Cognitive-Behavioral Treatment for Panic Disorder:

Current Status

TERRI M. LANDON, MA
DAVID H. BARLOW, PhD

Is cognitive behavioral treatment (CBT) appropriate for panic disorder with or without agoraphobia (PDA) in
children, adolescents, and adults? Are its effects durable? In this review, we survey various psychological
approaches to the treatment of PDA and examine the relative efficacy and clinical utility of each. A growing
body of research demonstrates that CBT is well-tolerated, cost-effective, and produces substantial treatment
gains for individuals with PDA over the short- and long-term. Nevertheless, not everyone benefits and there is
room for improvement among those who do. We address these shortcomings and consider recent developments.
(Journal of Psychiatric Practice 2004;10:211–226)

KEY WORDS: panic disorder, agoraphobia, cognitive-behavioral therapy, Panic Control Treatment, medication, com-
bination treatment, brief therapy, self-directed therapy, computer-assisted therapy, videoconferencing, virtual reality

Patients with panic disorder with or without agorapho-
bia (PDA)* are surprisingly more likely than patients
with other mental disorders to perceive their physical
and emotional health as inferior,1 and consequently uti-
lize healthcare services at three times the rate of most
other patients.2 Furthermore, PDA has a significant
impact on an individual’s ability to work and is associ-
ated with high rates of absenteeism and job loss.3 PDA
is also associated with increased use of antidepres-
sants, increased emergency room visits, reduced time
spent with hobbies and in relationships, and increased
substance abuse.4
History of CBT Approaches for PDA
As late as the 1960s, no psychological treatments had
been proven effective for PDA. In fact, early proponents
of behavior therapy, reflecting the state of knowledge at
that time, were reluctant to ask patients with agora-
phobia to engage in exposure exercises that might
cause anything more than minimal anxiety due to the
possible psychological harm that might ensue. In the
*The treatments reviewed here have generally been applied to
patients with no more than moderate agoraphobia. For more severe
agoraphobia, structured situational exposure exercises are often
added.
late 1960s, therapists began experimenting with facili-
tating exposure to phobic situations and demonstrated
that this strategy worked.4,5 Nevertheless, many
patients, although benefiting from direct in vivo expo-
sure, found themselves suffering from residual anxiety
and panic attacks, albeit with reduced avoidance
behavior. In fact, only 10%–20% of patients receiving
this form of treatment were judged to be “cured,”
although up to 60% showed some benefit, particularly
in reduction of agoraphobic behavior.6
In the 1980s, we turned our attention to directly tar-
geting panic attacks and resulting anxiety using cogni-
tive-behavioral treatment (CBT) approaches.6–9 The
particular variant of CBT developed in our center has
become known as Panic Control Treatment (PCT).10 In
PCT, patients are presented with the concept that the
dimensions of anxiety are grouped into three compo-
nents: physical, cognitive, and behavioral. The physical
component, which consists of somatic sensations that
trigger anxiety about the next possible panic attack,
LANDON and BARLOW: Center for Anxiety and Related Disorders,
Boston University.
Copyright ©2004 Lippincott Williams & Wilkins Inc.
Please send correspondence and reprint requests to: David H.
Barlow, PhD, Center for Anxiety and Related Disorders, Boston
University, 648 Beacon Street, 6th Floor, Boston, MA 02215.

