-
IdentifyingEfficacious Treatment Components
of Panic Control Treatment for Adolescents:A Preliminary
Examination
Jamie A. MiccoMolly L. Choate-Summers
Jill T. EhrenreichDonna B. PincusSara G. Mattis
ABSTRACT. Panic Control Treatment for Adolescents (PCT-A) is
adevelopmentally sensitive and efficacious treatment for
adolescentswith panic disorder. The present study is a preliminary
examination ofthe relative efficacy of individual treatment
components in PCT-A in asample of treatment completers; the study
identified when rapid im-provements in panic symptoms occurred over
the course of treatmentand which treatment components preceded
these gains. Twenty-one ad-olescents (ages 13-17) completed weekly
measures of panic-relevantsymptoms, which were examined for
between-session gains. Results in-
Jamie A. Micco, PhD, Molly L. Choate-Summers, PhD, Jill T.
Ehrenreich, PhD,Donna B. Pincus, PhD, and Sara G. Mattis, PhD, were
affiliated with the Center forAnxiety and Related Disorders at
Boston University at the time of this study. Dr. Choate-Summers is
now at the Pediatric Anxiety Research Clinic at Rhode Island
Hospital. Dr.Mattis is now in Private Practice in Winchester,
MA.
Address correspondence to: Jamie A. Micco, Massachusetts General
Hospital, De-partment of Psychiatry, 15 Parkman Street, ACC 812,
Boston, MA 02144 (E-mail:[email protected]).
This research was made possible by research grant R01 MH58641
from the Na-tional Institute of Mental Health, awarded to the last
author.
Portions of this paper were presented at the annual meeting of
the Association forthe Advancement of Behavior Therapy in Boston,
MA (November, 2003).
Child & Family Behavior Therapy, Vol. 29(4) 2007Available
online at http://cfbt.haworthpress.com
© 2007 by The Haworth Press, Inc. All rights
reserved.doi:10.1300/J019v29n04_01 1
mailto:[email protected]://cfbt.haworthpress.com
-
dicate that psychoeducation may precede notable decreases in
panic at-tacks while cognitive restructuring may contribute to
rapid declines inoverall anxiety and cognitive errors. The authors
discuss the importanceof future controlled dismantling studies to
examine the relative contribu-tion of PCT-A treatment components.
doi:10.1300/J019v29n04_01 [Arti-cle copies available for a fee from
The Haworth Document Delivery Service:1-800-HAWORTH. E-mail
address: Website: © 2007 by The Haworth Press, Inc. All
rightsreserved.]
KEYWORDS. Adolescents, panic disorder, panic control
treatment,cognitive behavioral therapy, sudden gains
PREVALENCE AND PHENOMENOLOGY OF PANICIN ADOLESCENT COMMUNITY
AND CLINICAL SAMPLES
The onset of panic disorder, with or without agoraphobia,
occursmost often in late adolescence (American Psychiatric
Association, 2000),although a number of community and clinical
studies have found thatfull-blown panic attacks and situational
avoidance are also prevalent inearly to mid-adolescence. While the
proportion of adolescents who en-dorse having experienced a panic
attack varies across studies, research-ers consistently find that
adolescents in the community endorse havinghad panic attacks both
with self-report measures and clinical interviews(Hayward, Killen,
& Taylor, 1989; Hayward, Killen, & Hammer, 1992;King,
Ollendick, Mattis, Yang, & Tonge, 1996; Lau, Calamari,
&Waraczynski, 1996; Macaulay & Kleinknecht, 1989). For
instance, alarge community study of 2,365 high school students
(mean age = 15.4years) found that 135 (5.7%) students reported a
lifetime history of atleast one panic attack with four or more
symptoms, and 62 (2.6%) re-ported at least one spontaneous panic
attack (Hayward, Killen,Kraemer, & Taylor, 2000). Prevalence
estimates of panic disorder inadolescence range from 0.5% (Hayward,
Killen, & Taylor, 2003) to1.6% (Reed & Wittchen, 1998) in
community samples.
In clinical samples, panic disorder is clearly a clinically
relevantproblem, with estimates ranging from 6% (in a pediatric
psycho-pharmacology clinic; Biederman et al., 1997) to
approximately 10% (inboth an anxiety disorders clinic and an
Italian outpatient clinic; Last &
2 CHILD & FAMILY BEHAVIOR THERAPY
mailto:[email protected]://www.HaworthPress.com
-
Strauss, 1989; Masi, Favilla, Mucci, & Millepiedi, 2000) of
referredchildren and adolescents meet criteria for the disorder.
Additionally,compared to psychiatric and non-clinical control
groups, adolescentswho meet criteria for panic and/or agoraphobia
have elevated comor-bidity with depression and other anxiety
disorders (Biederman et al.,1997), and they report higher anxiety
sensitivity compared to a clinicalcontrol sample of children
without panic disorder (Kearney et al.,1997). This underscores the
importance of developing efficacious treat-ments for children and
adolescents who experience panic attacks andpanic disorder.
