Clinical Case Studies

http://ccs.sagepub.com/

A Time-Series Study of the Treatment of Panic Disorder

Sara R. Elkins and Todd M. Moore
Clinical Case Studies 2011 10: 3 originally published online 6 December 2010
DOI: 10.1177/1534650110391901

The online version of this article can be found at:

http://ccs.sagepub.com/content/10/1/3

Published by:

http://www.sagepublications.com

Additional services and information for Clinical Case Studies can be found at:

Email Alerts: http://ccs.sagepub.com/cgi/alerts

Subscriptions: http://ccs.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

Citations: http://ccs.sagepub.com/content/10/1/3.refs.html

>> Version of Record - Jan 6, 2011

Proof - Dec 6, 2010

What is This?

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

 Clinical Case Studies

A Time-Series Study 10(1) 3­–22

© The Author(s) 2011
Reprints and permission: http://www.
of the Treatment of sagepub.com/journalsPermissions.nav
DOI: 10.1177/1534650110391901

Panic Disorder http://ccs.sagepub.com

Sara R. Elkins1 and Todd M. Moore1

Abstract
Although efficacy of cognitive-behavioral therapy (CBT) in the treatment of panic disorder has
been well documented, far fewer studies have investigated treatment outcome for panic disorder
among real-world patients with a range of complicating factors. The current study employed
a time-series approach to examine the effectiveness of CBT for panic disorder for a patient
who sought services at a university psychology clinic. Following a 16-session CBT treatment
protocol, the patient demonstrated significant decreases in self-reported distress, anxiety and
panic symptoms, and worry about having a panic attack. Several qualitative changes were also
notable following termination, including decreased tobacco and psychiatric medication usage
as well as decreased comorbid depressive symptoms and agoraphobia behaviors. Outcomes
were maintained 9 months post treatment. This study supports effectiveness of implementing
a CBT approach to the treatment of panic disorder with agoraphobia among complex patients.
Treatment implications and applications are discussed.

Keywords
time-series, panic disorder, agoraphobia, cognitive-behavioral therapy, treatment outcome

1 Theoretical and Research Basis

Panic disorder is a serious condition with 12-month and lifetime prevalence rates of approximately
2.7% and 4.7%, respectively (Kessler, Berglund, Demler, Jin, & Walters, 2005). Panic disorder
with or without agoraphobia can be associated with a number of impairments in important areas of
functioning, including increased risk for physical (Zaubler & Katon, 1996) and emotional health
problems (Andrade, Eaton, & Chilcoat, 1996; Kessler, Stein, & Berglund, 1998; Roy-Byrne &
Katon, 2000); impaired social, relational, and occupational functioning (Altamura, Santini, Salvadori,
& Mundo, 2005); substance abuse (Altamura, Santini, Salvadori, & Mundo, 2005); suicidal behav-
ior (Weissman, Klerman, Markowitz, & Ouellette, 1989); and greater use of medical and psychiat-
ric resources than individuals without panic disorder (Zaubler & Katon, 1998).
Contemporary cognitive-behavioral approaches treat panic disorder using a number of spe-
cific components, including information on panic, relaxation and breathing retraining, cognitive
restructuring, interoceptive and in vivo exposure, and fading of safety behaviors (Margraf, Barlow,
Clark, & Telch, 1993). Efficacy of cognitive-behavioral therapy (CBT) for panic disorder has

1
University of Tennessee, Knoxville, TN

Corresponding Author:
Sara R. Elkins, University of Tennessee, Department of Psychology, Austin Peay Building, Knoxville, TN 37996
Email: ssmith74@utk.edu

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

4 Clinical Case Studies 10(1)

been well documented across a number of independent evaluations. Findings show that CBT for
panic disorder typically produces high panic-free rates (70%-80%, for example, Barlow, Craske,
Cerny, & Klosko, 1989) and that these rates are well maintained over 2-year follow-up intervals
(Craske, Brown, & Barlow, 1991). In contrast, although medication approaches to the treatment
of panic disorder, such as benzodiazepine treatment, have demonstrated comparable acute effi-
cacy, studies have shown that the benefits of treatment decrease once medication is discontinued
(e.g., Ballenger et al., 1988; Pecknold, Swinson, Kuch, & Lewis, 1988; Rickels, Schweizer,
Weiss, & Zavodnick, 1993; Spiegel & Bruce, 1997). In addition, several studies have demon-
strated higher relapse rates among individuals treated with medication alone than those who
received CBT or a combination of CBT and pharmacotherapy (e.g., Gould, Otto, & Pollack,
1995; Roy-Byrne et al., 2005). Moreover, CBT has been shown to be effective even in cases of
individuals who suffer from nocturnal panic attacks and comorbid conditions such as depression
or other anxiety disorders, or when used in studies of discontinuation from high-potency benzo-
diazepines (Brown, Antony, & Barlow, 1995; Craske, Lang, Aikins, & Mystkowski, 2005; Otto,
Pollack, Sachs, Reiter, & Rosenbaum, 1993).
Randomized controlled studies on agoraphobia have also consistently established the efficacy
of CBT for agoraphobia. These studies have shown that after an average of 12 treatments, 69%
of patients demonstrate some level of clinically significant improvement, across a number of
different areas, by posttreatment (Craske, 1999) and at follow-up assessments. For example,
Fava, Zielezny, Savron, and Grandi (1995) demonstrated that only 18.5% of their symptom-free
patients relapsed over a 5- to 7-year period following exposure treatment for agoraphobia.
Although there is much agreement regarding the efficacy of CBT for panic disorder, it can be
argued that the results obtained from efficacy studies cannot be assumed to generalize to other
clinical settings, populations, and treatment providers (Hollon, 1996; Jacobson & Christensen,
1996; Seligman, 1996). Important factors in this distinction include comorbidity and severity of
disorders experienced by clinicians (e.g., extreme agoraphobia that may limit consistent clinic
attendance) but excluded from participation in many randomized controlled trials of CBT for
panic disorder. The effectiveness study method, therefore, adds the additional step of determin-
ing generalizability of the treatment and answers the question “for whom does such treatment
work?” The importance of the effectiveness study method is therefore highlighted in an era of
rising health care costs and declining benefits for patients, as it provides vital knowledge about
individual factors important in treatment and maintenance of treatment gains.
Therefore, the present study will utilize a time-series design (described below) to investigate the
effectiveness of a cognitive behavioral treatment for panic disorder with an adult patient treated in
an outpatient clinic. Although this study does not claim to be a controlled trial of the effectiveness
of CBT for panic disorder, the present article aims to systematically examine this treatment approach
in routine clinical practice. The following treatment outcome hypotheses were considered:

Hypothesis 1: A cognitive-behavioral approach would be effective for the treatment of

panic disorder. At termination, the patient’s five identified symptom clusters—number
of panic attacks, worry about panic attacks, avoidance behaviors, overall anxiety level,
and overall distress—would be decreased relative to before therapy began.
Hypothesis 2: Treatment gains would be maintained at all follow-up sessions.

One additional exploratory hypothesis was considered:

Hypothesis 3: Will decreases in the five measured symptoms (overall distress, average anxi-
ety, worry about panic attacks, number of panic attacks, and avoidance, described below)
occur simultaneously or will changes in one symptom precede changes in other symptoms?