Journal of Psychiatric Practice Vol. 10, No. 4 July 2004 211

 COGNITIVE-BEHAVIORAL TREATMENT FOR PANIC DISORDER
including symptoms of shortness of breath, palpitations,
and light-headedness, is directly addressed in treatment.
The principal means of resolving anxiety associated with
somatic symptoms involves exposing patients to intero-
ceptive sensations similar to these symptoms, which are
re-created in the therapist’s office. The cognitive compo-
nent of PCT works to redress information-processing
excesses or deficits, such as misconceptions, automatic
thoughts, and images and impulses associated with the
over-estimation of danger. For example, panic attacks
often trigger thoughts of dying or losing control. These
information-processing problems are addressed through
the use of cognitive restructuring techniques based on
the work of Beck.11 Finally, the behavioral component
includes modifying the specific emotional behaviors that
people engage in when they are anxious or panicking,
namely, various forms of escape and avoidance. These
responses can be overtly behavioral or representational
(cognitive) and must be prevented to ensure systematic
exposure to both interoceptive and situational cues. CBT
approaches in general have undergone extensive evalua-
tion resulting in substantial empirical support.
Efficacy of CBT for PDA
In two early controlled studies that evaluated CBT
approaches, Klosko et al. compared alprazolam and CBT
to placebo in the treatment of PDA.12 Results indicated
that 87% of patients receiving PCT were panic free by
the end of treatment and this was significantly better
than results with alprazolam (50%), placebo (36%), and
a wait-list control group (33%).13 Clark et al. compared
CBT to applied relaxation and imipramine, as well as a
wait-list control condition.14 Results suggested that CBT
produced a 75% and 76% panic-free status at post-treat-
ment and 12-month follow-up, respectively, compared
with 70% and 48% of the patients treated with
imipramine and 40% and 43% of the patients treated
with applied relaxation. Table 1 presents results from
these and other clinical trials published through 2001
that evaluated CBT for PDA in terms of panic-free sta-
tus, the one measure common to all studies up until that
time, the majority of which used an intent-to-treat
analysis.12,15–29 In most studies in which comparisons
were made, CBT was significantly more effective than
alternative treatments, including alternative psycholog-
ical treatments.29 Moreover, a meta-analysis by Gould
comparing the effectiveness of drugs, CBT, and combined
treatments in 43 controlled studies (using 76 treatment
interventions) published before 1995 found a similar
result.30 Specifically, they reported that CBT yielded the
212 July 2004
highest mean effect sizes (ES), (ES = 0.68). This com-
pared favorably with pharmacological treatments (ES =
0.47) as well as combination drug and CBT treatments
(ES = 0.56). Those studies that combined cognitive
restructuring techniques with interoceptive exposure, as
is the case with PCT, yielded the largest effect size (ES =
0.88). Analysis of results from follow-up investigations,
when available, suggested that patients receiving CBT
approaches were largely successful in maintaining treat-
ment gains.30 As a result of this empirical database, by
the mid-1990s CBT approaches were considered the psy-
chosocial treatment of choice for PDA.27
Subsequent studies have continued to provide empir-
ical support for CBT approaches, when formally com-
pared with alternative psychosocial treatments. For
example, Shear et al. developed an approach termed
Emotion Focused Therapy (EFT) that emphasizes emo-
tionally or interpersonally meaningful triggers for panic
attacks and encourages the patient to monitor panic
attacks and negative emotions that elicit them with the
purpose of learning new coping strategies for dealing
with the emotional response.20 Initial results indicated
relative equivalence of outcomes compared with tradi-
tional CBT approaches (see Table 1). However, a later
more systematic and sophisticated analysis,26 in which
EFT was compared with CBT, imipramine, and pill
placebo, at post-treatment and after 6-months mainte-
nance treatment, suggested that EFT was less effective
for the symptoms of PDA than either CBT or
imipramine, with results similar to those for placebo.
Developmental work on varying psychological
approaches to treating panic disorder continues. For
example, panic-focused psychodynamic psychotherapy
(PFPP) was investigated in an open-trial of 24 sessions
by Milrod et al.31 Seventy-six percent of patients in this
study responded, and these symptomatic gains were
maintained at a 6-month follow-up. Improvements were
also found in quality of life and depression. At our own
Center, Meuret et al. treated 37 patients with a novel
capnometric biofeedback training procedure targeting
carbon dioxide levels. After 5 sessions, 68% were panic-
free and 96% were at least “much improved.”32 These
and other approaches seem promising and warrant
future controlled comparisons to validate efficacy.
Integrated Drug and CBT Approaches
If CBT is effective in treating PDA, can the combination
of CBT and pharmacotherapy further enhance clinical
improvements? Close examination of the literature to
date suggests no clear advantages for the concurrent
Journal of Psychiatric Practice Vol. 10, No. 4
 COGNITIVE-BEHAVIORAL TREATMENT FOR PANIC DISORDER

Table 1. Clinical trials of cognitive-behavioral treatments for panic disorder

Clinical trial Length of Treatment type Treatment comparisons

follow-up (number of patients): % panic free (number of patients) = % panic free

Beck et al. 199215 Post-treatment Cognitive therapy (n = 17): 71% S (n =16) brief supportive therapy = 25%*

Klosko et al. 199012,13† Post-treatment Panic control treatment (PCT, exposure and NS (n = 16) alprazolam = 50%
cognitive restructuring) (n = 15): 87% S (n = 11) pill placebo = 36%
S (n = 15) wait list = 33%

Black et al. 199316 Post-treatment Cognitive therapy (n = 25): 32% S (n = 25) fluvoxamine = 68%
S (n = 25) pill placebo = 20%

Telch et al. 199317 Post-treatment Panic control treatment (PCT, exposure and S (n = 33) delayed treatment control = 30%
cognitive restructuring) (n = 34): 85%

Craske et al. 199518 Post-treatment Cognitive-behavioral therapy (n = 16): 53% S (n = 13) supportive therapy = 8%