PANIC CONTROL TREATMENTFOR PANIC DISORDER AND AGORAPHOBIA
A number of studies have established the efficacy of
cognitive-be-havioral treatments (CBT) for adults with panic
disorder and agora-phobia (Clark, 1989; Clark, Salkavakis,
Hackmann, Middleton, Anasta-siades, & Gelder, 1994; Telch,
Schmidt, Jaimez, & Harrington, 1995).Panic Control Treatment
(PCT) is one such cognitive-behavioral treat-ment developed by
Barlow and Craske (2000) in the mid-1980s. PCThas been found to be
superior to progressive muscle relaxation andwaitlist control
groups at both post-treatment and follow-up (Barlow,Craske, Cerny,
& Klosko, 1989; Craske, Brown, & Barlow, 1991), andit
appears to have a more durable effect at follow-up than
tricyclicmedication for panic-disordered patients (Barlow, Gorman,
Shear, &Woods, 2000).
Ollendick (1995) conducted the first controlled study of CBT
forpanic-disordered adolescents, which employed a multiple-baseline
de-sign with four participants (ages 13 to 17). The treatment
containedcomponents of PCT, but also included progressive muscle
relaxationand situational exposure. At post-treatment, all
adolescents reported areduction in the frequency of panic attacks,
less situational avoidance,and lower scores on self-report
questionnaires of anxiety sensitivity,fear, and overall anxiety
(Ollendick, 1995).
Given the efficacy of PCT with panic-disordered adults, as well
asOllendick’s finding that CBT can be successfully applied to
adolescentswith panic disorder, Mattis and colleagues (Hoffman
& Mattis, 2000;Mattis & Ollendick, 2002) developed a
developmentally sensitive adap-tation of the PCT protocol for
adolescents. Panic Control Treatment forAdolescents (PCT-A) shares
its predecessor’s focus on three main as-
Micco et al. 3
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pects of panic disorder. Specifically, PCT-A targets: (1) the
cognitive,or misinterpretational, aspect, (2) the hyperventilatory
response, and (3)conditioned reactions to physical sensations.
However, several changesin the protocol were made so that it would
be more appropriate for usewith adolescents. These changes include
clearer, simplified language(particularly during the
psychoeducational component of the manual)and visual and verbal
examples of important concepts. Situational ex-posure was also
added to the PCT-A manual, given the high frequencyof agoraphobic
avoidance in panic-disordered adolescents (Biedermanet al., 1997;
Kearney et al., 1997).
Results of a recent, randomized controlled trial of PCT-A
support theefficacy of the treatment protocol with adolescents who
have been diag-nosed with panic disorder and agoraphobia (Mattis,
Cohen, Hoffman,Pincus, Choate, & Micco, 2001; Mattis &
Pincus, 2003; Mattis, Pincus,Ehrenreich, & Barlow, 2006).
Compared to adolescents randomly as-signed to a waitlist control
group and assessed post-waitlist, adolescentsassigned to the
treatment group showed significantly greater improve-ments on
clinician severity ratings of panic disorder, the Multidimen-sional
Anxiety Scale for Children (MASC; March, 1997), and theRevised
Children’s Manifest Anxiety Scale (RCMAS; Reynolds &Richmond,
1978) at post-treatment assessment (Mattis et al., 2006),among
other measures (see Mattis et al., 2006, for a full review of
thestudy’s findings).
TREATMENT COMPONENTS OF PCT-A:DESCRIPTION AND RATIONALE
PCT-A consists of 11 individual treatment sessions that are
60-90 min-utes in length. There are seven main treatment components
of PCT-A,which are described in Table 1. Breathing retraining is
introduced in ses-sion three, following psychoeducation (session
one) and situation expo-sure (session two). The inclusion of
breathing retraining is based on thehyperventilation model of panic
disorder, which holds that subtle,chronic hyperventilation (or
overbreathing) in people with panic disorderleads to physical
symptoms that, when noticed, can spiral into afull-blown panic
attack (Ley, 1985). In support of this model, studieshave shown
that people with panic disorder have lower basal pCO2 levels(Roth,
Wilhelm, & Trabert, 1998; Papp et al., 1997) and greater
subjec-tive response to voluntary hyperventilation (Rapee, Brown,
Antony, &Barlow, 1992). Breathing retraining is intended to
correct the patient’s
4 CHILD & FAMILY BEHAVIOR THERAPY
-
tendency towards subtle hyperventilation, and thus decrease
physicalsensations that predispose the patient to experience a
panic attack.
The rationale for including cognitive restructuring and
hypothesistesting in PCT-A is based on Clark’s (1988) cognitive
model of panic,which holds that catastrophic misinterpretation of
normal physiologicalanxiety reactions result in panic attacks.
Indeed, adult patients withpanic disorder are more likely than
patients with other anxiety disordersand adults with no psychiatric
disorder to interpret ambiguous physicalsensations as something
being physically or mentally wrong with them(Clark et al., 1997).