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

Elkins and Moore 5

Although a similar article has been published in this journal demonstrating the effectiveness
of a CBT approach for panic disorder (Murad & Luiselli, 2002), the present study adds complexity
to the previous effectiveness study in significant ways. First, the present study adds the
complexity of time-series statistical analyses that provide additional scrutiny in examining
clinical outcomes. In addition, follow-up data in the present study was collected at 1, 6, 8, and
9 months post treatment as compared to a follow-up period of only 3 months in the Murad and
Luiselli (2002) study, which provides important data related to the long-term benefits and cost
effectiveness of this treatment. Also related to cost effectiveness is the demonstration that this
treatment can be applied successfully across relatively few treatment sessions (16 sessions in our
study as compared to 25 sessions in the Murad and Luiselli [2002] study). These differences
indicate the relative contribution of the current study to the literature on the effectiveness of
CBT for panic disorder among real-world clinical patients.

2 Case Presentation
Anthony (patient’s name has been changed to protect confidentiality) is a 36-year-old White
male who sought therapy at the University of Tennessee Psychological Clinic to treat symptoms
of anxiety and panic attacks.

3 Presenting Complaints
At the time of intake, Anthony reported experiencing a number of panic and anxiety symptoms
as well as agoraphobic behaviors. Typical panic symptoms experienced included racing
thoughts, heart palpitations, sweating, shakiness, shortness of breath, numbness from pelvis to
brain, feeling as if he was losing control, feelings of unreality, hyperattentiveness, a fear of uri-
nation during an attack, and he admits he often lost control of urination during a panic attack.
Anthony’s panic attacks were triggered primarily when riding with someone or driving alone in
his car. Attacks typically de-escalated when he returned home, which he identified as his “safe
place.” Typical attacks lasted between 5 and 30 min, but he also had several experiences where
attacks seemed to last for the better part of a day. Anthony also reported a significant amount of
anticipatory anxiety and agoraphobic avoidance behavior in situations that had triggered attacks
in the past or were similar in some way to situations where he had experienced a past panic
attack. These situations included being in hot rooms or cars, riding in elevators, being in a shop-
ping mall or other crowded place, hiking, camping, waiting in line, riding as a passenger or
driving with a passenger in a car, boating, and watching particularly arousing television pro-
grams (e.g., “Deadliest Catch”).
At intake, Anthony was receiving psychiatric services to treat his panic attacks, but despite
medication, his panic attacks were becoming more frequent and intense. His goals for therapy
were to “deal with attacks to the point I’m no longer thinking of them or scheduling around when
I think they may happen” and “no longer avoid situations for fear of having a panic attack.” He
also hoped to decrease his reliance on medication and make behavioral changes that would pre-
vent the return of panic symptoms.

4 History
Anthony grew up in Knoxville, Tennessee. He was the youngest of four children, and separated
by 8 years to his closest-in-age sibling. He lived within an intact family, although he recalled that
his parents experienced marital difficulties during his childhood and early adolescence (age 9-14).
Anthony performed well in school, maintaining a B average or above for all years of schooling.

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

6 Clinical Case Studies 10(1)

He attended Pellissippi State Community College and earned an associate’s degree in business
management. Anthony maintains a close relationship with his siblings and parents and works in
the construction business with his father. He is active in social activities and has a wide social
support network of family and friends from church and his Boy Scout troop (Anthony serves as
a scoutmaster). Anthony expressed some disappointment that he has not yet found a lifelong
romantic partner, and he expressed a desire to begin dating seriously and start a family.
Anthony experienced his first panic attack in 1992 at the age of 21, triggered by a driving trip
to a church camp where he was scheduled to be a counselor. This attack appeared to be triggered
by anxiety related to his role at the camp (i.e., involving public speaking) and included a number
of cognitive and somatic symptoms (e.g., shortness of breath, heart palpitations, sweating, feel-
ing as if he was losing control, and a fear of dying). He describes the attack as quite severe, with
intense symptoms lasting almost 1 hr. He had only a handful of panic attacks during the next
5 years but experienced a second severe attack at age 26 during a long drive following a fishing
trip to Florida. This attack appeared to come “out of the blue,” and Anthony was unable to pin-
point why panic symptoms arose. For the next 10 years, Anthony’s panic attacks continued to
increase in frequency and severity. In February of 2008, Anthony recalls that the “bottom
dropped out” and he began to have 3 to 4 panic attacks per week, each more severe and frighten-
ing than the last. He described this as a particularly stressful time in his work because of the crisis
within the housing market, and he began to have attacks frequently at work, on the way to job
sites, and during interviews with potential clients.
Anthony had received medication management for panic symptoms since 1999 but reported
only short-term effectiveness in the management of symptoms and noted that symptoms returned
with discontinuation of each medication. Previous medications included Elucibar, Paxil, Prozac,
and Klonopin. At the time of treatment, Anthony was taking Xanax prescribed as needed for
panic symptoms (0.5mg, up to 3 times daily) as well as Effexor for depressive symptoms (75mg,
2 times daily). Additional medical concerns included elevated blood pressure, and Anthony
reported heavy smokeless tobacco use (equivalent to four packs of cigarettes per day) for the last
10 years. He also reported moderate caffeine use (six caffeinated beverages daily). Anthony had
received no prior psychotherapy at any time in his life.

5 Assessment
Baseline Measures

Several measures were provided at baseline to obtain an accurate symptom picture of panic and
agoraphobia as well as to rule out other clinical symptomatology.
Panic symptoms were measured with the Panic Attack Questionnaire–revised (PAQ-R; Cox,
Norton, & Swinson, 1992). The PAQ-R gathers information on the phenomenology of an indi-
vidual’s panic attacks, including family history, onset and frequency, situational triggers, and
coping styles. The measure also instructs individuals to respond to a list of 26 Diagnostic and
statistical manual of mental disorders (DSM) symptoms that address physical and cognitive
aspects of panic. Internal consistency, construct validity, and factor structure have been shown for
this measure (Bouchard, Pelletier, Gauthier, Cote, & Laberge, 1997). Anthony’s responses indi-
cated a family history of panic attacks (brother) and a high frequency and severity of panic symp-
toms (although this measure does not provide a specific score or cutoff). He reported experiencing
approximately 20 panic attacks within the past year, 7 within the past month, and 3 within the
week prior to beginning therapy. Situational triggers listed included traveling, fishing, riding in
vehicles with friends, or situations where it would be difficult to leave if a panic attack occurred.