Margraf and
Schneider 199119 1 month Cognitive therapy (n = 22): 91% S wait list = 5%

Shear et al. 199420 6 months Cognitive-behavioral therapy (n = 23): 45% NS (n = 20) nonprescriptive treatment = 45%

Newman et al. 199021 12 months Cognitive therapy + medication (n = 24): 87% —

Cognitive therapy, no medication (n = 19): 87%

Ost et al. 199322 12 months Cognitive therapy (n = 19): 89%‡ NS (n = 17) applied relaxation = 74%‡

Clark et al. 199414 12 months Cognitive therapy (n= 23): 76% S (n = 23) applied relaxation = 43%‡
S (n = 18) imipramine = 48%‡

Cote et al. 199423 12 months Cognitive-behavioral therapy (n = 10): 100% —

Cognitive-behavioral therapy with reduced
therapist contact (n = 11): 91%

Barlow et al. 200024 12 months Panic control treatment (PCT, exposure and S (n = 63) PCT + pill placebo = 41%
cognitive restructuring) (n = 77): 31.9% S (n = 24) pill placebo = 13%
S (n = 83) imipramine = 19.7%
S (n = 65) PCT + imipramine = 26.3%

Craske et al. 199125§ 24 months Panic control treatment (PCT, exposure and S (n = 9) applied relaxation = 36%
cognitive restructuring) (n = 15): 81% S (n = 10) PCT + applied relaxation = 43%

Shear et al. 200126** 6 months Cognitive-behavioral therapy (n = 22): 91% S (n = 23) emotion focused therapy = 61%
S (n = 14) imipramine = 100%
S (n = 14) pill placebo = 50%

Source: Modified with permission from Barlow and Lehman 1996,27 © 1996 American Medical Association, all rights reserved.
Key: S = comparison was significant, NS = comparison was not significant, — = comparison not made.
*At8 weeks (the end of supportive therapy), 94% of the psychotherapy patients elected to crossover to 12 weeks of CT; at 1-year follow-up,
87% of the CT group and 79% of the crossover group remained panic-free.
†This study (completer analysis) is the only one in this table that is not intent-to-treat.
‡Percentage of patients who were panic free at follow-up and who had received no additional treatment during the follow-up period.
§Follow-up study of Barlow et al. 198928
**Percentages refer to % of participants who met "responder status;" to be a responder, a patient needed to achieve a score of 2 (much
improved) or better on the Clinical Global Impression Scale (CGI) as a result of study-specific treatment.20,24,26

Journal of Psychiatric Practice Vol. 10, No. 4 July 2004 213

 COGNITIVE-BEHAVIORAL TREATMENT FOR PANIC DISORDER

application of these treatments, especially in the long- Figure 1. Comparison of baseline, acute, and
term, relative to the use of CBT or medication alone.30,33 maintenance treatment for intent-to-
A recent review of published studies that examined treat (ITT) sample (N = 312)
combinations of benzodiazepines and CBT for PDA
found little evidence that the combination was superior Baseline
to CBT alone for most patients, and some studies have Acute
found poorer long-term outcomes for PCT when it has Maintenance
been administered in combination with benzodi-
2.0
azepines.24,34–36 One hypothesis is that fast-acting ben-

Panic Disorder Severity Scale

zodiazepines may interfere with the types of learning

Average Item Score (0–4)

that are most important for psychosocial treatment
1.5
interventions. There may be a benefit in combining
slower-acting antidepressants (e.g., imipramine), sero-
tonergic drugs (e.g., buspirone), and selective serotonin
1.0
reuptake inhibitors (SSRIs) with situational in vivo
exposure treatment30,37 but not with more cognitively
focused therapies that target panic attacks.33
0.5
In the multicenter comparative outcome study con-
ducted by Barlow et al., the combination of PCT plus
imipramine was compared with PCT plus placebo, PCT
0.0
alone, imipramine alone, and a pill placebo.24 The

PCT

Imipramine

Placebo

PCT plus
imipramine

PCT plus
placebo
results indicated that the combined treatment was not
significantly superior to either PCT or imipramine
alone at the acute phase, but shows some advantage at
the end of a 6-month maintenance treatment period
compared with monotherapy (and PCT plus placebo) Adapted with permission from Barlow et al. 200024
© 2000 American Medical Association, all rights reserved.
(Figure 1). However, combined treatment loses its
advantage when the medication is discontinued, with
PCT conditions (PCT alone and PCT + placebo) showing Figure 2. Posttreatment relapse rates* (N = 312)
greater durability (Figure 2). Attempts have been made
to extend this research to patients treated outside
research clinics. One study that examined a private 50
% Relapsed within 6 months