Cognitive restructuring addresses this misinter-
Micco et al. 5
TABLE 1. Treatment Components Included in PCT-A
Treatment Component Session(s)Introduced
Description
Psychoeducation 1-2 Therapist provides accurate information
aboutfeared physical sensations in the context ofthe body’s
fight/flight system and describesand discusses the “cycle of
panic”
Situational Exposure (SE) 2 Fear and Avoidance Hierarchy is
developed;therapist emphasizes that remaining in fearedsituations
will lead to habituation inpanic-related symptoms; exposure from
FAHis assigned at each session
Breathing Retraining (BR) 3-4 Adolescent is taught to breathe
slowly fromthe diaphragm and practices twice daily athome
Cognitive Restructuring (CR) 4-5 Described as “thinking like a
detective”;adolescent learns to identify automaticthoughts,
including probability overestimationand catastrophic thinking, and
is taught tochallenge thoughts by looking at the evidenceand
generating rational responses
Interoceptive Exposure (IE) 5-6 Adolescent is desensitized to
panic-likephysical sensations through a series ofexercises designed
to elicit these sensations,such as spinning in a chair, breathing
througha straw, and hyperventilating; exercises arerepeatedly
practiced in several settings untilthe sensations do not elicit
anxiety
Hypothesis Testing 7 Adolescent makes predictions regarding
theoutcome of a feared situation, engages in thesituation, and
evaluates his/her originalprediction
Naturalistic InteroceptiveExposure
8 Adolescent engages in situations in everydaylife that elicit
physical sensations (i.e.,drinking caffeine, exercising, going on a
rollercoaster)
-
pretational aspect of panic disorder, as does hypothesis testing
(behav-ioral experiments that test the accuracy of panic-related
cognitions).
Children and adolescents with panic disorder and panic attacks
aremore likely to experience anxiety sensitivity, or hypervigilance
and fearof physiological sensations than children and adolescents
without panicdisorder or panic attacks (Calamari et al., 2001;
Ginsburg & Drake,2002; Kearney et al., 1997; Weems, Hayward,
Killen, & Taylor, 2002).Thus, helping adolescents with panic
disorder become less fearful andvigilant of normal physiological
sensations appears to be an importanttreatment goal, and this is
the purpose of interoceptive exposure.
Although PCT-A is primarily an individual treatment, parents are
in-cluded in the last 10 minutes of sessions one, four, seven, and
11 ofPCT-A. Given that parents are integrally involved in their
adolescents’lives, it is expected that including them as part of
therapy will result ingreater reinforcement of the use of
cognitive-behavioral skills at home,although more research is
necessary to determine if this is the case(Barrett, 2000).
IDENTIFYING EFFICACIOUSTREATMENT COMPONENTS OF PCT
Examination of Specific Treatment Components of PCT in
Adults
Identifying components of a treatment that most effectively lead
tosymptom reduction allows researchers to “fine tune” the treatment
manualsthey develop and clinicians to spend more time on aspects of
treatment thatseem to work. There are a number of studies that have
examined the effi-cacy of specific cognitive-behavioral treatment
components for adults withpanic disorder, many of which have
compared interoceptive exposure (IE)to other treatment components
(Arntz, 2002; Bouchard et al., 1996; Craske,Rowe, Lewin, &
Noriega-Dimitri, 1997; Hecker, Fink, Vogeltanz, Thorpe,&
Sigmon, 1998; Ito, Noshirvani, Basoglu, & Marks, 1996). For
instance,Hecker and colleagues (1998) provided 18 patients with
panic disorderwith four sessions of cognitive therapy (CT) and four
sessions of IE; half ofthe patients got CT first, and half got IE
first. Results show that both treat-ments led to similar clinical
improvements, with the only difference beinglower self-ratings of
global disturbance in the CT-first group. The order ofthe treatment
components did not influence outcome, as most patientsmade
clinically significant treatment gains during the first half of
treatmentand maintained them during the second half (Hecker et al.,
1998). Another
6 CHILD & FAMILY BEHAVIOR THERAPY
-
study randomly assigned 26 patients with panic disorder and
agoraphobiato 10 weekly sessions of IE plus situational exposure
(SE) or SE alone; nei-ther treatment condition included CT (Ito et
al., 1996). There were few dif-ferences in treatment outcome
between the two groups, although morepatients who had both IE and
SE improved greater than 50% on measuresof apprehension and
agoraphobia (Ito et al., 1996).
Craske et al. (1997) compared IE to breathing retraining (BR) in
agroup of 38 adults with panic disorder and agoraphobia. All
patientswere treated using cognitive restructuring and SE, but half
also receivedIE while the other half received BR. While both
treatment packageswere equally effective on a number of
panic-relevant measures, thosewho had received IE (compared to
those who received BR) had fewerpanic attacks and lower overall
severity at post-treatment and fewerpanic attacks and phobic fears
at six-month follow-up (Craske et al.,1997). Schmidt and colleagues
(2000) found that adults with panic dis-order and agoraphobia who
received BR in combination with SE tendedto have lower end-state
functioning at a follow-up assessment whencompared to adults who
received SE without BR. The authors suggestthat this finding may be
due to patients using deep breathing in an at-tempt to avoid
panicky physical sensations during panic attacks(Schmidt et al.,
2000).
In sum, studies that have compared the efficacy of specific
treatmentcomponents that are included in PCT for adults have found
few differ-ences in overall outcome on panic-relevant measures,
including panicattack frequency, apprehension of panic, and
agoraphobic avoidance,although there is some evidence for the
efficacy of IE and SE having anadvantage over that of BR in
treatment outcome, particularly at fol-low-up. To date, however, no
study has looked at specific treatmentcomponents of panic control
treatment in children and adolescents.
