Treating Panic Disorder with Comorbidities: Why Focusing on the Panic May Be the Best Option

Treating Panic Disorder with Comorbidities: Why Focusing on the Panic May Be the Best Option

A common reason psychotherapists give for ignoring research is: “Research studies usually focus on one problem—the people I see often have multiple problems.” Whether this is reason enough to abandon evidence-based practice is debatable. The statement, however, does touch upon a very real concern: how do we choose a treatment focus for clients with multiple problems? The answer to this question isn’t always clear, but it is the responsibility of practitioners to see whether there is research that can guide a decision. In the case of panic disorder, research suggests clients will get the most bang for their buck by focusing on the panic.

A Little About the Study

It’s not a new study—it was published in 2007—but I thought it was really interesting when I originally read it and haven’t had a chance to write about it yet.  The first author is Dr. Michelle Craske, a professor at UCLA, and one of the most renowned anxiety researchers.

In this study, sixty-five people with panic disorder were randomly assigned to one of two groups. Everyone in the study received 12 weekly sessions of a manualized group cognitive behavioral treatment for panic disorder as well as 6 adjunct individual sessions spaced every two weeks. For half the participants, the individual sessions reinforced what was taught in the panic disorder group; for the other half, the individual session provided tailored cognitive behavioral treatment for a co-occurring disorder. The most common co-occurring conditions were major depressive disorder, generalized anxiety disorder, social anxiety, and specific phobia.

The individual sessions were scheduled every two weeks in order to simulate therapist “straying” from treating one condition to another. For example, someone with comorbid depression in the experimental group would receive cognitive behavior therapy for depression in the individual group, whereas someone in the control group would receive additional panic disorder treatment in the individual group. As a consequence, the control group only received panic disorder treatment regardless of comorbidities, and the experimental group received panic disorder treatment and individual sessions targeting a specific comorbidity.

The researchers assessed participants before treatment, post-treatment, and at 6- and 12-months following treatment.

“More of the Same” Wins Out

The results are by no means a slam dunk, but they suggest that people who only received panic disorder treatment did better—both for panic and the comorbid condition—than people who were treated for panic and a comorbid problem. Some of the effects were small, and superiority for panic treatment-only wasn’t across the board; however, the results suggest that not only can focusing on panic disorder result in improvements in comorbid conditions even if the co-morbid conditions aren’t directly addressed, but that it may be a better option than trying to address both. As the authors put it, “the results raise the interesting possibility that staying focused is superior to straying” (p. 1106).

Take Home Message

For therapists who are skeptical that conclusions drawn from research studies are applicable in their own work, this study probably didn’t win anyone over. The attempt at mimicking how an actual therapist would deal with comorbid conditions—devoting a session to it every two weeks—is a little contrived (although very creative!). I can see how someone might dismiss this single study.

My take? Given that panic disorder is one of the most treatable conditions in the research literature, I think this study offers some compelling evidence for treating the panic first. Once clients have learned to manage their panic, other problems may resolve on their own. If any problems remain after successful resolution of panic, then these problems may then be addressed. In a nutshell: for people with panic disorder and co-occurring conditions, it’s probably best to treat the panic first.

UPCOMING TRAINING EVENTS

ACT Precision Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Help You be Focused and Strategic in Your Interventions

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
June 18, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop focuses on helping you use ACT theory & in-session clinical markers to make more precise and strategic interventions. The main goal of this workshop is to help you become more adept at identifying in-session client behaviors that are indicators for particular ACT processes that are likely to be most relevant. The workshop uses a process we call ACT Circuit Training, which involves intensive analysis of a video of an ACT session and intentional practice in conceptualizing client behavior and generating possible ACT responses, followed by discussion and feedback. Read More.


ACT Agility Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Increase Flexible Responding

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
July 16, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop is intended to help therapists be more flexible and nimble in their use of ACT processes, strengthening their ability to fluidly shift as needed between processes within sessions. Therapist learning ACT often develop tunnel vision, focusing too much on particular processes or responding rigidly when more flexibility is needed. Read More.


Therapy and Research in Psychedelic Science (TRIPS) Seminar Series

Second Friday of each month from 12:00 PM – 1:00 PM (PT)

TRIPS is an online seminar series that hosts speakers discussing science-informed presentations and discussions about psychedelics to educate healthcare professionals. This series was created to guide healthcare providers and students preparing to be professionals towards the most relevant, pragmatic, and essential information about psychedelic-assisted therapy, changing legal statuses, and harm reduction approaches in order to better serve clients and communities. This seminar series is a fundraiser for our clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that Portland Psychotherapy investigators are preparing for and starting in the Fall of 2021. All proceeds after presenter remuneration will go to fund this clinical trial. Read more.

June 11th, 2021 Becoming a Psychedelic-Informed Therapist: Toward Developing Your Own Practice with Nathan Gates, M.A., LCPC
September 10th, 2021 – Cultural Considerations in Outreach to and Assessment of Minoritized/Marginalized Individuals in Psychedelic-Assisted Psychotherapy with Terence Ching, Ph.D.