48.3%
practice sample found that concurrent treatment (CBT
plus one of several antipanic drugs) resulted in lower 40
40.0%
relapse rates (14.3%) than medication alone (78.1%) at
the end of 1 year. The median number of CBT sessions 30
was 28, ranging from 12 to 84. This study, however, did
not examine the long-term effectiveness of the integrat- 20
ed treatment and patients were assigned to treatment 16.7% 17.9%
based on their preference.38 10
Turning to sequential combinations, CBT in isolation
has been found to benefit patients who had an initial 0
positive response to pharmacotherapy after discontinu-
PCT plus
imipramine

Imipramine
alone

PCT plus
placebo

PCT alone

ation of benzodiazepine treatment and also to benefit

patients who had an initial poor response to the drug.37
A study by Otto et al. revealed that 76% of patients who
received CBT while benzodiazepines were being tapered
successfully completed discontinuation, in comparison
*Based on Clinical Global Improvement Scale (CGI) for intent-to-fol-
with only 25% of patients who experienced a slow taper low patients 6 months after treatment discontinuation.
alone.39 Spiegel and Bruce reviewed additional data Adapted with permission from Barlow et al. 200024
supporting the ability of CBT techniques to assist © 2000 American Medical Association, all rights reserved.

214 July 2004 Journal of Psychiatric Practice Vol. 10, No. 4

 COGNITIVE-BEHAVIORAL TREATMENT FOR PANIC DISORDER
patients in discontinuing benzodiazepine use. They
found that 6 months following a slow, flexible taper of
alprazolam in 20 patients with PDA, roughly half of the
group that did not receive concurrent CBT therapy
relapsed.40 Furthermore, Schmidt et al. did not find any
apparent immediate or long-term adverse effects of
antidepressant discontinuation in patients with PDA
who received CBT. In this study, when patients with
PDA were randomly assigned to discontinue or not dis-
continue antidepressants at week 8 of a 12-week group
CBT treatment, no differences were found between
groups at post-treatment and 6-month follow-up, sug-
gesting that CBT helps patients discontinue antidepres-
sant treatment for PDA.41 Whittal et al. also found that
outpatients with PDA were able to successfully discon-
tinue SSRI treatment in the context of a structured
group program of CBT, while demonstrating clinical
improvement.42 These results were maintained at 3-
month follow-up, providing further evidence that manu-
alized CBT may be useful in the discontinuation of
pharmacological PDA treatment with benzodiazepines
and SSRIs.
CBT may also alleviate symptoms of panic in patients
whose symptoms do not respond to pharmacothera-
py.39,43–45 Nonresponders to pharmacotherapy have been
treated successfully with CBT both in a group setting
and in individual treatment.39 Conversely, based on
work being conducted by our multi-site team as well as
other researchers, pharmacotherapy may be beneficial
in patients who have an inadequate response to CBT.46
For example, one well-controlled study found that an
adjunctive SSRI (paroxetine) reduced agoraphobic
behavior and discomfort associated with anxiety in
patients who were initially unsuccessfully treated with
CBT alone, suggesting that referral to pharmacothera-
py is an option for non responders to CBT.47 More data
are needed to investigate effective strategies for treat-
ment-resistant patients, and future research should
consider the types of patients that do not benefit and
how CBT can be further improved.
CBT for Children and Adolescents with PDA
Although the existence of PDA in adults is well estab-
lished in the literature, less is known about these disor-
ders and their treatment in children and adolescents.48,49
One key controversy has been whether these phenome-
na even exist in youth. For example, Nelles and Barlow
have argued that few if any children experience sponta-
neous panic attacks, because developmentally they may
not have the cognitive capacity to experience catastroph-
Journal of Psychiatric Practice Vol. 10, No. 4
ic attributions of dying, losing control, or going crazy in
the presence of sensations characteristic of panic.50
However, numerous findings support the conclusion
that panic attacks and PDA occur in adolescence51–55
with reports of 35.9%–63.3% of adolescents in communi-
ty samples experiencing panic attacks in their lifetimes.
There is also some evidence of panic, although occurring
less frequently, in pre-pubertal children. For example,
retrospective reports of adolescents and adults as well as
several clinical case reports with children indicate that
panic and related symptomatology occur in childhood
(see Ollendick et al.49 and Pincus et al.56 for comprehen-
sive reviews). It is generally agreed, however, that most
panic attacks that occur prior to puberty are triggered by
a specific stressor, rather than occurring unexpectedly or
“out of the blue.”57 Thus, treatment studies to date have
focused on addressing PDA in adolescents. In an initial
treatment study by Ollendick using a multiple-baseline
design, four adolescents with PDA were treated using
CBT procedures, such as breathing retraining, cue-con-
trolled and applied relaxation, positive self-instruction
training, cognitive coping strategies, and gradual expo-