“Sudden Gains” Treatment Studies
One way of examining the contribution of individual treatment
com-ponents to overall improvement is to look at between-session
treatmentchanges. If an abrupt reduction in symptoms occurs
following a specificsession, a treatment component addressed in
that session may have con-tributed to overall improvement. Tang and
DeRubeis (1999) examinedbetween-session changes for adults
receiving CBT for depression,particularly looking for abrupt
changes from one session to the next, or“sudden gains” in
treatment. The researchers found that significantcognitive changes
(as measured by a clinician rating scale) tended to
Micco et al. 7
-
precede sudden gains on the Beck Depression Inventory (Tang
&DeRubeis, 1999). Pham and colleagues (2004) found similar
results intheir analysis of sudden gains on the Anxiety Sensitivity
Index (ASI)for adults receiving CBT for panic disorder.
Specifically, patients whomade sudden gains had significantly lower
anxiety sensitivity atpost-treatment compared to patients who did
not make sudden gains(Pham, Tang, Zinbarg, & Andrusyna, 2004).
Thus, analysis of be-tween-session treatment change may contribute
to an understanding ofthe contribution of treatment components and
have an impact on treat-ment outcome.
AIMS OF THE PRESENT STUDY
Given that a sizeable number of adolescents and children present
toclinical settings with panic disorder and agoraphobia or
sub-syndromalpanic disorder, it is important to evaluate the
efficacy of treatments pro-vided to this population. While PCT-A
appears to be an efficacioustreatment for panic-disordered
adolescents, it is unclear which compo-nents of the protocol
actively contribute to the treatment’s efficacy.There have been a
number of studies examining the relative efficacy ofspecific CBT
components for adults with panic disorder but not for ado-lescents.
The purpose of the present study is to conduct a
preliminaryexamination of panic-related symptom changes in relation
to the intro-duction of different treatment components of PCT-A,
using suddengains analysis. However, in contrast to Tang and
DeRubeis (1999), whocompared individuals who made sudden gains to
those who did not, thepurpose of the present study is to identify
when adolescents with panicdisorder as a group experienced
significant improvements in panic-re-lated symptoms over the course
of PCT-A. More specifically, wesought to generate hypotheses about
the relative efficacy of the treat-ment components of PCT-A by
determining which treatment compo-nents of PCT-A were followed by
sudden treatment gains.
METHODS
Participants
The data used in the present analysis were drawn from a
randomized,controlled trial of PCT-A at an outpatient anxiety
disorders clinic. Thestudy included 21 adolescents (18 girls, three
boys; mean age = 15.38,
8 CHILD & FAMILY BEHAVIOR THERAPY
-
SD = 1.16) who completed the treatment in its entirety. All
adolescents,ages 13 to 17, who were principally diagnosed with
panic disorder (withor without agoraphobia) at intake via the
Anxiety Disorders InterviewSchedule, Child/Parent Version
(ADIS-IV-C/P; Silverman & Albano,1996) between 1998 and 2002
were offered participation in the project.Exclusion criteria
included diagnosis of a psychotic disorder, pervasivedevelopmental
disorder, mental retardation, and current suicidal idea-tion.
Adolescents taking psychiatric medication were required to takethe
same dose of the medication for at least one month (for
anti-anxietymedications) or three months (for anti-depressant
medications) priorto participation in the project and remain on the
same dose of medica-tion until the end of their participation in
the study. Of those who wereoffered the project, 80% agreed to
participate; the primary reason foradolescents choosing not to
participate was not wanting to wait fortreatment should they be
randomized to the waitlist condition of thestudy.
Adolescents who were eligible and agreed to participate in the
proj-ect reviewed and signed informed consent and assent forms,
along withtheir parents, after which they were randomly assigned to
either thetreatment or waitlist condition. The latter involved
bi-weekly, 30-min-utes “check-in” sessions over the course of eight
weeks, during whichadolescents established rapport with their
therapist and described anypanic-related symptoms they experienced
over the course of the inter-vening two weeks. Other than the
completion of weekly monitoringforms, waitlist sessions did not
include any cognitive-behavioral treat-ment components. After the
completion of the waitlist period, adoles-cents in this group
received a full-course of PCT-A. Therapists includeddoctoral
students in clinical psychology and doctoral-level psycholo-gists.
All sessions were videotaped, and 32.5% of the sessions were
ran-domly selected and reviewed for treatment integrity by either
abachelor’s level research assistant or doctoral student. All
session com-ponents were rated on a scale from 1 (not at all
covered in session) to 5(completely and thoroughly covered in
session) and then averaged tocreate one treatment adherence rating
for the entire session. The averagetreatment adherence across
sessions in this study was 4.57 (SD = .37).