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

Elkins and Moore 7

In addition to the above-listed, research-based measure, Anthony was administered the Min-
nesota Multiphasic Personality Inventory–2 (MMPI-2) as well as the Anxiety Disorders Inter-
view Schedule (ADIS-IV) Clinical Interview.
The MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) is a self-report
personality assessment designed to evaluate psychopathology and assist with the diagnosis of
mental disorders as well as provide information related to the personality profile of an individual.
The MMPI-2 is composed of 567 true or false items assessing a wide range of clinical pathology
and personality dimensions, and yields validity, clinical, and content scales. The MMPI-2 is
considered the gold standard in personality assessment and has demonstrated moderate to high
internal consistency estimates for validity, clinical, and content scales as well as high test–retest
reliability (Butcher et al., 1989). Anthony’s results produced a valid clinical profile, indicating
that his scores are a good picture of his present level of personality functioning. Although Anthony’s
results on the MMPI-2 did not produce any clinically significant elevations of pathology (≥65),
it is valuable to consider the relative frequency of endorsed dimensions within his personality
profile. His two highest endorsed clinical scales included hysteria (Hy, T-score = 57) and psych-
asthenia (Pt, T-score = 57), indicating a profile with the following descriptors: overcontrolled,
tense, anxious, passive, ingratiating, somatization. This profile suggests a moderate anxiety disor-
der in a psychologically naive individual who is likely to develop hysterical symptomatology in
response to psychological stress. In addition, Anthony’s results indicated a clinically significant
elevation (T-score = 70) for the anxiety content scale, and he endorsed 10 critical items within
this scale.
The ADIS-IV (Di Nardo, Brown, & Barlow, 1994) is a structured clinical interview designed
to evaluate the presence of anxiety disorders and allow differential diagnosis among anxiety
disorders, based on Diagnostic and statistical manual of mental disorders (4th ed., text revision;
DSM-IV-TR; American Psychiatric Association, 2000) criteria. The ADIS-IV has demonstrated
good to excellent reliability for the majority of DSM-IV anxiety categories (Brown, Di Nardo,
Lehman, & Campbell, 2001) and convergent and discriminant validity (Brown, Chorpita, &
Barlow, 1998). Based on his responses on this measure, Anthony met criteria for panic disorder
with agoraphobia.

Diagnosis
Based on the DSM-IV-TR diagnostic system, Anthony met seven of the symptom criteria for a
panic attack (four or more symptoms required for diagnosis), including heart palpitations, sweat-
ing, shakiness, shortness of breath, numbness, feelings of losing control, and derealization. In
addition, he met criteria for panic disorder, characterized by (a) recurrent panic attacks, (b) unex-
pected attacks, (c) at least 1 month of persistent worry about the recurrence of panic symptoms or
consequences associated with exhibiting panic symptoms, and (d) significant behavioral changes
related to the attacks. Anthony also met criteria for agoraphobia, as he repeatedly avoided situa-
tions where he feared having an attack or where he believed escape would be difficult.
Differential diagnosis would suggest one additional diagnostic category to be investigated.
Although Anthony met several of the criteria for social phobia, his avoidance was not limited to
social situations. In fact, Anthony’s panic attacks often occurred when he was alone, therefore he
actively limited his amount of time spent alone, preferring to surround himself with a wide sup-
port network of friends and family. In addition, Anthony reported subclinical depression that did
not meet criteria for diagnosis at that time. However, his reported quantity of nicotine (equivalent
to four packs of cigarettes per day), as well as associated features of tolerance and withdrawal,
indicate he also met criteria for nicotine dependence. Therefore, based on the results from

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

8 Clinical Case Studies 10(1)

baseline measures and self-report provided during the initial intake interview, Anthony met
criteria for the following diagnostic conditions:

Diagnostic code Diagnostic category

Axis I 300.21 Panic disorder with agoraphobia
305.10 Nicotine dependence
Axis II V71.09 None
Axis III Elevated blood pressure
Axis IV Occupational stressors
Axis V GAF Current: 50
Highest past year: 65

It was therefore recommended that Anthony begin individual cognitive behavioral psycho-
therapy to treat panic and agoraphobia symptoms.

6 Case Conceptualization
Studies on the etiology of panic disorder have emphasized a psychobiological conceptualization
of the development of the disorder (Barlow, 2000; Craske, 2003). Genetically, studies have indi-
cated that panic disorder has substantial genetic heterogeneity and that a complex linkage of genes
may participate to confer vulnerability through yet-to-be determined pathways. From a psycho-
logical perspective, the initial panic attack is viewed from a stress-diathesis model, such that the
first attack is prone to occur within a stressful situation (Craske & Barlow, 2007a). Indeed, Anthony’s
initial attack occurred during a trip where he was scheduled to speak in a group setting, and he
endorsed significant anxiety related to this event, displaying a range of cognitive and physiologi-
cal symptoms of panic. According to the psychobiological conceptualization of panic, attacks are
maintained because of the “fear of fear,” or fear of bodily sensations associated with panic, that
develops after the initial attack. This fear is reinforced through interoceptive conditioning (i.e.,
learned anxiety about internal states through aversive associations) and the misappraisal of bodily
sensations as dangerous or catastrophic. In addition, anxiety becomes tied to specific contexts in
which panic attacks have previously occurred or where escape might be difficult, thereby reinforc-
ing avoidance behaviors related to these contexts. Consistent with the theory, Anthony’s attacks
appeared to be maintained by fear that his symptoms were harmful (predicted impending cardiac
problems) and that these attacks would occur while he was in confined spaces or in the presence
of others. These erroneous beliefs contributed to avoidance of malls, restaurants, church meetings,
or any other setting where he would become embarrassed by panic symptoms or escape might be
difficult. His belief about the harmfulness of his symptoms also contributed to his reliance on fast-
acting medication to reduce his symptoms (and use of the medication bottle as a safety signal,
even if he did not consume the medication). As Anthony continued to restrict his social encounters
and other life behaviors, negative cognitions became more frequent and more catastrophic, thereby
strengthening the connection between symptoms and negative outcomes.

7 Course of Treatment and Assessment of Progress

Treatment Measures

The treatment protocol utilized an A-B outcome design with a pretreatment baseline phase, treat-
ment phase, and follow-up phase to test whether treatment gains were maintained.

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

Elkins and Moore 9

At intake, Anthony was administered the Outcome Questionnaire 45.2 (OQ-45.2; Lambert,
Gregersen, & Burlingame, 2004) as a baseline measure of overall distress. The OQ-45.2 is a
45-item measure used to measure patient progress (symptom reduction) in therapy by repeated
administration during the course of treatment, at termination, and at follow-up sessions. Indi-
vidual items measure symptom status across a wide variety of disorders and assess personal and
social factors related to overall quality of life. Several studies report that the OQ-45 is a highly
reliable measure and report high criterion validity with other measures of psychological distress,
interpersonal functioning, and social performance (Lambert et al., 1996; Lambert, Gregersen, &
Burlingame, 2004; Umphress, Lambert, Smart, Barlow, & Clouse, 1997). The OQ-45 has also
demonstrated excellent sensitivity to change during outpatient psychotherapy (Lambert, Okiishi,
Finch, & Johnson, 1998; Vermeersch et al., 2004).
In addition, following the collection of interview data, five questions were developed in
cooperation with Anthony and specified to address his most prevalent reported symptoms.
Anthony was then provided the forms with the five listed questions and he was asked to com-
plete questions once daily. The questions were intended to measure treatment outcome and
were completed by Anthony during the baseline period and throughout the course of treatment,
termination, and follow-up. Questions were based on the DSM-IV-TR criteria for panic disorder
with agoraphobia. The first three questions were measured on a Likert-type scale ranging from
1 (not at all) to 9 (extremely) and included the following:

1. Overall distress (this is a general overall rating of how you felt)

2. Overall level of anxiety
3. Level of worry about having a panic attack

The fourth question was recorded as a discrete number with no top range.

4. How many panic attacks did you experience today? Please list the number of panic
attacks experienced (If one or more panic attacks occurred, please complete a panic
attack record for each attack).

The fifth question required a dichotomous (yes or no) response.

5. Was there a time when you did not do something you wanted to do because of worry
about having a panic attack? If yes, please explain on a separate sheet of paper.

