Cognitive Behavioural Therapy (CBT) for Panic (with or without Agoraphobia)

Core Components

Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT, and are used in the treatment of a variety of mental health disorders. This therapy recognises the interrelationship between thoughts, beliefs, and behaviours, and how alterations in one domain can impact other domains. CBT therefore identifies, challenges, and modifies dysfunctional cognitive structures, facilitating emotional and behavioural changes.

In the context of panic disorder (PD), CBT aims to equip patients with the techniques to reduce the physical, emotional, and behavioural components of panic attacks. Core components of CBT for PD can therefore include; 1) functional analysis to help develop an individualized vicious circle model, which shows the sequence of events in a panic attack; 2) discussion techniques and behavioural experiments to help patients identify panic-related negative automatic thoughts and images, challenge maladaptive misinterpretations of their body sensations, and change their maintaining strategies; and 3) exposure therapy (e.g. interoceptive exposure) to alter the pathological fear structure by inducing the physical symptoms that are linked with the threat appraisal. CBT can also include skills training to help patients develop healthy stress management/ relaxation techniques.

As part of treatment, patient's complete self-report questionnaires (e.g. panic disorder weekly summary scale) and a daily panic diary to assess the effectiveness of the treatment strategy. CBT also has homework components as these provide opportunities for patients to challenge themselves between sessions, and to generalise the skills learnt to their everyday lives. CBT benefits from a collaborative therapeutic relationship between therapist and patient, as this facilitates achievement of the goals of the intervention (e.g.  identification of problems, learning of relevant skills, and application of learned skills). CBT for PD is time-limited and is typically delivered over a specified period of time.

Fidelity

CBT for PD should be delivered by competent practitioner(s) with ongoing supervision. The intervention should be delivered as per validated manual, and the stipulated content and structure should be adhered to in order to ensure consistency in delivery. Treatment adherence and practitioner competence should be monitored and evaluated using appropriate measures, e.g. via recording of treatment sessions and auditing of recorded sessions.

Modifiable Components

CBT for PD can be delivered as a low or high intensity intervention. These include;

• Individual non-facilitated self-help with no therapist support or with minimal therapist contact (e.g. occasional 5-minute telephone calls)
• Individual guided self-help interventions delivered online (using computers or mobile devices) in formats that include text, video files, audio files, interactive programmes, virtual reality, and CBT applications. There are variations in the duration of input from the therapist with remote delivery of CBT-T interventions aiming to reduce demands on therapist’s time.
• High intensity CBT delivered individually, in weekly sessions of 1-2 hours each, in a total of 7–14 hours, over 4 months.

A stepped approach to care is applied, with low intensity interventions offered for mild to moderate panic disorder, and high intensity interventions offered when there is inadequate response to low-intensity intervention or for moderate to severe panic disorder. CBT can also be offered as brief CBT delivered over about 7 hours, and integrated with structured self-help materials.

CBT can also be delivered as an internet/online intervention (i.e. iCBT), with or without therapist assistance. As iCBT, the techniques taught do not deviate from the CBT protocol. Hence, iCBT components can include cognitive techniques and behavioural elements that include exposure therapy.

Support for Organisation / Practice

Implementation Support

Implementation support is provided mainly by trained supervisors who support the application of CBT within each therapist’s practice. Support for implementing CBT is available through the NES Psychological Interventions and CAMHS workstreams, including webinars, and supervisor training.

Licence Requirements

Licence requirements not confirmed.

Start-up Costs

There are no start-up costs associated with training provided within university training programmes (if training through an NHS place) or by NES. Costs apply when training is provided by private organisations. 

Building Staff Competency

Qualifications Required

Staff will usually hold an undergraduate degree in a relevant area (e.g. nursing, psychology, medicine) and will have completed postgraduate training in CBT (PG Diploma, MSc or Doctoral level).

Training Requirements

Cognitive Behavioural Therapy (CBT) training is included in the adult and child focused MSc CBT/PTPC programmes and the Doctorate in Clinical psychology training programmes in Scotland. Additional training in CBT is available through the NES Psychology Trauma and CAMHS workstreams.

Supervision Requirements

Regular (minimum 1 hour a month) supervision by a supervisor who is a CBT therapist and has completed the following pathway of supervision training:

• NES Generic supervision competences training (GSC) (or equivalent)
• NES Specialist Supervision Training: CBT (adult or child focus)

It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/). There is additional training available that specifically supports CBT supervision skills. 

Theory of Change

The cognitive model suggests that panic disorders can be treated by correcting patients’ maladaptive beliefs about their panic associated somatic sensation. CBT therefore aims to help patients identify their negative misinterpretation of panic associated bodily sensations, generate realistic alternative interpretations of body sensations, and evaluate the validity of the interpretations via discussions and behavioural experiments. These are expected to alter the fear sensation, and result in substantial belief change.  

