The Support Group recently had the privilege of hosting Michael. W. Otto, PHD - a world expert on anxiety and affective disorders and cognitive behavioural therapy (CBT). Through the generous support of twelve of the group's pharmaceutical company sponsors, Prof. Otto was flown out to South Africa at the end of February to present three very successful workshops in Johannesburg (at the Johannesburg General Hospital), Pretoria (Weskoppies Hospital) and Cape Town (Tygerburg Hospital). Prof. Otto also gave an hours talk at the public meeting held at the Sandton Library.
Prof. Otto holds the prestigious position of Associate Professor of Psychology at Harvard Medical School. He is also the director of the cognitive behaviour therapy programme at the Massachusetts General Hospital where a lot of ground breaking clinical and behavioural programmes for the treatment of anxiety disorders have been developed. Prof. Otto is a fellow of the American Psychological Association and has published over 100 articles, chapters and books spanning his research interests.
Prof. Otto's workshops in South Africa focused specifically on the use of CBT in the treatment of panic disorder. The presentations were very well attended by South Africa’s mental health professionals. Over 350 people attended the Johannesburg symposium, whilst over 80 people were present at both the Pretoria and Cape Town symposiums respectively. Each full day symposium was broken up into segments.
As an introduction to each symposium, Prof. Otto outlined the unique elements in CBT. CBT tends to be highly structured, skill oriented and time limited. It is also very practical and can be delivered in an individual or group setting with a high cost-benefit ratio. CBT is particularly useful in patients who respond poorly to medication or patients who are discontinuing their medication.
In the first part of his workshop, Prof. Otto discussed the common demographic and diagnostic characteristics of individuals with panic disorder.
In the second segment of his presentation, Prof. Otto discussed the cognitive behavioural model of panic disorder, known as the "fear of fear cycle". When an individual is exposed to a stressor or perceived threat, he/she might develop an alarm reaction, i.e., a panic attack. Although this alarm reaction should be seen as a protective response to danger, when there is no external dangerous event to explain the reaction, attention turns inwards and the individual may misinterpret the alarm reaction as catastrophic warning signs. Some catastrophic cognitions could include: "Am I having a heart attack?", "What if I lose control?", "What if others notice?". These faulty cognitions result in a vigilance to the symptoms, anticipatory anxiety, memories of past episodes and an expectation of catastrophic future episodes. This behaviour, in turn, only results in increased anxiety and somatic sensations which inevitably leads onto another alarm reaction/panic attack. And, thus, the "fear of fear cycle" is perpetuated.
CBT, on its own, targets patterns that maintain panic disorder and provides instruction for the use of these skills in the future. Some issues that could result in CBT being less effective in a patient include those instances when the patient shows poor compliance to the program, has low motivation to do his/her exposure assignments and /or is still on antidepressants or benzodiazapines that prevent the patient from truely conquering the cycle.
Prof. Otto's last segment on the treatment of panic was very practical and involved a detailed presentation of the CBT interventions that are used successfully with panic patients. The treatment elements include an informational component, somatic management skills, cognitive interventions and exposure exercises.
Dr Otto has formulated a 12 session program which can be used in an individual or group setting. In the first three sessions, the patients are presented with practical information on the "fear of fear" cycle and the role of catastrophic cognitions and reactions to somatic sensations. The patients are taught to identify these catastrophic thoughts and how to restructure them so that they are not that terrifying. The patients are also taught diaphragmatic breathing and relaxation skills.
In the next three sessions, the patients are introduced to introceptive exposure exercises. Introceptive exposure is when the patients are purposefully exposed to the somatic sensations of anxiety associated with panic. This is achieved through a variety of exercises such as head rolling (creates anxiety sensation of dizziness), hyperventilation, stair running (results in fast heartbeat), mirror staring (results in sense of depersonalisation often experienced during anxiety) and so on. The aim of the exercises is to get the patients used to these sensations that are associated with panic, so that the likelihood of these sensations triggering panic attacks in the future is decreased. Cognitive restructuring is also continued in conjunction with these activities.
In sessions 7-9, the patients continue with their introceptive exercises, but now naturalistic exposure and in vivo exposure are also introduced. Naturalistic exposure involves exposing the patients to activities that more naturally evoke "panic" sensations (e.g.: normal exercise, riding a merry-go-round). In vivo exposure involves exposing the patients to the real-life situations they prefer to avoid.
Finally, in the last three sessions, emphasis is placed on the naturalistic and in vivo exposure. Patients learn to guide their own treatment through principles they have learnt during their sessions. In essence, they are encouraged to become their own "therapists".
The rationale behind the 12 step programme is that once the patients learn to distinguish the somatic sensations from the fear of imagined catastrophic events, their fear of sensations is markedly decreased. Patients experience only the sensations and not the fear, and thus, they stop having panic episodes and eliminate intensification of any initial anxiety sensations.
Prof Otto also pointed out a number of common errors made in the treatment of panic disorder. Misdiagnosing panic disorder as another anxiety disorder, doing inconsistent or low intensity introceptive exposure with patients, targeting the wrong underlying fear in a patient, teaching inadequate cognitive restructuring and making inappropriate use of breathing and relaxation techniques can all result in poor treatment results.
There are certain factors which make panic disorder a lot more difficult to treat effectively. If a panic patient is also suffering from depression, Obsessive Compulsive Disorder or agoraphobia he/she will be far more difficult to treat. Furthermore, panic patients who also suffer from a personality disorder, particularly Cluster B personality disorders, can be very complicated cases.