Ten girls and two boys from the immediate treatment group
com-pleted all the measures of interest to the present study. Two
additionaladolescents, one girl and one boy, dropped out of
treatment after sessioneight and are not included in the analyses
below. Of the waitlist group,eight girls and one boy who chose to
participate in treatment after com-pleting the waitlist period also
completed all study measures; two girls
Micco et al. 9
-
and one boy chose not to participate in treatment after
completing thewaitlist period. As the waitlist group did not differ
from the immediatetreatment group prior to treatment initiation on
measures of anxiety,panic disorder, depression, or anxiety
sensitivity (Mattis et al., 2006),both groups were combined to
analyze their treatment sessions. Thus,21 adolescents are included
in the present study.
Despite efforts to recruit a more ethnically diverse sample, all
partici-pants in the study were Caucasian. Most of the adolescents’
parentswere married (90%), while 10% were divorced or separated.
The modallevel of education for both parents was a bachelor’s
degree. Of the 21participants, 19 were diagnosed with panic
disorder with agoraphobia atthe initial assessment, while two were
diagnosed with panic disorderwithout agoraphobia. The mean
clinician severity rating of panic disor-der, based on the
ADIS-IV-C/P (zero to eight, with a CSR of four andhigher
representing a clinical level of severity), was 5.52. Most of
theparticipants (85.7%) had at least one additional clinical
anxiety or mooddisorder; the mean number of additional diagnoses
was 1.71.
Measures
Weekly Measures
Weekly Record of Anxiety and Depression (WRAD). The WRAD is
amonitoring form on which adolescents recorded their daily levels
of av-erage anxiety, depression, and pleasantness on a zero (not at
all) to eight(very much) scale. In a study of younger children
(grades 3-6), the useof a daily self-monitoring form to record
anxiety symptoms was foundto be reliable, and the form
differentiated test-anxious from non-test-anxious children (Beidel,
Neal, & Lederer, 1991). Adolescents in thepresent study brought
the WRAD to session each week and reviewed itwith their therapist.
The present study used the “average anxiety” com-ponent of the
WRAD. We averaged the adolescents’ daily anxiety rat-ings for each
week, which yielded one average anxiety rating persession.
Panic Attack Record (PAR). Adolescents monitored the
frequencyand qualitative aspects of panic attacks over the course
of the week onthe PAR, a self-monitoring form initially developed
for adults byRapee, Craske, and Barlow (1990). Adolescents were
instructed to useone form per panic attack and to record the
duration of the attack, maxi-mum anxiety level, possible
antecedents, and symptoms. In a largelycollege-aged sample, Nelson
and Clum (2002) found that the frequency
10 CHILD & FAMILY BEHAVIOR THERAPY
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of panic attacks over a two-week period as measured by the PAR
corre-lated highly (r = .89) with the frequency as measured by a
Panic AttackFrequency Calendar. From the PAR, we calculated the
average numberof unexpected, full-blown panic attacks (i.e., with
four or more physicalor cognitive symptoms) adolescents experienced
in the week prior toeach session of PCT-A.
Weekly Measure After Session 5
Belief Ratings. Belief ratings measured the degree to which
adoles-cents engaged in “probability overestimation” and
“catastrophic think-ing.” Probability overestimation is the
tendency to think that events aremore likely to occur than evidence
would suggest. Catastrophic think-ing is the tendency to believe
that the consequences of a feared outcomewould be horrible and too
difficult to handle. At session five, adoles-cents identified their
most anxiety-provoking probability overestima-tion and rated the
likelihood that the thought would come true (0 = not atall likely
to 100 = very likely). In addition, adolescents identified
theirworst catastrophic thought and rated their ability to cope if
the fearedoutcome actually occurred (0 = very poorly to 100 = very
well). At ev-ery session after session five, adolescents re-rated
these two beliefs.
Measure Collected at Session 11
Perceptions of Treatment Questionnaire (PTQ). The PTQ is
aself-report questionnaire, designed for the purposes of the
PCT-Astudy, which includes both forced-choice and free-response
questions.This measure assesses the aspects of treatment that
adolescents did anddid not find to be helpful, such as specific
treatment components andtherapist alliance. For the purposes of the
present study, we only exam-ined adolescents’ responses to the
free-response PTQ question, “Whatwas most helpful about the
treatment?”
Data Analysis
Sudden gains, or treatment improvements, using group averages
foreach measure were analyzed for each of the three weekly
measures. Ifan adolescent did not complete a measure for a
particular session, it wasnot replaced with an individual average
and instead dropped from thecalculated group average for that
particular session. Although suddengains have previously been
examined across individuals completing
Micco et al. 11
-
treatment for depression (Tang & DeRubeis, 1999; Stiles et
al., 2003),there is no precedent for examining sudden gains from
session-to-ses-sion across group averages. Thus, for each measure,
we defined the firstcriterion for a sudden gain as a
between-session change score of at leasttwo standard deviations
from the mean of all between-session changesacross the 11 sessions.
This “two standard deviation” criterion ensuredthat sudden gains
were large relative to overall changes. In addition,similar to
criteria established in Tang and DeRubeis’ (1999) study, sud-den
gains had to represent at least 25% of the pre-gain session’s
WRADscore, panic attack frequency, or belief rating. Furthermore,
to ensurethat the improvement was stable, the mean scores across
the three ses-sions before the sudden gain had to be significantly
higher than themean scores across the three sessions after the gain
(when applicable),using a t-test with an alpha of 0.05. Finally, we
examined the PTQ todetermine which treatment component adolescents
perceived to bemost helpful during PCT-A.