Following a 14-day baseline period of answering daily questions, Anthony began the
treatment phase, which lasted 16 sessions. Anthony returned the daily rating sheets when he
came to the weekly therapy session. The OQ-45.2 was administered monthly during the
treatment phase, at termination, and at four additional follow-up sessions (1, 6, 8, and 9 months;
8 month follow-up session was by patient request). Baseline observations were compared to
observations during the treatment phase as well as observations at follow-up.

Treatment Sessions
The cognitive behavioral treatment approach utilized for the study was based on the Mastery of
Your Anxiety and Panic manual by Craske and Barlow (2007a). This treatment is a well-estab-
lished, evidence-based treatment approach that typically yields high panic-free rates at termination
and at subsequent follow-up visits, as long as 2 years from termination (Barlow, Craske, Cerny, &
Klosko, 1989; Brown & Barlow, 1995; Craske, Brown, & Barlow, 1991; Tsao, Mystkowski,

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

10 Clinical Case Studies 10(1)

Zucker, & Craske, 2002, 2005). Treatment is typically completed in between 12 and 15 sessions,
depending on the patient’s speed of comprehension and implementation of various tasks, level of
avoidance behavior (requiring additional sessions for exposure practices), and the presence of
coexisting disorders. Treatment sessions emphasize five main components, including education on
panic and agoraphobia, coping skills for panic symptoms (breathing retraining, muscle relaxation,
positive visualization), cognitive skills (overestimations, catastrophic cognitions), interoceptive
and in vivo exposure, and consolidation and maintenance of progress. The therapy was delivered
by a clinical psychology doctoral student receiving training in CBT. Therapy was supervised by a
licensed clinical psychologist with training and experience in CBT.
The early stage of treatment involved education about the concepts of anxiety and panic. The
therapist provided a description of the three component system of panic and anxiety (i.e., physi-
cal sensations, thoughts, and behavior) and the difference between symptoms of panic and symp-
toms of anxiety, and decomposed a typical panic sequence with Anthony. The physiology of
panic was discussed and the adaptive function of anxiety was explored. This stage also included
discussion of daily monitoring of symptoms, and Anthony was provided an explanation and
rationale for use of the daily mood record to record symptoms of panic, anxiety, and depression.
He was also encouraged to utilize the panic attack record to aid him in noticing triggers and early
warning signs for his panic attacks, thus making attacks somewhat more predictable.
During the second phase of treatment, Anthony was taught physical coping skills that would
aid him in managing and reducing panic symptoms. A hyperventilation (i.e., overbreathing)
exercise was utilized to induce symptoms similar to a panic attack, and the physiology of over-
breathing and its relation to panic symptoms were discussed. The process of slowed diaphrag-
matic breathing utilizing a one-in-relax-out procedure as well as attention to the breaths was
demonstrated by the therapist and practiced with Anthony in session. Anthony was also instructed
about the practice of progressive muscle relaxation, which helped him to gain better control of
physical tension produced by anxiety and involves deliberately applying tension to one muscle
group at a time and then releasing tension and directing attention to noticing and experiencing
the relaxation of these muscle groups. The final relaxation skill taught was positive visualization
that involved Anthony imagining himself successfully managing and surviving panic symptoms.
The third phase of treatment involved incorporation of cognitive coping skills for managing
and reducing panic symptoms. The therapist and Anthony analyzed current worry thoughts,
overestimations, and catastrophic thinking and discussed how to modify these types of thinking
patterns using analysis, alternative evidence, and prediction testing, as well as learning decatastro-
phizing strategies (e.g., “so what” statements). During this phase of treatment, the therapist also
instructed Anthony in in-session breathing practice with a distracting stimulus as well as applied
breathing practice when experiencing panic symptoms. At the end of this phase of treatment, the
therapist and Anthony established a hierarchy of agoraphobia situations that were ranked in
increasing order of anxiety. Situations avoided included driving, flying, waiting in lines, crowds,
restaurants, being long distances from home, hairdressers, long walks, boats, and elevators.
During the fourth phase of treatment, the techniques of interoceptive exposure and in vivo
exposure were explained, demonstrated, and practiced. This phase began with a period of plan-
ning for interoceptive exposure, which included a rationale for interoceptive exposure and the
benefits of learning new ways of responding to physical sensations. The therapist instructed
Anthony in in-session induction of panic-similar physical sensations and ranked these inductions
based on similarity to those in a real panic attack and amount of anxiety these symptoms pro-
duced. Each exercise was performed until anxiety and fear were decreased to a mild level (2 or
below on a scale from 0 to 8). During between-session practices in this phase, Anthony reported
that he had completed all symptom induction exercises while alone and was concerned that he
would not be able to reduce his anxiety if completing the exercises in front of others. The

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

Elkins and Moore 11

therapist and Anthony discussed including a friend in his induction exercise to determine whether
he would be able to reduce his anxiety, and this was implemented in subsequent between-session
practices. During this phase of treatment, Anthony reported feeling more confident about his
ability to control his panic attacks using physical and cognitive strategies. Finally, the therapist
and Anthony worked together to create a natural activities hierarchy and determine graduated
trials for between-session practices (e.g., hot stuffy rooms, hot stuffy car, camping). It was
explained that the physical sensations might be the same when completing the induction exer-
cises and natural activities exercises but that after repeated practice, his anxiety and fear about
the sensations would start to decrease for the natural activities just as for the induction exercises.
The therapist and Anthony also discussed reasons why panic might recur during treatment, par-
ticularly during symptom induction or in vivo exposure exercises.
In addition to interoceptive exercises, Anthony was also trained in exposure to feared agora-
phobia situations so that he might gain better tolerance of fear and anxiety symptoms. A hierarchy
of agoraphobia situations was created cooperatively with Anthony and practice situations were
initiated between sessions in a graduated fashion. Areas of difficulty and avoidance behavior were
addressed during therapy sessions as well as an analysis of what was learned from exposure prac-
tices. The final portion of the exposure component involved inducing physical sensations during
planned exposure exercises, which emphasized simultaneous exposure to internal and external
cues, in an attempt to prepare Anthony for what will be experienced in situations in the future.
The final phase of treatment involved a review of the main components of treatment, an
evaluation of progress made toward goals, discussion of strategies to maintain goals, and discus-
sion of long-term life goals. Anthony reported a belief that all therapeutic goals had been met,
including reduction of panic and anxiety symptoms, reduction of depressive symptoms (which
was not a target of treatment), and an increase in his participation in previously avoided activi-
ties. Long-term life goals identified included “go on a boating trip to Florida”; “make my busi-
ness successful and hopefully work less”; “find my life partner, get married, and start a family”;
and “go, do, and function without ever having to think about panic.”