sure to uncomfortable sensations and feared situa-
tions.58 After treatment, panic attacks were eliminated,
agoraphobic avoidance was reduced, and related mani-
fest anxiety, fear, and depression were reduced to nor-
mative levels. Gains were maintained at 6-month follow
up. Encouraged by these results, Hoffman and Mattis
developed an age-appropriate adaptation of PCT for
PDA in adolescence. Their article contains a detailed
account of the content of each session.59 Following the
adult PCT protocol, the adolescent version (APCT) aims
to address three aspects of panic attacks and general
anxiety: the cognitive/misinterpretational aspect, the
hyperventilatory response, and conditioned reactions to
physical sensations. The adapted protocol retains the
original content of each adult PCT session, but uses
clear, simplified language, and verbal and visual exam-
ples to illustrate many of the concepts. For example, the
three aspects of panic and anxiety are referred to as
“what you feel,” “what you think,” and “what you do.” A
handout entitled “The Cycle of Panic” was developed to
provide a visual illustration of the interactions among
the three components. Lively examples of concepts such
as anxious apprehension and avoidance are used to con-
solidate the adolescent’s understanding of panic-related
processes. For example, to describe anxious apprehen-
sion, the therapist uses the analogy of a swimmer who
has been warned that a shark has been spotted in the
water. The swimmer who did not receive this alert may
enjoy a relaxed day at the beach, whereas the alerted
July 2004 215
 COGNITIVE-BEHAVIORAL TREATMENT FOR PANIC DISORDER
swimmer is always cautious about the possibility of a
shark. Thus, the main difference between adolescent and
adult treatments is the use of “adolescent-friendly”
materials that are adapted for this population.
Moreover, the first two sessions are longer (90 minutes)
and consist of psychoeducation. Parents are invited to
join the last 10 minutes of four sessions (Session 1, 4, 7,
and 11). During this time, the adolescent is encouraged
to explain the material to his or her parents, and parents
are encouraged to ask questions or discuss progress with
the adolescent and the therapist. Finally, exposures are
framed as hypothesis testing (“let’s predict the future”)
and tailored to the individual adolescent’s feared situa-
tions, whether in vivo or interoceptively-based.
We are in the midst of an NIMH-funded treatment
outcome study evaluating the effectiveness of this pro-
tocol for the treatment of panic disorder in adolescents.
Data collection for 21 adolescents (ages 14–17) has been
completed (12 adolescent completers randomly assigned
to the treatment condition and 9 to the wait-list control
condition). This sample size is fairly high given the cur-
rent consensus that approximately 1% of adolescents
meet DSM-IV criteria for panic disorder.51–55
Furthermore, this is by far the largest controlled treat-
ment outcome study to look at the efficacy of CBT for
PDA in adolescents. Of all participants enrolled, only 2
dropped out, suggesting that the treatment is accept-
able to adolescents. Initial results indicate that 84% of
adolescents (n = 19 analyzed, including the 9 patients on
the wait-list who then went on to receive active treat-
ment) who completed APCT were diagnosis-free at post-
treatment, whereas no adolescents on the wait-list were
diagnosis-free at the post-wait-list assessment. In addi-
tion, adolescents in the treatment group showed signifi-
cantly greater improvement on a number of anxiety
measures than adolescents in the wait-list group.
The Impact of CBT on Comorbidity
Treating PDA effectively in all populations is especially
important given the likelihood that it will co-occur with
other significant problems. Epidemiological studies
have found significant comorbidity between PDA and
many medical and mental disorders.60 Although find-
ings from studies estimating the co-occurrence of PDA
with personality disorders and depression are equivocal
(reviews have reported that between 35%–95% of
patients with PDA meet criteria for an Axis II personal-
ity disorder, depending on the type of measure used,
some with questionable validity,61,62 and one-half to two-
thirds of patients with PDA report past or present major
216 July 2004
depression63,64), it is clear that comorbid anxiety disor-
ders are particularly common. For example, Brown and
Barlow found generalized anxiety disorder to be the
most prevalent comorbid condition with PDA, occurring
at a rate of 32.5%.65,66 Tsao et al. found that social pho-
bia and specific phobias also commonly co-occur with
PDA.67 Fortunately, results of treatment studies, both
with medication and psychosocial treatment, suggest
that current therapies for PDA relieve symptoms and
also restore quality of life.11 CBT for PDA has also been
found to reduce the number and severity of additional
diagnoses for which patients meet criteria post-treat-
ment, and these improvements are sustained at a 6-
month follow-up.33,67 More recent research has
demonstrated that CBT for PDA has beneficial effects
on patients’ physical health status, resulting in positive
reductions in nonpsychiatric medical symptoms during
treatment and 6 months later.68
From Research to Clinic: Applicability of CBT in
Practice
