, Nepean Hospital, Sydney/Penrith, NSW, Australia This pilot study reports the outcome of cognitive behaviour therapy for panic disorder augmented by panic surfing. This treatment approach encourages acceptance of feelings rather than control of symptoms and anxiety, at the same time also targeting catastrophic misinterpretations, bodily vigilance and safety-seeking behaviours. Eighteen participants completed a brief group treatment for panic disorder incorporating psychoeducation, panic surfing, interoceptive exposure, graded exposure and cognitive restructuring. Significant improvements occurred over the course of this treatment and were maintained at a 1-month follow-up. Results suggest that cognitive behaviour therapy augmented by panic surfing may be effective in the treatment of panic disorder, but there is a need for controlled studies and investigation of the relative contribution of its various components. Copyright © 2008 John Wiley & Sons, Ltd. * Correspondence to: David Berle, Nepean Anxiety Disor-ders Clinic, Department of Psychological Medicine, Nepean Hospital, PO Box 63, Penrith NSW 2751, Australia.E-mail: berled@wahs.nsw.gov.au ment are most relevant to treatment outcome (e.g., Schmidt et al., 2000).A case in point is the role of panic control strat-egies, such as breathing retraining and applied relaxation, which are aimed at controlling bodily sensations. It has been proposed that behaviours designed to keep a person ‘safe’ from a false threat  by using panic control techniques prevent correc-tive learning (Salkovskis, Clark, & Gelder, 1996). Consequently, many cognitive interventions focus on correcting hypersensitivity to bodily sensations and the misinterpretation of these sensations as signalling immediate threat (Schmidt et al., 2000).A related issue is the role of bodily vigilance in maintaining panic disorder. Schmidt, Lerew, and Trakowski (1997) have suggested that a height-ened focus on the body increases the likelihood of perceiving threatening sensations and proposed INTRODUCTION Cognitive–behavioural therapy (CBT) is a well-established treatment for panic disorder. However, dropout rates of up to 25% are common (e.g., Shear, Pilkoniz, Cloitre & Leon, 1994) and, of those offered treatment, only approximately 50% may respond at the end of treatment (e.g., Barlow, Gorman, Shear, & Woods, 2000). Traditional CBT has been multicomponent (Andrews, Crino, Hunt, Lampe, & Page, 1994), but more recently there has  been a debate as to which components of treat- Practitioner Report  CBT Augmented by Panic Surfing  441 Copyright © 2008 John Wiley & Sons, Ltd.  Clin. Psychol. Psychother. 15 , 440–445 (2008) DOI : 10.1002/cpp that panic control strategies could actually increase  bodily vigilance and thereby escalate panic symp-toms. Outcome studies have promoted interocep-tive exposure, designed to reduce the effects of  bodily vigilance, as an effective component of CBT for panic disorder (Craske, Rowe, Lewin, & Noriega-Dimitri, 1997).This brief review suggests that there is need for improving psychological treatments for panic dis-order. In this regard, panic surfing, an approach initially developed by Baillie and Rapee (1998), may be promising. It is drawn from Clare Weekes’  book ‘ Self-Help For Your Nerves ’ (Weekes, 1974) and also has connections to strategies used in drug and alcohol treatment for ‘riding out the wave of an urge’. Panic surfing is added to the standard com-ponents of CBT, with a specific emphasis. It aims to promote awareness of the experience of anxiety, decrease fear of fear and improve coping with the anxiety without attempting to control it. Clients are encouraged to ‘ride out the wave of anxiety’, and the idea ‘ride it, don’t fight it’ is emphasized. Panic surfing is meant to enhance cognitive restructuring (in terms of challenging maladaptive responses to anxiety and its symptoms), and clients are actively discouraged from performing safety-seeking and anxiety-maintaining behaviours of any kind. The key components of CBT augmented by panic surfing are listed in Table 1.Panic surfing is consistent with some acceptance- based approaches in that both aim to develop a willingness to experience a range of emotions, at the same time asking clients to refrain from attempts to control bodily sensations (Levitt & Karekla, 2005). Panic surfing also fits with Adrian Wells’ (Wells & Matthews, 1994) strategy of asking clients to focus more closely on the process of anxious thinking rather than on the content of anxious thoughts.The aim of this paper is to describe CBT aug-mented by panic surfing and to present the results of a pilot study of the effectiveness of this approach. This was a naturalistic study that was not system-atically planned, but was conducted in routine clinical practice. METHOD Participants Eighteen patients, (15 females; 83.3%) who attended an anxiety disorders clinic for treatment of panic disorder with or without agoraphobia, were recruited for this study. Their mean age was 35.6 years (standard deviation =  10.3); 10 (55.6%) patients were currently married or in a de facto  