RESULTS
Sudden Gains on WRAD, PAR, and Belief Ratings
The mean “average anxiety” score on the WRAD, as rated by the
ad-olescents on a scale from zero to eight, was 2.90 (SD = 1.70) at
pre-treatment and 1.20 (SD = 1.77) at session 11. The average
between-ses-sion change across all sessions on the WRAD-Average
Anxiety was adecrease of 0.15 units (SD = 0.33; range =
�0.40-0.70). Thus, a be-tween-session change on the WRAD had to
exceed 0.66 to meet the twoSD criterion as a sudden gain. The mean
decrease in average anxiety be-tween sessions four and five was
0.70, which met the first criterion.This gain was also greater than
25% of the previous session’s mean av-erage anxiety rating of 0.30
(0.30 � 0.25 = 0.08). In addition, the meanaverage anxiety rating
for the three sessions preceding the sudden gain(2.87) was
significantly greater than that of the three sessions after
thesudden gain (2.27; t = 10.39, p = 0.01). This significant
improvement inaverage anxiety notably occurred after the
introduction of cognitive re-structuring in the treatment protocol.
No additional between-sessionchanges in average anxiety met sudden
gain criteria (see Figure 1).
Adolescents experienced an average of 2.63 (SD = 3.50) panic
at-tacks a week at pre-treatment, which decreased to 0.31 (SD =
0.58) atsession 11. The average between-session decrease in number
of
12 CHILD & FAMILY BEHAVIOR THERAPY
-
full-blown panic attacks (as measured by the PAR) was 0.26 (SD
=0.50; range = �0.25-1.50). In order to be considered a “sudden
gain,” abetween-session change in frequency of panic attacks would
have to ex-ceed 1.00. One between-session change met this
criterion: the averagedecrease in panic attacks between sessions
one and two (after the firstsession of psychoeducation) was 1.50
(see Figure 2). This between-ses-sion change met the second
criterion to be considered a “sudden gain”;it was greater than at
least 25% of the previous session’s panic attackfrequency of 2.88
(2.88 � 0.25 = 0.72). However, although the meannumber of panic
attacks of the two sessions before the sudden gain(pre-treatment
and session one; mean = 2.76) was greater than the meanfrequency of
attacks in the three sessions after the sudden gain (1.53),this
difference is not statistically significant. Thus, the decrease in
panicattacks between sessions one and two cannot be considered a
full sud-den gain. No other between-session changes on the PAR met
the suddengain criteria.
Adolescents’ belief in their most salient probability
overestimationdropped from a mean belief rating of 49.00 (SD =
35.12) at session fiveto 13.05 (SD = 25.73) at session 11. The mean
between-session de-crease in adolescents’ belief ratings was 5.99
percentage points (SD =
Micco et al. 13
3.5
3
2.5
2
1.5
1
0.5
0Pre 1 2 3 4 5 6 7 8 9 10 11
Ave
rag
eA
nxi
ety
(0-8
)
Session
FIGURE 1. Mean change in average anxiety, as measured by the
WRAD,across treatment sessions.
-
6.59; range = 0.55-18.83). One between-session change was
greaterthan two standard deviations from the mean (13.18); between
sessionsfive and six, the average decrease in adolescents’ belief
ratings was18.83. Because belief ratings were recorded beginning at
session five,the change between sessions five and six cannot be
compared to beliefratings at earlier sessions. However, the belief
rating at session five(49.00) is higher than the average belief
rating of the three sessions fol-lowing the sudden gain (26.15).
This sudden change in probabilityoverestimation belief came after
the second session of cognitive re-structuring (see Figure 3). At
the individual level, eight out of 21 partic-ipants (38.1%)
experienced a rapid decrease in their belief ratingsbetween
sessions five and six (i.e., a decrease that exceeded two stan-dard
deviations from the individual’s mean change in belief ratingsfrom
sessions five through 11).
Adolescent’s coping ratings (i.e., belief in how well they could
copeif a feared outcome did occur) increased from an average of
56.57 (SD =30.70) at session five to 78.14 (SD = 29.56) at session
11. The mean be-tween-session increase in coping ratings was 3.60
percentage points(SD = 3.44; range = �1.20-9.48). The average
increase in coping rat-ings between sessions five and six was 9.48,
which is higher than two
14 CHILD & FAMILY BEHAVIOR THERAPY
3.5
3
2.5
2
1.5
1
0.5
0Pre 1 2 3 4 5 6 7 8 9 10 11
Ave
rag
e#
ofW
eekl
yP
anic
Att
acks
Session
FIGURE 2. Mean change in panic attack frequency, as measured by
the PAR,across treatment sessions.
-
standard deviations from the mean (6.88). The mean coping rating
atsession five (56.57) is lower than the average coping ratings at
the twosessions following the sudden gain (69.59). Of the 21
participants,seven (33.3%) experienced an individual marked
increase in their cop-ing ratings (i.e., greater than two standard
deviations from their individ-ual mean change in coping ratings
from sessions five to 11). No otherbetween-session changes in
coping ratings met criteria to be considereda sudden gain (see
Figure 3).
