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


Using Acceptance and Commitment Therapy to Guide Exposure Therapy: The Basics

Brian Thompson, PhD, Brian Pilecki, PhD, and Joanne Chan, PsyD
September 17th, 2021 from 12-3pm

This is a beginner workshop intended to provide the foundations of exposure therapy including types of exposure interventions and design effective exposure exercises for various anxiety disorders and OCRDs. Participants will learn how to use ACT processes to guide the implementation of exposure techniques and how ACT processes may be enhanced by traditional exposure methods. This workshop will provide some background in theory and will emphasize applying exposure to clinical contexts using case studies, exposure demonstrations, and the practice of new skills by participants. Read More.


Overcoming Barriers to Effective ACT-Informed Exposure Therapy

Brian Thompson, PhD and Brian Pilecki, PhD
October 15th, 2021 from 12-3pm

This workshop will offer a brief introduction to Acceptance and Commitment Therapy-informed exposure and focus on practical ways to address common problems in implementation. Case examples will be provided to illustrate common client barriers such as lack of buy-in and difficulty grasping core ACT concepts. Strategies for overcoming these barriers will be offered and participants will have the opportunity to practice newly acquired skills through role-plays and break-out rooms.Read More.


An Introduction to Psychedelic-Assisted Psychotherapy for Clinicians

Brian Pilecki, PhD and Jason Luoma, PhD
October 22nd, 2021 from 9am-12:15pm

Psychedelic assisted therapy is emerging as a highly effective form of mental health treatment. This workshop will provide health care professionals an overview of this new clinical area. The workshop will highlight the importance of preparation and integration, as well as how to use a harm reduction approach to provide therapeutic support to clients using psychedelics on their own. The current legal status of psychedelics will be reviewed, including Oregon’s developing a legal psilocybin-assisted therapy program. Finally, diversity issues around lack of access for underserved and non-majority populations will be explored, as well as the prevalence of cultural appropriation and colonialism in modern psychedelic medicine. Read More.


Acceptance & Commitment Therapy – An Experiential & Practical Introduction

Jason Luoma, PhD and Jenna LeJeune, PhD
November 13th and 14th, 2021 from 8:30am-4:30pm
at Milagro Theatre- El Zocalo
This two-day in-person workshop provides a thorough overview of the theory, principles, and techniques of Acceptance and Commitment Therapy. It is intended for those who are relatively new to ACT and for those who have done some reading on their own about ACT but who may not have had the opportunity to participate in more experiential learning, observe models, or receive feedback while using the ACT model. Read More.


Ethical & Legal Considerations in Psychedelic Integration Therapy

Brian Pilecki, PhD and Jason Luoma, PhD
November 19th, 2021 from 9am-11am

There is an increasing demand from clients seeking therapeutic support in their personal use of psychedelics. However, many clinicians interested in psychedelic preparation and integration are unsure as to how to provide these services as psychedelics mostly remain illegal. In this workshop, we will outline legal and ethical frameworks relevant to providing therapy to clients around their personal use of psychedelics, as well as describe how harm reduction approaches are suitable for this developing clinical area. Read More.


De-Mystifying Self-As-Context in ACT: Practical Strategies for Clients

Brian Pilecki, PhD and Kati Lear, PhD
December 3rd, 2021 from 12pm-1:30pm

This workshop will outline how self-as-context can be used to conceptualize commonly discussed topics in therapy such as self-esteem, confidence, identity, and inner conflict. Participants will learn how to flexibly practice practical self-as-context interventions that can be used with clients, as well as have a chance to practice newly learned skills through structured role-play exercises in breakout groups. Read More.


Values in Therapy: An Intro to Working with Values from an ACT Perspective

Jenna LeJeune, PhD
January 21, 2022 from 12pm-2:00pm

This workshop will provide a theoretical and conceptual overview of values from a contextual behavioral science perspective. We will cover the “what”, “why”, “when”, and “how” of values within ACT. While we will also provide an overview of various values exercises and measures that can be used with clients, the emphasis in this workshop will be on providing a foundational framework that will help clinicians approach values work from a functional perspective rather than a primarily technique-focused approach. Read More.



Culturally Responsive Therapy: How to Apply Anti-Racist Values in Session

Christy Tadros, LPCC and RaQuel Neal, LCSW
February 4th, 2022 from 1:30pm-4:45pm
and February 5th from 9:00am-12:00pm

This 2 day 6-hour training will help therapists develop their ability to support clients from a different racial background than them, with a particular focus on Black, Indigenous and People of Color. Through a multicultural social justice framework, it will integrate research and clinical experience to teach a therapeutic model for rapport building, assessment, and treatment. This model is not a rigid therapeutic modality, but provides a contextual lens to build a strong, culturally grounded therapeutic relationship. It is a flexible model and can align with many therapeutic modalities, including a contextual behavioral approach to therapy. Read More.


Truffle Hunting: Bringing Values to Life in the Therapy Room

Jenna LeJeune, PhD
February 25, 2022 from 12pm-2:00pm

This brief workshop is designed to help clinicians deepen their values work with clients by shifting the focus from the content of values conversations to the quality of those conversation. By listening for and deepening the qualities of effective values conversations participants will get a taste for how more experiential and relationally-based values work can supercharge therapy. Participants will have opportunities to both observe demonstrations and practice in small groups with the benefit of feedback. Read More.


Values Prototyping: Using Action to Help Clients Explore Their Values

Jenna LeJeune, PhD
March 18, 2022 from 12pm-2:00pm

This workshop will focus on one specific experiential tool called “values prototyping” that helps clients learn more about their values through engaging in intentional valuing. As participants will hopefully already have a solid foundation of some of the core concepts of the values process in ACT, this workshop will dive right in on how to use values prototyping to help clients learn more about what they would choose to value in their life. You will have the chance to practice developing a values prototype in small groups with the benefit of feedback, so that by the end of the workshop you will be able to use this tool in your work with clients. Read More.


The Invitation to Change Approach: Helping Families Affected by Addiction

Jeff Foote, PhD and Cordelia Kraus, LPC, CADC 1, certified CRAFT clinician
May 13th and 14th, 2022 from 9:00am-5:00pm
at University of Portland, Terrace Room
This two-day in-person workshop will provide skills training for professionals focused on the process of working with clients who have a loved one struggling with substance use issues. The Invitation to Change Approach draws on CRAFT (Community Reinforcement and Family Training), MI (Motivational Interviewing), and ACT (Acceptance and Commitment Therapy) to provide a compassionate and collaborative way of working with the families and concerned significant others of people who struggle with substance use. 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.

October 8th, 2021Psychedelic-Assisted Therapist Training: Current Perspectives and a Look Forward with Dr. Elizabeth Nielson

November 12th, 2021Psychedelic Research: Implications for Palliative Care and End-of-Life Existential Distress with Anthony Bossis, Ph.D.

December 10th, 2021Implementing Culturally-Attuned & Anti-Racist Psychedelic Therapy: Impact over Intention with Jamilah R. George, M.Div., M.S.

January 14th, 2022Psilocybin-Assisted Therapy of Major Depressive Disorder using Acceptance and Commitment Therapy as a Therapeutic Frame with Jordan Sloshower, MD, MSc

February 11th, 2022 – Drug-Drug Interactions Between Psychiatric Medications and MDMA or Psilocybin with Aryan Sarparast, MD