relationship; four (22.2%) had post-secondary school qualifications; and 10 (55.6%) were engaged in paid employment. Patients were usually referred  by their general practitioners, but some were self-referred, and others were referred by other mental health professionals and health care services. The study was approved by the local institutional review board.Clinic attendees were considered eligible to par-ticipate if panic disorder with or without agora-phobia was the condition for which they sought help or which caused the most distress or func-tional impairment. Patients with a history of psychosis or bipolar disorder, as well as patients with current psychosis, bipolar disorder, substance abuse or dependence, severe depression, severe personality disorder, self-harming behaviour and suicidality, are not treated in the clinic, and did not participate in the study. Those with a current depressive disorder were eligible to participate, so long as panic disorder was considered their prin-cipal diagnosis.Information regarding current medication use was available for 15 of the 18 participants. Of these 15, four were not taking any medication. Of the 11 Table 1. Key principals of cognitive behaviour therapy augmented by panic surfingUnderstanding of anxiety by using the paradigm of a fight or flight responseUnderstanding of the role of bodily hypervigilancePromoting a sense of ‘riding out the wave of anxiety’ in an accepting manner instead of trying to control symptomsRealistic appraisal of bodily sensationsAcknowledgement of physical feelings rather than distraction from these feelingsAcceptance of physical feelings through the rating of their intensity, instead of anticipating the worstAbandoning an anxiety-maintaining tendency to wish that panic would end quicklyAcknowledgement that catastrophic misinterpretations of physical feelings is problematic, not the physical feelings themselvesCessation of maladaptive behaviours (e.g., any avoidance or safety-seeking behaviours) that maintain the problem  442 C. Lamplugh et al. Copyright © 2008 John Wiley & Sons, Ltd.  Clin. Psychol. Psychother. 15 , 440–445 (2008) DOI : 10.1002/cpp patients on current psychopharmacotherapy, five were using more than one medication. The medi-cations were as follows: alprazolam (five patients); paroxetine (three); diazepam (three); sertraline (two); mirtazapine (one); amitriptyline (one); imip-ramine (one); and hypericum (one).  Instruments The Composite International Diagnostic Inter-view, version 2.1 (CIDI;   World Health Organi-zation, 1997), was used to confirm participants’ primary diagnosis. The CIDI is a structured diag-nostic interview, which yields a range of Interna-tional Classification of Diseases-10 and Diagnostic and Statistical Manual of Mental Disorders-IV diagnoses.The following self-report instruments, com-monly used in panic disorder treatment studies, were used to assess changes over the course of treatment:1. the Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally, 1986) was used to assess fear of anxiety-related symptoms. It consists of 16 items that are each rated on a 5-point scale;2. the Body Sensations Questionnaire (BSQ; Chambless, Caputo, Gallagher, & Bright, 1984) is a 17-item scale that was used to measure the intensity of fear associated with particular physical symptoms of arousal;3. the Mobility Inventory for Agoraphobia (MI; Chambless, Caputo, Jasin, Gracely, & Williams, 1985) assesses the degree to which respondents avoid 27 typical agoraphobic situations, when alone and when accompanied. Each situation is rated on a 5-point scale, and separate mean item scores are generated for the ‘alone’ and ‘accompanied’ subscales;4. the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) is a 21-item self-report scale that assesses common features of anxiety, such as nervousness, inability to relax, fear of losing control and various somatic symp-toms. Each item is rated on a 4-point scale; and5. the Beck Depression Inventory II (BDI-II; Beck, Steer, & Brown, 1996) is a 21-item self-report scale that assesses symptoms of depression. Each item is rated on a 4-point scale and a total score is obtained by summing the item scores. Procedures Intake Patients were initially screened over the tele-phone for appropriateness to be seen at the Nepean Anxiety Disorders Clinic. Once this was estab-lished, an assessment appointment was made. Initial Assessment Assessment included a face-to-face unstructured clinical interview lasting on average 1 hour. Eligi- ble patients were invited to participate in the study and the CIDI was then administered to consent-ing patients. Participants were also given a set of questionnaires to complete at home (‘pre-therapy’ point of assessment). Treatment Participants attended a 5-day group therapy programme for 4 hours each day. Group ses-sions were conducted by one of the Masters- or doctorate-trained clinical psychologists (CL, DB or DM) and usually consisted of five participants. Each therapist was receiving weekly individual supervision and there were daily consultations among the therapists during the running of each group. A treatment manual, broadly based on the content of three other CBT programmes (Andrews et al., 1994; Baillie & Rapee, 1998; Barlow & Craske, 1994), but modified to incorporate panic surfing and to exclude panic control strategies (e.g.,  breathing retraining techniques), was developed for the study and distributed to the participants. The components of the treatment programme are outlined below. Psychoeducation.  