Treatment Outcome Results

Tracking of symptom improvement relative to the psychological intervention was conducted
through simulation modeling analysis (SMA; Borckardt, 2008), a time-series analysis program
for short time-series data streams. SMA employs a bootstrapping methodology that enables anal-
ysis of symptom change with a relatively small number of observations per phase and accounts
for the autocorrelation inherently present in temporal research. SMA provides descriptive statis-
tics, Pearson’s correlations, and level change statistics for baseline and treatment phases. Auto-
correlation values for the overall data set (rather than individual values) were utilized in all tests
of level change to determine significance of treatment effects, per SMA recommendations indi-
cating this is the most conservative approach to reduce the Type I error rate (Borckardt, 2008).
Descriptive results examining mean comparisons of daily variables across baseline and treat-
ment phases revealed significant mean differences for each of the five measured variables, such
that levels of distress decreased between baseline and treatment phases (see Table 1). A Bonfer-
roni correction was employed to account for multiple comparisons, and p values ≤ 0.01 were
considered significant. Using this method, all of the measured daily variables remained signifi-
cant except for reported avoidance behaviors. In addition, regression slopes across baseline and
treatment demonstrated decreases for each of the five daily variables, and these trends are visu-
ally represented in Figures 1 to 5.
After controlling for autocorrelation present across time points, overall distress (R = -0.329,
p = .0002), average anxiety (R = -.353, p = .0006), average worry about having a panic attack

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

12 Clinical Case Studies 10(1)

Table 1. Descriptive Statistics and Pearson’s Correlations for Daily Measures

Baseline (n = 16) Treatment (n = 140) Overall (N = 156)

M SD M SD r p
Overall distress 4.56 1.97 2.65 1.63 -.329 .0001
Average anxiety 4.94 2.25 2.57 1.86 -.353 .0001
Average worry about 8.75 0.66 2.64 2.24 -.655 .0001
  having a panic attack
Number of panic attacks 0.31 0.68 0.02 0.19 -.299 .006
Avoidance behaviors 0.25 0.43 0.08 0.27 -.176 .03

I II III IV V
9

8
I. Education
II. Relaxation
7
III. Cognitive Skills
6 IV. Exposure-Interoceptive
Overall Distress

V. Exposure-In Vivo
5

Figure 1. Daily ratings for overall distress across baseline and treatment

(R = -.655, p = .0001), and number of panic attacks (R = -.299, p = .0001) showed statistically
significant decreases between baseline and treatment phases, supporting significant treatment
effects for these variables not because of random error (see Table 2). The only daily mea-
sure that did not meet statistical significance (p = .01) was avoidance behaviors (R = -.176,
p = .0226), though the trend effect was in the expected direction (decreased from baseline to
treatment).
Monthly OQ-45.2 assessments were utilized during baseline, treatment, and follow-up phases.
Although there was an insufficient number of follow-up data points for statistical analysis using
the SMA program, visual analysis of the trend line (see Figure 6) demonstrates a decrease in
overall symptomatology from baseline (score = 63), to termination (score = 32), and last follow-
up visit (score = 14). In addition, effect sizes were calculated for this measure from baseline to
treatment as well as from treatment to follow-up. Findings showed a large effect size from base-
line to treatment (Cohen’s d = 3.10, r = 0.84) and a moderate effect size from treatment to follow-
up phases (Cohen’s d = 1.53, r = 0.61).

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

Elkins and Moore 13

I II III IV V
9

8
I. Education
II. Relaxation
7
III. Cognitive Skills
6 IV. Exposure-Interoceptive
Average Anxiety

V. Exposure-In Vivo
5

Figure 2. Daily ratings for average anxiety across baseline and treatment

I II III IV V
9

8
I. Education
Worry About Having a Panic Attack

II. Relaxation
7
III. Cognitive Skills
6 IV. Exposure-Interoceptive
V. Exposure-In Vivo
5

Figure 3. Daily ratings for worry about panic across baseline and treatment

Cross-lagged correlations were utilized to determine statistical patterns of symptom change

across treatment. Per patient report, the predominant and most negative symptom experienced
was worry about having future panic attacks. This is consistent with target symptom reporting

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

14 Clinical Case Studies 10(1)

I II III IV V
3

I. Education
II. Relaxation
III. Cognitive Skills
Number of Panic Attacks

2 IV. Exposure-Interoceptive
V. Exposure-In Vivo

Figure 4. Daily ratings for number of panic attacks across baseline and treatment

I II III IV V

1
I. Education
II. Relaxation
III. Cognitive Skills
Avoidance Behaviors

IV. Exposure -Interoceptive

V. Exposure -In Vivo

Figure 5. Daily ratings for avoidance behaviors across baseline and treatment

across treatment, as the patient only experienced eight panic attacks throughout baseline and
treatment phases but reported high levels of anticipatory anxiety throughout baseline and much
of the treatment phase. In addition, this symptom exhibited the largest change over time (steepest

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

Elkins and Moore 15

Table 2. Autocorrelations and Level Change From Baseline to Treatment Phases

Overall (N = 156)
Baseline (n = 16) Treatment (n = 140)
Level
Autocorrelation Autocorrelation Autocorrelation change
(Lag-1) p (Lag-1) p (Lag-1) p R p
Overall distress –.213 .288 .611 .0001 .549 .0001 –.329 .0002
Average anxiety .238 .103 .536 .0001 .556 .0001 –.353 .0006
Average worry –.086 .368 .637 .0001 .793 .0001 –.655 .0001
about having
a panic attack
Number of –.148 .351 .395 .0040 .125 .0510 –.299 .0001
panic attacks
Avoidance –.022 .619 .212 .011 .189 .008 –.176 .0226
behaviors

I II
70

60

I. Start of Treatment Period

50
II. Start of Follow-Up Period
OQ-45 Total Score

40

30

20

10

Figure 6. Monthly ratings of overall distress on the OQ-45.2 across baseline, treatment, and follow-up
phases
Note: OQ-45.2 = Outcome Questionnaire 45.2.

slope), and as such, level of worry about having a panic attack was cross-correlated with both
number of attacks experienced and reported avoidance behaviors. Reported levels of overall
distress and average anxiety demonstrated strong cross-correlations with worry about attacks
(distress and worry, r = .75; anxiety and worry, r = .80) and therefore were not cross-correlated
with number of attacks and avoidance behaviors. A range of lags from -5 to +5 was employed,
and a Bonferroni correction was used to adjust for multiple comparisons based on the number of
lags of interest (i.e., -5 to +5 and 1 correlation at lag 0, total of 11 comparisons). Lagged results
for the target symptoms are presented in Figures 7 and 8. As Figure 7 illustrates, for number of

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

16 Clinical Case Studies 10(1)

0.4
0.35 **

Extent of Influence |r|

0.3 **
0.25
**
* *
0.2
0.15
0.1
0.05
0
–5 –4 –3 –2 –1 0 1 2 3 4 5
worry leads # of attacks # of attacks leads worry

Direction and Timing of Influence

Figure 7. Cross-correlational analyses showing direction of temporal relationship of change in number

of attacks with change in level of worry about panic during therapy
*p ≤ .01. **p ≤ .001.