Research Design & Number of Studies

A number of studies have reported the effectiveness of CBT in the management of panic disorder. Some of the best available evidence include seven meta-analyses that compared the efficacy of psychological interventions for anxiety disorders. The description of studies and outcomes mentioned below have been limited to CBT interventions for PD only or for mixed anxiety disorders when outcomes have not been reported for PD specifically.

Adult Evidence

• The first meta-analysis included, among other analysis, 13 RCTs that evaluated CBT in adults (≥16 years) with panic disorder with or without agoraphobia (van Dis et al, 2020). CBT was delivered in individual, group, or internet treatment formats, however, duration of delivery was not mentioned
• The second meta-analytic study included 12 RCTs (N=584) that evaluated the effectiveness of iCBT in adults (≥18 years) who meet the criteria for panic disorder (Andrews et al, 2018)
• The third study was a network meta-analysis that included, amongst other analysis, 17-18 randomised controlled trials (RCTs) evaluating the effectiveness of CBT in adults with a formal diagnosis of panic disorder with or without agoraphobia (Pompoli et al 2015). CBT was delivered face-to-face in both individual and group formats, delivered over any length of time (including single session)
• The fourth meta-analysis included 30 studies RCTs, cross-over, and cluster randomised trials that evaluated the effectiveness of therapist guided iCBT in 2181 adults (≥18 years) with primary diagnosis of an anxiety disorder (including 8 studies for panic disorder) (Olthuis et al, 2015). Participants engaged with treatment from their homes and therapists were located externally (e.g. primary care settings, community mental health clinics, or private practice clinics). Therapist support was not provided face-to-face
• The fifth meta-analytic study included 51 RCTs that evaluated the effectiveness of individually and group delivered CBT in adults with panic disorder (Bandelow et al, 2015; Bandelow et al, 2018). The psychological therapies in the study were delivered over an average of 12.4 ± 5.5 weeks
• The sixth meta-analysis included 47 controlled studies (N=7725) of psychosocial treatments (including CBT) delivered to adults diagnosed with panic disorder and/or agoraphobia or who had precise description of the condition (Mitte et al, 2005). CBT was delivered over an average of 16.2 hours, however, delivery format was not mentioned
• The seven meta-analysis included 19 RCTs with a total of 832 patients diagnosed with panic disorder with or without agoraphobia (Gould et al, 1995). CBT (vs non-active control comparison) was delivered over 4-15 weeks, however, delivery format was not specified

Adult Outcomes

Outcomes Achieved for iCBT

Compared to control group (including waiting list, no treatment, or placebo control), the following outcomes were observed;

• Significantly reduced anxiety symptoms at post-treatment (Olthuis et al, 2015)
• Significantly reduced severity of panic disorder at post-treatment. Follow-up data specifically for patients with panic disorder was not provided (Andrews et al, 2018)
• Significantly improved quality of life at post-treatment (Olthuis et al, 2015)
• Significantly greater clinically important improvement in anxiety at post-treatment (Olthuis et al, 2015)

Outcomes Achieved for Face-To-Face Delivery or for Unspecified Delivery Format

• Significantly reduced anxiety symptoms (van Dis et al, 2020; Mitte et al, 2005; Bandelow et al, 2015) and depression symptoms at post-treatment (Mitte et al, 2005). Improvement in anxiety symptoms were maintained at 6-12 months follow-up (van Dis et al, 2020), an up to 2 years follow-up (Bandelow et al, 2018)
• Significantly reduced panic frequency at post-treatment, sustained for at least 6 months follow-up (Gould et al, 1995)
• Significantly improved quality of life at post-treatment (Olthuis et al, 2015; Mitte et al, 2005)
• Significantly improved short-term remission and short-term response (i.e. substantial improvement from baseline) (Pompoli et al, 2016). Short-term refers to the period within 6 months of study commencement

Children and Young People (CYP) Evidence

CBT can be delivered to children and young people (CYP) with anxiety disorders. The high comorbidity rates of anxiety disorders in CYP, and the difficulty in establishing differential diagnosis for GAD and other anxiety disorders in very young patients limits the availability of evidence in CYP. Some of the best available evidence include three meta-analytic studies and one RCT. The studies are described below;