Patients were educated about the harmless nature of anxiety and the fight/flight response to threat. A model of the maintenance of anxiety and panic was presented, in which the role of hypervigilance, misinterpretation of bodily sen-sations and safety-seeking behaviours was empha-sized. This was in accordance with the principles of CBT augmented by panic surfing as outlined in Table 1. Panic Surfing Instructions.  On each day of the group therapy, patients were instructed that if they experienced a panic attack, they should try to ‘surf out’ the feelings. Panic surfing guidelines were presented to patients as follows:1. describe the feelings;2. rate the intensity of the feelings (on a scale of 0 to 8);  CBT Augmented by Panic Surfing  443 Copyright © 2008 John Wiley & Sons, Ltd.  Clin. Psychol. Psychother. 15 , 440–445 (2008) DOI : 10.1002/cpp 3. remind yourself of the natural causes for the feelings;4. remind yourself of the role of hypervigilance and remember that thoughts and not the feel-ings, are problematic;5. try not to rush through the feelings; and6. avoid behaviours aimed at controlling the feelings. Interoceptive Exposure.  Patients were encouraged to practice interoceptive exposure exercises (e.g., hyperventilation, spinning in a chair) with the goals of decreasing hypervigilance and creating more opportunities to practice panic surfing. Graded in vivo  Exposure.  A hierarchy of anxiety-inducing and/or avoided situations was deter-mined for each participant in the group. Patients were then encouraged to ‘surf out the wave of anxiety’ in each situation in which they practiced exposure. Cognitive Restructuring.  Patients were encouraged to identify and challenge misinterpretations of their bodily sensations, but they were instructed to ‘surf out’ the anxiety whenever panic attacks occurred. Subsequent Assessment Homework tasks were reviewed and remaining areas of difficulty were discussed on the day 5 of group therapy. Relapse prevention issues were also considered and questionnaires were adminis-tered (‘post-therapy’ point of assessment). Ques-tionnaires were re-administered and participant progress was further reviewed 1 month follow-ing completion of day 5 of the treatment (‘review’ point of assessment). Statistical Analyses Wilcoxon Signed Ranks tests were used to compare questionnaire scores between pre- and post-therapy; between pre-therapy and review; and between post-therapy and review. We used non-parametric statistics due to our small sample size and because scores on some questionnaires (e.g., on the MI) did not conform to a normal distribution. Due to numerous extreme scores on the MI-accompanied subscale, we only report the MI-alone scores here. Bonferroni corrections were used to control the Type I error rate when multiple comparisons were made. RESULTS Table 2 shows the means, standard deviations and medians of the questionnaire scores at pre-treatment, post-treatment and review. All scores, aside from those on the MI-alone subscale, declined significantly from pre- to post-treatment (ASI:  z   =   − 3.12,  p   =  0.002; BAI:  z   =   − 2.89,  p   =  0.004; BDI:  z   =   − 3.20,  p   =  0.001; BSQ:  z   =   − 3.46,  p   <  0.001). The MI-alone scale scores decreased significantly from pre-treatment to review (  z   =   − 3.20,  p   =  0.001). There were no significant changes between the post-treatment and review scores on any of the other scales. DISCUSSION The results of this pilot study indicate that CBT augmented by panic surfing is an effective short-term treatment for panic disorder. There were statistically significant improvements between pre- and post-treatment scores on all measures, except Table 2. Questionnaire scores at pre-treatment, post-treatment and review ( n   =  18)Pre-treatmentPost-treatmentReviewMeanSDMedianMeanSDMedianMeanSDMedianASI41.11 a 12.0142.0026.94  b 15.0627.5023.89  b 14.7221.00BSQ3.25 a 0.693.302.29  b 0.872.292.25  b 0.872.21MI—Alone2.62 a 0.932.802.171.021.661.95  b 0.901.53BAI32.11 a 16.7733.0017.33  b 11.9514.5016.28  b 9.9916.50BDI23.28 a 10.5920.0015.00  b 10.5012.5014.72  b 8.6213.50 Figures with different superscripts differ significantly from each other after a Bonferroni correction for multiple comparisons (0.05/3 =  0.017).ASI =  Anxiety Sensitivity Index. BAI =  Beck Anxiety Inventory. BDI =  Beck Depression Inventory II. BSQ =  Body Sensations Questionnaire. MI =  Mobility Inventory. SD =  standard deviation.  444 C. Lamplugh et al. Copyright © 2008 John Wiley & Sons, Ltd.  Clin. Psychol. Psychother. 