Adolescents’ Perceptions of Treatment
Adolescent participants were asked to give a free response to
the fol-lowing question on the PTQ: “What was most helpful about
the treat-ment?” Of the 19 participants who completed the PTQ,
seven (36.8%)described cognitive restructuring as most helpful,
while six (31.6%) feltthe psychoeducational component of treatment
was most helpful. Three(15.8%) listed breathing retraining and two
(10.5%) listed situationalexposure. One participant (5.3%) said
that she found “having someoneto talk to” was most helpful to
her.
Micco et al. 15
90
80
70
60
50
40
30
20
10
05 6 7 8 9 10 11
Session
Belief RatingCoping Rating
FIGURE 3. Mean change in probability overestimation belief
ratings and cata-strophic cognition coping ratings across treatment
sessions.
-
DISCUSSION
The present study is a preliminary examination of the relative
effi-cacy of PCT-A treatment components with the aim of generating
hy-potheses for additional controlled studies of this treatment.
Our resultssuggest that over the course of PCT-A, adolescents
experienced periodsof rapid improvement in panic-relevant symptoms.
At pre-treatment,adolescents in this study experienced an average
of 2.63 panic attacksper week, which is higher than the average
weekly frequency of 0.92experienced by “severe” non-clinical
adolescent panickers (calculatedfrom the three-week frequency of
panic attacks), as reported byMacaulay and Kleinknecht (1989).
After adolescents in the presentstudy received their first session
of treatment, they experienced an aver-age of one-and-a-half fewer
unexpected, full-blown panic attacks thanthey did the previous
week. Although this decrease did not meet ourthird criterion to be
termed a “sudden gain” (likely the result of onlyhaving only two
sessions pre-gain on which to conduct the t-test), ado-lescents
continued to experience fewer than two panic attacks per weekon
average after session one, an improvement that is clinically
mean-ingful. While this decrease in frequency of panic attacks may
well bethe result of relief from initiating treatment, it is also
possible that thedecrease is related to the first session of
psychoeducation regardinganxiety and panic, which emphasizes the
interrelationship betweenthoughts, physical sensations, and
avoidance. Between sessions oneand two, each adolescent evaluated
his/her own panic attacks in the con-text of the “cycle of panic”
they learned at the first session. They werealso oriented to the
treatment model by their therapist, which likelyresulted in an
expectation of greater control over panic symptoms; thissense of
control, in turn, may have led to a decrease in panic attacks.
Adolescents also experienced improvement in their ratings of
aver-age anxiety between sessions four and five, as measured by the
WRAD.This sudden gain occurred after the first session of cognitive
restructur-ing (CR), during which adolescents learn how to gather
evidenceagainst and challenge probability overestimations.
Similarly, therewere significant cognitive improvements between
sessions five and sixon two variables: how much adolescents
believed their most salientprobability overestimation was true, and
how confident they were intheir ability to deal with feared
outcomes. These improvements oc-curred after the second session of
CR, during which adolescents iden-tify catastrophic cognitions and
determine ways that they could copewith feared outcomes if they
actually occurred.
16 CHILD & FAMILY BEHAVIOR THERAPY
-
Thus, it appears that psychoeducation and CR are two
treatmentcomponents after which sudden symptom improvements were
ob-served, although further studies are essential to determining if
these areindeed active treatment ingredients. Interestingly, these
were the sametwo treatment components that adolescents reported as
being most help-ful to them on the PTQ. However, given the
limitations of our data, it isdifficult to determine if each
treatment component led to improvementin the specific symptom of
panic disorder it intended to target, mainlybecause of the overlap
in the presentation of different treatment compo-nents.
Nevertheless, our impression is that CR appeared to precede
asignificant decrease in intensity of cognitive errors, as measured
by thebelief and coping ratings, suggesting that there is
specificity to thistreatment component. On the other hand, BR and
IE did not result insudden decreases in panic attacks as would be
expected, although thefrequency of panic attacks continued to
decline steadily after bothtreatment components were fully
introduced.
There are a number of limitations of this study that prevent us
fromdrawing definitive conclusions about the relative importance of
eachtreatment component. First, because of the overlap in the
presentationof treatment components (for example, clients are still
working on BRwhen they begin CR) and the lack of a control group,
we cannot saywith certainty that the sudden gains we found were the
direct result ofone particular treatment component. It was
especially difficult to exam-ine what effect SE had on the
adolescents’ symptoms of panic and ago-raphobia because this
component was an active part of every sessionbeginning at session
two and because the measure of avoidance in theoverarching study
(the Fear and Avoidance Hierarchy) was not col-lected weekly over
the course of the protocol. Also, while we can saythat there was a
sustained decrease in cognitive errors on the belief rat-ing
measure after session five, we cannot be certain that there were
nochanges in adolescents’ belief ratings before the introduction of
CR, asthis measure was not collected before session five (it was
originallyconceived as a treatment tool).