0.35

0.3 * ** ** ** ** **
Extent of Influence |r|

* *
0.25

0.2

0.15

0.1

0.05

0
–5 –4 –3 –2 –1 0 1 2 3 4 5
avoidance leads worry worry leads avoidance

Direction and Timing of Influence

Figure 8. Cross-correlational analyses showing direction of temporal relationship of change in level of

worry about panic with change in avoidance behaviors during therapy
*p ≤ .01. **p ≤ .001.

attacks and worry, significant cross-correlations were obtained at the 0, +1, +2, +4, and +5 lags,
indicating that decreases in number of attacks preceded decreases in level of worry by 1, 2, 4, and
5 weeks. As Figure 8 illustrates, for worry and avoidance behavior, significant cross-correlations
were obtained at the +1, +2, +3, and +5 lags, indicating that decreases in worry preceded decreases
in avoidance behavior by 1, 2, 3, and 5 weeks. However, results also indicate significant correla-
tions at -1and -3 lags, suggesting that at these time points, decreases in avoidance behavior may
also precede decreases in worry about future panic attacks.
Visual examination of Figures 3 to 5 was used to determine which aspects of treatment pre-
ceded the dramatic decreases in number of attacks, worry about future panic attacks, and avoid-
ance behaviors. Examination suggests that the 6-week period of education about panic and

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

Elkins and Moore 17

incorporation of coping skills (relaxation and cognitive skills) was effective for reducing the
patient’s number of panic attacks from five, experienced during baseline, to none, experienced
during these first three components of treatment. This information, combined with results of
cross-lagged correlations, suggests that education and coping skills led to a decrease in number
of attacks, which led to a decrease in worry about attacks and subsequent decrease in avoidance
behaviors. However, results from cross-lagged correlations for worry and avoidance behaviors
also suggest the presence of a possible reverse pattern, where reductions in avoidance behavior
may also fuel further decreases in worry about future attacks. In fact, this pattern is consistent
with Craske and Barlow’s (2007a) treatment conceptualization such that increases in participa-
tion in previously enjoyed activities may lead to increases in competency or feelings of control
about future panic symptoms.

8 Complicating Factors
Anthony’s use of antidepressant and antianxiety medication throughout the course of treatment
may have contributed somewhat to the significant gains achieved during the period of psycho-
therapy intervention. However, Anthony reported decreased use of Xanax to manage anxiety
symptoms during the course of treatment and discontinuation of use entirely at termination and
all subsequent follow-up sessions. In addition, at the 9-month follow-up session, Anthony
reported that his psychiatrist was aiding him in a program to taper off his use of Effexor because
of a significant decrease in depressive symptoms following termination. It may be that the effect
of treatment to reduce panic symptoms, improve management of symptoms, and decrease avoid-
ance behavior led to improved self-efficacy to control panic and anticipatory worry, which
allowed Anthony to reduce coping strategies (medication) no longer perceived as necessary to
manage his anxiety.
A complicating factor related to the interpretation of the results is that although Anthony’s
avoidance behavior decreased over the course of treatment, the decrease did not meet statistical
significance after correcting for multiple comparisons. This result may be related to the pattern
of results for the treatment phase of the study. Specifically, two peaks in avoidance behavior
occurred during the latter portion of treatment (see Figure 5). This finding is not surprising from
a clinical perspective, as later treatment sessions involved interoceptive and in vivo practice of
exposure exercises defined in session. As exposure exercises involve facing physical sensations
and situations that have prompted panic symptoms in the past, such exposure can prompt a return
to avoidance behaviors in an attempt to decrease anxiety. Similar findings have been demon-
strated in theoretical and clinical literature (see Barlow & Craske, 1994; Craske & Barlow,
2007a, 2007b, for review). It is interesting to note that when these two peaks in avoidance behav-
ior were removed from the data stream, we achieved statistical significance for level change
from baseline to treatment phases (R = -0.204, p = 0.0106), thus supporting our conjecture that
treatment gains had been achieved in this area, despite a temporary return of symptoms.

9 Managed Care Considerations

As health care costs in the United States continue to rise, the importance of determining cost
effective forms of mental health treatment steadily grows. The results of the current study sug-
gest that treatment of panic disorder with agoraphobia can be successfully conducted within
more complex clinical populations. In addition, CBT treatments for panic have been routinely
examined in community mental health and medical settings with positive results (Roy-Byrne
et al., 2005; Wade, Treat, & Stuart, 1998) and are becoming more frequently utilized in these
settings with increased focus on providing behavioral health in primary care settings. Typical

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

18 Clinical Case Studies 10(1)

CBT approaches for panic disorder can be completed in as few as 12 sessions and can be modi-
fied to incorporate simultaneous pharmacological treatment if necessary. In addition, the patient
self-help manual can be used to enable the patient continue to process information and prac-
tice techniques between sessions, which may serve to facilitate a faster rate of change and
decrease the likelihood of attrition. Finally, CBT approaches for panic disorder do not require
extensive training in administration and can be tailored to meet the specific symptoms or com-
plicating factors of each patient (e.g., comorbid mental health problems, physical health prob-
lems, severity of symptoms; Craske & Barlow, 2007a).

10 Follow-Up
Following termination, Anthony was contacted for 1-month, 6-month, and 9-month follow-up
sessions during which the therapist and patient discussed maintenance of treatment gains, problem-
solved areas of difficulty, and discussed new achievements made toward goals. During the 8th
month, Anthony contacted the therapist to discuss anxiety and depressive symptoms regarding a
trip his parents (primary support group) planned to take overseas. The therapist met briefly with
Anthony to process and validate his emotions, discuss coping strategies to manage symptoms
(e.g., journaling, maintaining routine, seeking other social support), and offer support and encour-
agement. As noted above, Anthony completed the OQ-45.2 at each follow-up session. Findings
demonstrated a decrease in symptoms from treatment to follow-up sessions with a moderate
effect size (Cohen’s d = 1.53, r = 0.61).
Throughout the follow-up period, Anthony submitted periodic email updates regarding his
progress. Information communicated in these updates indicated that he had not only maintained
treatment gains (no panic symptoms) but had also completed the life goal of accompanying his
father on a boating trip to Florida—a trip the two had not made together in the last 7 years because
of Anthony’s symptoms. Thus, in addition to measurable improvements during the treatment
period, anecdotal evidence supports Anthony’s continued progress toward his long-term goals.
At the final follow-up session 9 months post termination, Anthony provided a description of
the most important parts of treatment that had aided his reduction of symptoms and maintenance
of treatment gains. Specific treatment mechanisms identified included “an increased sense of
control” as a result of improved coping skills and exposure practices which “helped me to face
what I feared.”

11 Treatment Implications of the Case

Overall, the results of the current study indicate that CBT was successful in the reduction of
panic symptoms, worry, and avoidance behaviors for a client diagnosed with panic disorder with
agoraphobia, as well as reductions in other symptoms and behaviors not specifically targeted
during treatment. Specifically, Anthony reported a decrease in depressive symptoms (as mea-
sured by the daily mood record, completed during treatment; beginning of treatment = 4.2, ter-
mination = 1.6 on a scale from 0 to 8) as well as a decrease in smokeless tobacco use (from 2 cans
per day at baseline to less than half a can per day at termination). These findings suggest that
treatment of panic disorder in more complex clinical populations and potentially with complex
patients in other settings (medical, community mental health) may have the added benefit of
reducing comorbid mental health symptoms as well as negative health-related behaviors. In fact,
a simultaneous decrease in depressive symptomatology during the course of treatment for panic
disorder is supported by prior empirical literature (Barlow, Craske, Cerny, & Klosko, 1989;
Telch et al., 1993; Wade, Treat, & Stuart, 1998), although this has been less measured in ran-
domized controlled trials of treatment for panic disorder.