15 , 440–445 (2008) DOI : 10.1002/cpp MI. These improvements were maintained at a 1-month review. On the MI, a significant improve-ment was noted at a review, not at a post-treatment point of assessment. This suggests that when com-pared with other aspects of panic disorder, avoid-ance behaviour needs more time for significant improvement to occur. Although treatment gains were quick (over a period of less than a week) and significant, it is noteworthy that even at a review, symptoms of anxiety and depression continued to  be present at a mild to moderate level; perhaps one or more review sessions would be needed to bring about further improvements.The favourable outcome of CBT augmented  by panic surfing could have been a consequence of several factors. First, it was delivered in a very intense, structured and ‘condensed’ fashion. Second, this treatment programme incorporated some of the CBT approaches that have previously  been demonstrated to be effective. Third, although speculative, the effect of these core components of CBT might have been amplified by the panic surfing approach, especially by emphasizing the acceptance, rather than control, of anxiety sensa-tions. Fourth, CBT augmented by panic surfing appears to comprehensively draw together a number of complex ideas in a format that is simple and easily understandable, thus contributing to the generally good acceptance by our patients. Finally, a group format could have accelerated and ampli-fied patients’ learning process, because they were able to directly observe the application of the skills that they were learning from the therapist.One caveat is that patients need to be willing to accept anxiety and to comprehend the principles of CBT enhanced by panic surfing in order to benefit from it. Therefore, patients presenting with over-whelming and/or disabling symptoms may find it difficult to learn and apply the principles of this approach at that particular time as their motiva-tion is to reduce their anxiety symptoms without delay.Being a preliminary investigation of the effec-tiveness of CBT augmented by panic surfing, our pilot study has a number of limitations. First, it was not designed to test to what extent various components of our treatment ‘package’ might have contributed to the outcomes. Second, we did not have a control group of patients (e.g., those who could have been on a waiting list) for com-parison, and therefore, we could not ascertain to what extent non-specific factors might have played a role in affecting the results. Third, our patients were not followed up over longer periods of time and it is not known whether and for how long the observed treatment gains were maintained. Fur-thermore, with regards to outcome measures, we relied only on self-report instruments and we did not have an index of the intensity and frequency of panic attacks. Although it would have been useful to have this information, measures like ASI and BSQ were adequate to assess whether the fear of anxiety- and arousal-related symptoms decreased as one of the main aims of panic surfing. Finally, it is difficult to establish the generalizability of the present findings as referrals to our clinic were screened for suitability before clinic attendees were considered for inclusion in the study.In conclusion, CBT augmented by panic surfing was delivered as an intensive 5-day group pro-gramme. This pilot study showed that improve-ments occurred very quickly and that they tended to be maintained over a short follow-up period. Although these results seem promising and suggest that this treatment programme might also be cost-effective, the main tasks for future research are to conduct controlled studies comparing CBT with panic surfing to CBT alone and to investigate the relative contribution of the various components of CBT augmented by panic surfing. REFERENCES Andrews, G., Crino, R., Hunt, C., Lampe, L., & Page, A. (1994). The treatment of anxiety disorders, clinician’s  guide and patient manuals . Cambridge, UK: Cambridge University Press.Baillie, A., & Rapee, R. (1998). Panic surfing: A self-treatment . Workbook for Panic Disorder. Sydney, Australia: Macquarie Lighthouse Press.Barlow, D.H., & Craske, M.G. (1994).  Mastery of your anxiety and panic . New York: University of Albany.Barlow, D.H., Gorman, J.M., Shear, K.M., & Woods, S.W. (2000). Cognitive-behavioral therapy, Imipramine, or their combination for panic disorder: A randomized controlled trial.  JAMA , 283 , 2529–2536 (DOI: 10.1001/ jama.283.19.2529).Beck, A.T., Epstein, N., Brown, G., & Steer, R.A. (1988). An inventory for measuring clinical anxiety: Psychometric properties.  Journal of Consulting and Clinical Psychology , 56 , 893–897 (DOI: 10.1037/0022-006X.56.6.893).Beck, A.T., Steer, R.A., & Brown, G.K. (1996). BDI-II Beck Depression Inventory  (2nd ed.). San Antonio: Harcourt Brace & Company, The Psychological Corporation.Chambless, D.L., Caputo, C., Gallagher, R., & Bright, P. (1984). Assessment of fear of fear in agoraphobia: The Body Sensations Questionnaire and the agorapho- bic. Cognitions Questionnaire. Journal of Consulting and Clinical Psychology , 52 , 1090–1097 (DOI: 10.1037/0022-006X.52.6.1090).
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