• The first meta-analysis included 115 randomized and nonrandomized comparative studies (Wang et al, 2017). The study enrolled 7719 CYP (aged 3-18 years) with confirmed diagnoses of PD, SAD, GAD, specific phobias, or separation anxiety. Participants had a mean age of 9.2 (5.4-16.1) years, and 55.6% were female. CBT was delivered face-to-face to children with varying degrees of parent involvement
• The second meta-analysis included 41 studies with 1806 participants (James et al, 2013). The studies were RCTs, including cross-over trials and cluster-randomised trials, of manualised and documented modular CBT of at least nine sessions, involving direct contact with the child. CBT was delivered individually or in group format, with or without family involvement. Participants were aged 4-19 years, and met the diagnostic criteria for anxiety disorder, including one or more disorders of GAD, over-anxious disorder, social anxiety disorder (SAD), or panic disorder (PD).
• The third meta-analysis included 20 RCTs of cognitive behavioural therapy (CBT) for anxiety disorders (including GAD, PD, social phobia, overanxious disorder) in children and adolescents aged 4-17 years (Ishikawa et al, 2007). CBT was delivered in group or individual formats, with or without family involvement
• The RCT was conducted in USA, and it evaluated the effectiveness of an 8-day intensive CBT (plus 4 weeks of phone contact to supervise continued in-vivo exposure) in 55 adolescents with a primary diagnosis of panic disorder with agoraphobia (Gallo et al, 2012). Participants were aged 12–17 years, majority female (i.e. 60%) and mostly Caucasian (i.e. 85.5%). The delivery format of the intervention was not specified.

CYP Outcomes

Compared to the control group (including waiting list, no treatment), the following outcomes were observed for CBT delivered face-to-face or via unspecified format;

• Significantly reduced anxiety symptoms at post-treatment (Wang et al, 2017; James et al, 2013; Ishikawa et al, 2007), and up to two years follow-up (Ishikawa et al, 2007)
• Significantly greater remission in anxiety diagnosis and treatment response at post-treatment (Wang et al, 2017)
• Significantly reduced frequency of comorbid diagnoses and severity of comorbid diagnoses at post-treatment (Gallo et al, 2012)

Values

Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT. In the context of panic disorder, CBT aims to help patients identify their negative misinterpretation of panic associated bodily sensations, generate realistic alternative interpretations of body sensations, and evaluate the validity of the interpretations. These are intended to reduce the physical, emotional, and behavioural components of panic attacks.

• Does the focus of the intervention align with the requirements of your organisation?

Priorities

CBT identifies, challenges, and modifies dysfunctional cognitive structures, facilitating emotional and behavioural changes. CBT can be used in the management of different anxiety disorders e.g. panic disorder, separation anxiety, social anxiety, specific phobias, and generalised anxiety disorder. CBT can be delivered to children, young people and adults, in individual or group formats, either in-person or remotely (with varying levels of therapist’s assistance).

• In what format will CBT be delivered (in person vs online; individual vs group)?
• What anxiety disorder will this intervention aim to treat?

Existing Initiatives

• Does your service currently deliver interventions to treat panic disorder?
• Are existing initiatives practicable and effective?
• Do existing initiatives fit current and anticipated requirements?

Workforce

Cognitive Behavioural Therapy can be delivered by healthcare professionals (e.g. psychologists, psychiatrists, or mental health nurses) who have undergone training to support its delivery. CBT can be delivered to patients weekly.

• Does your service have qualified practitioners who are available and interested in learning and delivering CBT?
• Can your service support the time commitment required for practitioner training, supervision, and intervention delivery?
• Will your practitioners deliver CBT face-to-face or remotely (including guided self-help CBT)?
• If delivered face-to-face, is there capacity to support its delivery?

Technology Support

Cognitive Behavioural Therapy can be delivered without access to technology but access to video platforms for remote delivery can be useful as is access to methods of recording sessions for supervision.

• Will CBT be delivered in-person or remotely?
• Does your service have the technology to support CBT remote delivery?
• Can your practitioners access technology to record sessions for supervision?

Administrative Support

CBT for panic disorder can be delivered as a low intensity intervention (e.g. non-facilitated self-help intervention, guided self-help intervention), or high intensity intervention (i.e. delivered individually, in weekly sessions of 1-2 hours each, in a total of 7–14 hours). Face-to-face delivery can be held in several settings including community mental health centres, outpatient clinic settings, and hospitals. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.

• In what setting will CBT be delivered?
• Does your service have a venue to deliver CBT sessions?
• Can administrative supports be provided to deliver CBT as a low and high intensity intervention?

Financial Support

Scottish Government/NES Psychology routinely funds training programmes in CBT and supervisor training. Training is available from other organisations at a cost.

• Can your service financially support practitioner training costs if accessed outside NES?

Comparable Population

CBT has been shown to be effective in the treatment of a range of anxiety disorders, including panic disorder, generalised anxiety disorder, social phobia, and co-morbid anxiety disorders. CBT has been delivered to children, young people and adults.

• Is this comparable to the population your service would like to serve?

Desired Outcome

CBT is associated with significant improvements across several outcomes including anxiety, depression, severity of panic disorder, and quality of life.

• Is delivering CBT for the treatment of panic disorders a priority for your organisation?
• Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?