A second limitation is the small sample size of 21 adolescents,
all ofwhom were Caucasian. Most of the adolescents came from intact
fami-lies and had well-educated parents. These characteristics of
our samplemay limit the generalizability of the findings to other
populations. In ad-dition, all participants in the present study
were treatment completers;we may have found that some treatment
components were less effectiveif participants who did not complete
the full treatment had been in-cluded in the analyses. A third
limitation is that there is no standard defi-
Micco et al. 17
-
nition of a “sudden gain” across group averages on a measure;
thedefinition that we used was modeled after that of Tang and
DeRubeis(1999), who looked at individual sudden gains, but our
criterion thatsudden gains had to be larger than two standard
deviations from themean on each measure was somewhat arbitrary,
selected to ensure thatthe sudden gains we found were large
compared to changes across treat-ment. However, this criterion may
have missed between-sessionchanges that fell short of the two
standard deviation criterion but werestill clinically significant.
For future studies examining session-by-ses-sion changes, a
standard definition of a mean “sudden gain” should beestablished so
that the criteria are not reinvented with each study, whichlimits
uniform interpretation of the results. Treatment outcome
re-searchers seeking an established but conservative definition of
suddentreatment gains may wish to employ the sudden gains criteria
used inthe present study.
Finally, despite the fact that daily self-monitoring of anxiety
andpanic attack records are widely used in cognitive-behavioral
treatmentfor anxiety, there have been few studies of their
psychometric proper-ties and none of the two measures designed
particularly for the study ofPCT-A’s efficacy (the belief ratings
and the PTQ). Nevertheless, it hasbeen shown that even children
younger than the adolescents in thisstudy can reliably complete
self-monitoring forms of anxiety symptoms(Beidel et al., 1991).
Furthermore, the portion of the PTQ used in thepresent study for a
qualitative analysis of what adolescents thought wasmost helpful
during treatment was intended as a supplement to theirquantitative
ratings. However, future studies of cognitive-behavioraltreatment
components may wish to include well-validated self-reportmeasures
that are collected on a weekly basis in addition to
weeklyself-monitoring and in-session belief ratings.
While a number of controlled studies comparing CBT
ingredientsfor panic disorder have been conducted with adults
(i.e., Craske et al.,1997; Hecker et al., 1998), there have been no
studies for CBT of ado-lescent panic, and very few studies in the
child CBT literature in gen-eral, that have looked at the
contribution of individual treatmentcomponents to a treatment
manual as a whole. In a discussion of mech-anisms of change in
cognitive-behavioral treatments for anxious chil-dren and
adolescents, Hudson (2005) stresses the importance of
futureresearch examining the differential efficacy of individual
treatmentcomponents. Along these lines, we recommend that the
“active ingre-dients” of PCT-A be examined more closely through
controlled dis-mantling studies. For example, the efficacy of SE in
PCT-A can be
18 CHILD & FAMILY BEHAVIOR THERAPY
-
established by comparing panic-disordered adolescents who
receivestandard PCT-A to those who participate in PCT-A without the
inclu-sion of SE.
The degree to which BR contributes to the overall efficacy of
PCT-Ais of particular interest in light of Schmidt and colleagues
(2000) find-ing that this treatment component may put adults with
panic disorder atrisk for relapse, and Craske et al.’s (1997)
finding that IE is superior toBR. Meuret, Wilhelm, Ritz, and Roth
(2003) suggest that at this point,arguments for or against the
inclusion of BR in treatment for panic dis-order are premature
given the significant variability in studies that haveexamined this
treatment component (i.e., type of BR used, patient selec-tion,
study design). The authors argue that BR appears to
correctmaladaptive breathing patterns that increase vulnerability
to panic at-tacks and that further research is necessary to clarify
the role of BR inthe treatment of panic disorder (Meuret et al.,
2003).
In addition, given our finding that psychoeducation may have
con-tributed to a significant reduction in average frequency of
panic attacks,future research might examine if psychoeducation
alone leads to theprevention of panic disorder and agoraphobia in
adolescents at risk fordeveloping the disorder, such as adolescents
who have parents withpanic disorder or adolescents who have
previously experienced lim-ited-symptom panic attacks.
CONCLUSION
The fact that as many as 10% of children and adolescents
presentingto outpatient clinics meet criteria for panic disorder
emphasizes the im-portance of developing and honing efficacious
treatments for this popu-lation. Evidence suggests that PCT-A
results in significant treatmentimprovements in adolescents with
panic disorder and agoraphobia(Mattis et al., 1996), although which
components of this treatment con-tribute to its efficacy remain to
be seen. Our session-by-session analysisof treatment gains on
panic-relevant measures suggests that psycho-education may
contribute to a reduction in the frequency of panic at-tacks, while
cognitive restructuring appears to play a role in
decreasingadolescents’ self-report of overall anxiety and the
degree to which ado-lescents engage in cognitive errors. As
clinical researchers develop in-creasingly helpful treatments for
childhood anxiety disorders, it isparticularly important to obtain
more definitive evidence of the treat-ment components (individually
and/or in combination) that are neces-
Micco et al. 19
-
sary and sufficient to produce lasting treatment gains. Thus,
werecommend that future research extend our findings by further
elucidat-ing the role of each treatment component of PCT-A in
reducing adoles-cents’ panic symptoms.
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RECEIVED: 8/18/06REVISED: 11/10/06
ACCEPTED: 11/20/06
doi:10.1300/J019v29n04_01
Micco et al. 23