Although controlled studies have demonstrated the effi-
cacy of CBT approaches for PDA in research clinics,
questions have been raised about the applicability of
these approaches in actual clinical practice. Studies
have now appeared evaluating CBT approaches in dif-
ferent service settings. For example, Wade et al. exam-
ined the transportability of CBT for PDA to a
community mental health center (CMHC) setting using
a benchmarking strategy.69 They conducted a point-by-
point comparison of the treatment outcome data
obtained in their clinical service setting with outcome
data obtained in two research clinics (i.e., the bench-
mark). Patients, who were selected without exclusionary
criteria, participated in PCT that involved a 15-session
group treatment protocol described in the Mastery of
Your Anxiety and Panic (MAP) manual.70 Participants
were expected to complete daily self-monitoring, weekly
readings in the client MAP manual, diaphragm breath-
ing exercises, thought identifications and modifications,
and exposure to internal and situational anxiety-pro-
voking cues. The treatment was conducted by psycholo-
gists and trained master’s-level clinicians self-selected
from the CMHC adult outpatient staff. Session 1 of the
protocol was conducted individually for each partici-
pant, and significant others (e.g. spouses, parents) were
encouraged to attend. Sessions 2–14 of the treatment
consisted of weekly, 90-minute group sessions, with the
option of receiving concurrent individual sessions (60
minutes) after session 9. Patients with agoraphobia
Journal of Psychiatric Practice Vol. 10, No. 4
 COGNITIVE-BEHAVIORAL TREATMENT FOR PANIC DISORDER
were also given the option of receiving a 2-session mod-
ule on agoraphobic exposure. Those who declined these
optional sessions received 12–13 sessions. Results
showed that CMHC treatment completers improved on
virtually every measure of functioning, and the magni-
tude of these improvements was comparable to those of
the improvements reported in the controlled efficacy
studies of Barlow et al.28 and Telch et al.17 For example,
the proportion of patients reporting panic-free status
increased from 18.2% pretreatment to 87.2% post-treat-
ment, in the Wade et al. study compared with 29.4% pre-
treatment and 85.3% post-treatment in the Telch et al.
study and 15.4% pretreatment and 84.6% post-treat-
ment in the Barlow et al. study. The percentages of
patients achieving normative functioning posttreatment
on measures of panic, anticipatory anxiety, and depres-
sion were found to be similar in the CMHC and the
benchmark samples. Of the CMHC patients who were
contacted at 1 year follow-up (70% of the sample), 89%
were panic free and remained at normative levels of
functioning, an outcome comparable to those seen in
more controlled research settings.71 A study conducted
by Garcia-Palacios et al. used a similar benchmarking
strategy to directly compare outcomes of CBT for PDA
in a research center (university clinic) and a public men-
tal healthcare unit.72 The patients in both settings
received 14 (1.5 hour) weekly group sessions of CBT (an
adaptation of PCT). Specifically, this program included
an educational component, non-focused cognitive thera-
py (cognitive identification and discussion of automatic
thoughts in general situations that produce discomfort),
focused cognitive therapy (identification of these
thoughts in panic-agoraphobia situations), training in
slow-breathing techniques, training in distraction tech-
niques, exposure to internal and external stimuli that
are avoided by the patients, and relapse prevention. A
series of self-help manuals was also used as support for
each one of the components of the therapy. Those attend-
ing the public mental health center were referred by
their doctor and treated by the clinical psychologist
attached to this unit and the patients attending the
university clinic were treated by therapists at the
research center (clinical psychologists trained in CBT).
Both settings also involved co-therapists who were stu-
dents beginning their clinical training. Results indicat-
ed that the patients treated in the public mental
healthcare unit showed significant improvement on all
of the variables analyzed, including panic-free status,
anticipatory anxiety, agoraphobic avoidance, and
depression. The percentage of patients meeting clinical-
ly-significant change criteria at the public mental
Journal of Psychiatric Practice Vol. 10, No. 4
health center was similar to that obtained in the sample
who went to the university to receive treatment.
Moreover, the improvement at the public health center
was comparable to the improvement obtained in con-
trolled studies (e.g., Barlow et al.,28 Clark et al.,14 Telch
et al.17) and in the study in a CMHC by Wade et al.69
described above. The results suggest that CBT for PDA
is generalizable and a viable treatment for use in com-
munity mental health settings.
Further data on the effectiveness of CBT for PDA in
actual clinical practice was provided by Penava et al.,
who investigated the rate of symptom improvement in
patients receiving group CBT treatment in an outpa-
tient clinic setting.73 Treatment was a standard pro-
gram of 12 sessions that emphasized all the major
elements of PCT. Patients achieved significant treat-