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

Elkins and Moore 19

It is also important to highlight Anthony’s lengthy medication treatment history for panic
symptoms. In medication treatment trials, Anthony might have been classified as “treatment
resistant” because of the continued presence of significant panic symptoms despite 10 years of
medication treatment. Yet, Anthony responded quite well to CBT treatment, which may bring
into question the validity of defining an individual as “treatment resistant” without participation
in a CBT trial. This finding is consistent with other studies demonstrating remittance of panic
symptoms after CBT for individuals who responded poorly to medication treatments (e.g., Heldt
et al., 2003; Otto, Pollack, Penava, & Zucker, 1999; Pollack, Otto, Kaspi, Hammerness, &
Rosenbaum, 1994), as well as sustained benefit of these CBT effects well after discontinuation
of therapy (e.g., Heldt et al., 2006).
In addition to effectiveness of these components of treatment, it is also important to empha-
size the impact of Anthony’s effortful participation in his treatment in reduction of symptoms
and maintenance of progress. In fact, Anthony attended all treatment and follow-up sessions and
completed all in-session and between-session exercises without interruption, factors which are
not the experience of many clinicians. Although this study adds to the existing literature related
to treatment effectiveness, it would be important to test this treatment approach with single-case
designs among those who have additional risk factors (e.g., comorbidity with other psychologi-
cal disorders, low income or other resources, low levels of support), to determine how this treat-
ment approach might impact outcome within these additional constraints.
An important clinical application indicated in the current study relates to the importance of
balancing a manualized approach to treatment with clinical flexibility. For example, although the
typical length of treatment identified by the Mastery of Your Anxiety and Panic manual is
between 12 and 15 treatment sessions and treatment length in the current study was 16 sessions
with four follow-up “booster sessions,” these additional booster sessions were important in
Anthony’s sense of mastery (completed all exposure activities on hierarchy rather than just ini-
tial activities) and maintenance of treatment gains (follow-up sessions were used for review and
problem solving). Clinical flexibility may also be an important factor to consider when applying
this treatment to patients with comorbidity or significant barriers to treatment.

12 Recommendations to Clinicians and Students

Overall, the present case study builds on the existing empirical base supporting the use of
CBT in the treatment of panic disorder and provides an application of this approach using a
single-participant, time-series research design. This study provides important clinical indica-
tions regarding the generalizability of this treatment approach for complex clinical popula-
tions and implies that future research should continue to examine this approach in clinical
practice settings to determine important individual factors that may contribute to treatment
outcome.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication
of this article.

Funding
The author(s) received no financial support for the research and/or authorship of this article.

References
Altamura, A. C., Santini, A., Salvadori, D., & Mundo, E. (2005). Duration of untreated illness in panic
disorder: A poor outcome risk factor? Neuropsychiatric Disease and Treatment, 1, 345-347.

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

20 Clinical Case Studies 10(1)

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.,
text revision). Washington, DC: Author.
Andrade, L., Eaton, W. W., & Chilcoat, H. (1996). Lifetime comorbidity of panic attacks and major depres-
sion in a population-based study. British Journal of Psychiatry, 165, 363-369.
Ballenger, J. C., Burrows, G. D., DuPont, R. L., Lesser, I. M., Noyes, R., Pecknold, J. C., . . . Swinson, R. P.
(1988). Alprazolam in panic disorder and agoraphobia: Results from a multicenter trial. I. Efficacy in
short-term treatment. Archives of General Psychiatry, 45, 413-422.
Barlow, D. H. (2000). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.).
New York, NY: Guilford.
Barlow, D. H., & Craske, M. G. (1994). Mastery of your anxiety and panic (3rd ed.). San Antonio, TX:
Graywind /The Psychological Corporation.
Barlow, D. H., Craske, M. G., Cerny, J. A., & Klosko, J. S. (1989). Behavioral treatment of panic disorder.
Behavior Therapy, 20, 261-282.
Borckardt, J. J. (2008). Time series analysis program for short time series data streams, Version 8.3.3:
User’s guide [Software manual]. Retrieved April 16, 2010, from http://www.clinicalresearcher.org/
SMA_Guide.pdf
Bouchard, S., Pelletier, M. H., Gauthier, J. G., Cote, G., & Laberge, B. (1997). The assessment of panic
using self-report: A comprehensive survey of validated instruments. Journal of Anxiety Disorders, 11,
89-111.
Brown, T. A., Antony, M. M., & Barlow, D. H. (1995). Diagnostic comorbidity in panic disorder: Effect on
treatment outcome and course of comorbid diagnoses following treatment. Journal of Consulting and
Clinical Psychology, 63, 408-418.
Brown, T. A., & Barlow, D. H. (1995). Long-term outcome in cognitive-behavioral treatment of panic dis-
order: Clinical predictors and alternative strategies for assessment. Journal of Consulting and Clinical
Psychology, 63, 754-765.
Brown, T. A., Chorpita, B. F., & Barlow, D. H. (1998). Structural relationships among dimensions of the
DSM-IV anxiety and mood disorders and dimensions of negative affect, positive affect, and autonomic
arousal. Journal of Abnormal Psychology, 107, 179-192.
Brown, T. A., Di Nardo, P. A., Lehman, C. L., & Campbell, L. A. (2001). Reliability of DSM-IV anxiety
and mood disorders: Implications for the classification of emotional disorders. Journal of Abnormal
Psychology, 110, 49-58.
Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaemmer, B. (1989). Minnesota Multi-
phasic Personality Inventory-2 (MMPI-2): Manual for administration and scoring. Minneapolis, MN:
University of Minnesota Press.
Cox, B. J., Norton, G. R., & Swinson, R. P. (1992). The Panic Attack Questionnaire–Revised. Toronto,
Ontario, Canada: Clarke Institute of Psychiatry.
Craske, M. G. (1999). Anxiety disorders: Psychological approaches to theory and treatment. Boulder, CO:
Westview Press.
Craske, M. G. (2003). The origins of phobias and anxiety disorders: Why more women than men? Oxford,
UK: Elsevier.
Craske, M. G., & Barlow, D. H. (2007a). Mastery of your anxiety and panic: Therapist guide (4th ed.).
New York, NY: Oxford University Press.
Craske, M. G., & Barlow, D. H. (2007b). Panic disorder and agoraphobia. In D. H. Barlow (Ed.), Clinical
handbook of psychological disorders (4th ed., pp. 1-64). New York, NY: Guilford.
Craske, M. G., Brown, T. A., & Barlow, D. H. (1991). Behavioral treatment of panic disorder: A two-year
follow-up. Behavior Therapy, 22, 289-304.
Craske, M. G., Lang, A. J., Aikins, D., & Mystkowski, J. (2005). Cognitive behavioral therapy for nocturnal
panic. Behavior Therapy, 36, 43-54.