ment gains on all of the PDA dimensions that were
assessed. The rate of improvement was also closely
examined, and results showed that the largest reduction
in symptoms occurred during the first third of the treat-
ment program, although there was evidence of contin-
ued symptom improvement across the full course of
treatment.
CBT for PDA has also been evaluated in primary care
settings. This is important because most patients with
PDA have their initial contact with the healthcare sys-
tem in a primary care setting, with only 35% of patients
receiving their first contact in mental health care set-
tings.74 With these facts in mind, Craske et al. studied
an adaptation of PCT for a primary care setting that
combines CBT and medications.75 The researchers
examined the acceptability of this intervention to pri-
mary care physicians and patients. Their collaborative
care model involves a therapist (behavioral health spe-
cialist), psychopharmacologist, and primary care physi-
cian who work together to coordinate the patient’s care.
Specifically, six visits were provided with the behavioral
health specialist in the primary care clinic over the
course of 3 months, with six follow-up phone contacts
over the subsequent 12 months. The CBT consisted of an
abridged version of Panic Control Treatment (PCT),
with psychoeducation, breathing retraining, cognitive
restructuring, interoceptive and in vivo exposure com-
ponents, and relapse prevention. The six phone contacts
following the in-session visits were 15-minutes in
length, reinforced the relapse prevention plan, allowed
ongoing symptom monitoring, and facilitated psychi-
atric consultation. This treatment was coordinated with
medication management since the behavioral health
specialists communicated with psychiatrists after each
patient visit. The psychiatrists then used information
July 2004 217
 COGNITIVE-BEHAVIORAL TREATMENT FOR PANIC DISORDER
gathered by these therapists to make medication rec-
ommendations that were relayed to the primary care
physicians along with updates on patient progress.
Whenever complex situations arose, direct communica-
tion was initiated between the psychiatrist and the pri-
mary care physician, or occasionally (10%–15% of the
time) between psychiatrists and patients. Psychiatrists
also advised behavioral health specialists about strate-
gies for managing medication side effects, providing
information to be conveyed to patients. The majority
(73.7%) of patients who initiated treatment completed
it, suggesting that treatment for PDA can be successful-
ly carried out in a general medical setting, such as a
hospital or clinic, although outcomes from this ongoing
study have yet to be reported. The relatively high rate of
completion does, however, support the suggestion made
by other researchers that some patients are more likely
to accept mental health treatment when offered in the
primary care setting.76
Sharp and Power also demonstrated that patients
with PDA can be successfully treated with CBT in their
local general practice health center or surgery.77 In this
study, patients were seen for 9 sessions (30–60 minutes)
over 13 weeks and received CBT based on a written
treatment manual.10 Treatment emphasized the impor-
tance of patients confronting their panic attacks, within
the context of exposure outings if necessary, and
attempting to replace behavioral and cognitive avoid-
ances with more approach centered actions. Patients
receiving medication received 1 week of single-blind
placebo followed by 12 weeks of either fluvoxamine or
placebo and the CBT protocol. The largest treatment
gains, in terms of acute global ratings of clinical
improvement, were shown by the groups who received
CBT alone or combined CBT and fluvoxamine.77
Further data supporting the generalizability of CBT
to real-world clinical settings can be found in studies of
patients with PDA from diverse backgrounds. For exam-
ple, Heldt et al. examined outcomes of CBT with
patients in a Brazilian public hospital who had failed to
respond to pharmacotherapy.78 Treatment in this set-
ting using a 12-week CBT protocol (psychoeducation,
diaphragmatic breathing, muscle relaxation, cognitive
restructuring, interoceptive and in vivo exposure,
relapse prevention) was delivered over 4 months by two
experienced therapists. The program was associated
with significant reductions in symptom severity on all
outcome measures: specifically, 81% of patients were
panic-free after treatment, while 68% and 47% of
patients showed a 50% reduction in agoraphobic avoid-
ance and anticipatory anxiety, respectively.78 Sanderson
218 July 2004
et al. also examined the generalizability of 12-session
manual-driven CBT70 for PDA in an ethnically diverse
population.79 The sample was 30 patients (53%
Hispanic, 43% Caucasian, and 3% African-American)
who received outpatient treatment at an urban medical
center in New York and were treated by clinical psy-
chology interns. These investigators found that 50% of
patients were panic-free post-treatment (80% of
patients experienced no more than one panic attack dur-
ing the final week of treatment, compared to more fre-
quent panic attacks at pre-treatment) and that
significant reductions were obtained on all other meas-
ures of improvement. There were no significant effects