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

Elkins and Moore 21

Di Nardo, P. A., Brown, T. A., & Barlow, D. H. (1994). Anxiety disorders interview schedule for DSM-IV:
Lifetime version (ADIS-IV-L). San Antonio, TX: Psychological Corporation.
Fava, G. A., Zielezny, M., Savron, G., & Grandi, S. (1995). Long-term effects of behavioral treatment for
panic disorder with agoraphobia. British Journal of Psychiatry, 166, 87-92.
Gould, R. A., Otto, M. W., & Pollack, M. H. (1995). A meta-analysis of treatment outcome for panic dis-
order. Clinical Psychology Review, 15, 819-844.
Heldt, E., Manfro, G. G., Kipper, L., Blaya, C., Isolan, L., & Otto, M. W. (2006). One-year follow up of
pharmacotherapy-resistant patients with panic disorder treated with cognitive-behavior therapy: Out-
come and predictors of remission. Behavior Research and Therapy, 44, 657-665.
Heldt, E., Manfro, G. G., Kipper, L., Blaya, C., Maltz, S., Isolan, L., . . . Otto, M. W. (2003). Treating
medication-resistant panic disorder: Predictors and outcome of cognitive-behavior therapy in a
Brazilian public hospital. Psychotherapy and Psychosomatics, 72, 43-48.
Hollon, S. D. (1996). The efficacy and effectiveness of psychotherapy relative to medications. American
Psychologist, 51, 1025-1030.
Jacobson, N. S., & Christensen, A. (1996). Studying the effectiveness of psychotherapy: How well can
clinical trials do the job? American Psychologist, 51, 1031-1039.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., & Walters, E. E. (2005). Lifetime prevalence and age-of-
onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of
General Psychiatry, 62, 593-602.
Kessler, R. C., Stein, M. B., & Berglund, P. (1998). Social phobia subtypes in the National Comorbidity
Survey. American Journal of Psychiatry, 155, 613-619.
Lambert, M. J., Gregersen, A. T., & Burlingame, G. M. (2004). The Outcome Questionnaire-45. In M. E.
Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment: Vol. 3.
Instruments for adults (3rd ed., pp. 191-234). Mahwah, NJ: Lawrence Erlbaum.
Lambert, M. J., Okiishi, J. C., Finch, A. E., & Johnson, L. D. (1998). Outcome assessment: From conceptu-
alization to implementation. Professional Psychology: Research and Practice, 29, 63-70.
Lambert, M. J., Burlingame, G. M., Umphress, V., Hansen, N. B., Vermeersch, D. A., Clouse, G. C., &
Yanchar, S. C. (1996). The reliability and validity of the outcome questionnaire. Clinical Psychology &
Psychotherapy, 3, 249-258.
Margraf, J., Barlow, D. H., Clark, D. M., & Telch, M. J. (1993). Psychological treatment of panic: Work
in progress on outcome, active ingredients, and follow-up. Behaviour Research and Therapy, 31, 1-8.
Murad, H., & Luiselli, J. K. (2002). Evaluation of a cognitive-behavioral treatment protocol for panic dis-
order. Clinical Case Studies, 1, 122-132.
Otto, M. W., Pollack, M. H., Penava, S. J., & Zucker, G. (1999). Group cognitive-behavior therapy for
patients failing to respond to pharmacotherapy for panic disorder: A clinical case series. Behaviour
Research and Therapy, 37, 763-770.
Otto, M. W., Pollack, M. H., Sachs, G. S., Reiter, S. R., & Rosenbaum, J. F. (1993). Discontinuation of ben-
zodiazepine treatment: Efficacy of cognitive-behavior therapy for clients with panic disorder. American
Journal of Psychiatry, 150, 1485-1490.
Pecknold, J. D., Swinson, R. P., Kuch, K., & Lewis, C. P. (1988). Alprazolam in panic disorder and agoraphobia:
Results from a multicenter trial. III. Discontinuation effects. Archives of General Psychiatry, 45, 429-436.
Pollack, M. H., Otto, M. W., Kaspi, S. P., Hammerness, P. G., & Rosenbaum, J. F., (1994). Cognitive-
behavior therapy for treatment-refractory panic disorder. Journal of Clinical Psychiatry, 55, 200-205.
Rickels, K., Schweizer, E., Weiss, S., & Zavodnick, S. (1993). Maintenance drug treatment for panic dis-
order: II. Short- and long-term outcome after drug taper. Archives of General Psychiatry, 50, 61-68.
Roy-Byrne, P. P., Craske, M. G., Stein, M. B., Sullivan, G., Bystritsky, A., Katon, W. J., . . . Sherbourne, C. D.
(2005). A randomized effectiveness trial of cognitive behavior therapy and medication for primary care
panic disorder. Archives of General Psychiatry, 62, 290-298.

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

22 Clinical Case Studies 10(1)

Roy-Byrne, P. P., & Katon, W. (2000). Anxiety management in the medical setting: Rationale, barriers to
diagnosis and treatment, and proposed solutions. In D. I. Mostofsky & D. L. Barlow (Eds.), The man-
agement of stress and anxiety in medical disorders (pp. 1-15). Needham Heights, MA: Allyn & Bacon.
Seligman, M. E. P. (1996). Science as an ally of practice. American Psychologist, 51, 1072-1079.
Spiegel, D. A., & Bruce, T. J. (1997). Benzodiazepines and exposure-based cognitive behavior therapies
for panic disorder: Conclusions from combined treatment trials. American Journal of Psychiatry, 154,
773-781.
Telch, M. J., Lucas, J. A., Schmidt, N. B., Hanna, H. H., Jaimez, T. L., & Lucas, R. A. (1993). Group
cognitive-behavioral treatment of panic disorder. Behaviour Research and Therapy, 31, 279-287.
Tsao, J. C., Mystkowski, J., Zucker, B., & Craske, M. (2002). Effects of cognitive-behavior therapy for
panic disorder on comorbid conditions: Replication and extension. Behavior Therapy, 33, 493-509.
Tsao, J. C., Mystkowski, J. L., Zucker, B. G., & Craske, M. G. (2005). Impact of cognitive behavioral ther-
apy for panic disorder on comorbidity: A controlled investigation. Behaviour Research and Therapy,
43, 959-970.
Umphress, V. J., Lambert, M. J., Smart, D. W., Barlow, S. H., & Clouse, G. C. (1997). Concurrent and
construct validity of the outcome questionnaire. Journal of Psychoeducational Assessment, 15, 40-55.
Vermeersch, D. A., Whipple, J. L., Lambert, M. J., Hawkins, E. J., Burchfield, C. M., & Okiishi, J. C.
(2004). Outcome questionnaire: Is it sensitive to changes in counseling center clients? Journal of Coun-
seling Psychology, 51, 38-49.
Wade, W. A., Treat, T. A., & Stuart, G. L. (1998). Transporting an empirically supported treatment for
panic disorder to a service clinic setting: A benchmarking strategy. Journal of Consulting and Clinical
Psychology, 66, 231-39
Weissman, M. M., Klerman, G. L., Markowitz, J. S., & Ouellette, R. (1989). Suicidal ideation and suicide
attempts in panic disorder and attacks. New England Journal of Medicine, 321, 1209-1214.
Zaubler, T., & Katon, W. (1996). Panic disorder and medical comorbidity: A review of the medical and
psychiatric literature. Bulletin of the Menninger Clinic, 60(2 Suppl. A), A12-A38.
Zaubler, T., & Katon, W. (1998). Panic disorder in the general medical setting. Journal of Psychosomatic
Research, 44, 25-42.

Bios
Sara R. Elkins, MA, is a doctoral student at the University of Tennessee. Her research interests focus on
internalizing and externalizing problems in childhood and adolescence, parenting practices, and treatment
outcome studies.

Todd M. Moore, PhD, is an assistant professor of psychology at the University of Tennessee. His research
interests and publications focus on intimate partner violence and addiction. He is particularly interested in
research using handheld computers to examine the extent to which the immediate effects of alcohol lead to
partner violence, and to examine the effects of cravings and negative emotions on risk for relapse among
substance abusers.

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011