for race on measures of anxiety and depression when
the Hispanic and Caucasian groups were compared,
indicating that the treatment was equally effective for
both groups. Although the panic-free status found in
this study was lower than that found in other studies
(e.g. 85% in Barlow et al. 198928), the authors note that
their sample had a higher frequency of panic attacks at
pre-treatment and thus more panic attacks had to be
eliminated to reach panic-free status.79 It is not clear
whether SES, pre-treatment severity, or both had an
impact on rates of response in this study. However,
patients in this study had an equivalent treatment
response to those treated in Barlow’s clinic, as measured
by reductions in anxiety, depression, and frequency of
panic attacks. Sanderson et al. noted that their results
may have been influenced by the fact that the study was
conducted in a non-research setting. The authors also
suggested that an additional explanation for the
reduced panic-free status found with this sample may
be the potential presence of psychosocial stressors
among patients from lower socioeconomic backgrounds
who seek out services in urban medical centers.
Although psychosocial stressors were not examined,
Sanderson et al. suggested that it is possible that
patient response would increase if treatment were
broadened to address life stressors. Although it is diffi-
cult to draw general conclusions, available evidence
indicates CBT for PDA is transportable to various clini-
cally representative settings and that the findings are
comparable with outcome data achieved in clinical
research centers.
Cost Effectiveness, Dissemination, and
Innovations in CBT
The treatment outcome data make a compelling case
that effective treatment of PDA can decrease therapy
costs and increase quality of life.66 Otto et al. conducted
Journal of Psychiatric Practice Vol. 10, No. 4
 COGNITIVE-BEHAVIORAL TREATMENT FOR PANIC DISORDER
a cost-analysis of actual billable rates for CBT and
pharmacologic treatments in their clinic.80 They found
that, over the course of 1 year, group CBT emerged as the
lowest cost treatment, with a total annual visit cost of
$523, followed by pharmacotherapy visit costs of $884,
and individual CBT visit costs of $1,357. However, when
medication costs ($1,395) were added to the costs of
pharmacotherapy sessions, pharmacotherapy averaged
$2,305, emerging as the most expensive treatment.80
Despite the demonstrated efficacy and favorable cost
profile of CBT for PDA, most patients treated in clinical
practice settings do not receive it.81,82 Specifically, as few
as 10%–15% of patients with panic disorder actually
receive CBT for PDA.83–87 Many patients receive med-
ication treatment long before psychosocial treatment is
considered.80 According to a 1991 Consensus Statement
from the National Institutes of Health, barriers such as
accessibility often prevent panic sufferers from taking
advantage of effective cognitive-behavioral intervention
techniques.88 This may be because physicians and the
general public have limited knowledge of the nature and
benefits of cognitive-behavioral therapies.89 Most
patients with PDA have their first contact with a
healthcare professional in general medical practice and
almost half of the patients are then treated in that set-
ting.90 Forty-three percent of patients with PDA are
first seen by an emergency room (ER) physician, and
26% of patients go on to receive care from a mental
health professional in the ER, primarily from psychia-
trists. This suggests that ER physicians could genuine-
ly benefit from education about effective treatments for
PDA.74 Alternative approaches to dissemination may be
especially vital to panic sufferers who are seen in set-
tings where traditional forms of treatment are not
immediately available. An interesting study found that
simple exposure assignments given to PDA patients
presenting to an ER resulted in significant improve-
ments that were not shared by patients who received
reassurance alone.91
A further barrier to dissemination seems to exist at
the graduate training level for psychologists. A survey of
APA-accredited doctoral programs in clinical psychology
in North America done by the Task Force on Promotion
and Dissemination of Psychological Procedures demon-
strated that more than one-fifth of the programs did not
teach anything about 75% or more of the evidence-based
treatments listed by the Task Force, the majority of
which are cognitive-behavioral interventions.92 It is not
yet clear whether this situation has improved during
the last decade, although interest seems to be increas-
ing. There is no reason to believe that psychiatric resi-
Journal of Psychiatric Practice Vol. 10, No. 4
dencies fare any better. Wilson suggested that cognitive-
behavioral therapists must do more to encourage dis-
semination, for example, by providing improved
treatment manuals that are more “therapist friendly”
and protocols that provide better practical guidelines
and address more of the common clinical difficulties
that practitioners encounter.82 Huppert and Baker-
Morisette offer such practical guidelines in their “insid-
er’s guide” to panic control treatment, which makes
user-friendly suggestions for therapists who are using
the MAP therapist guide.10,93 Calhoun et al. also offer a
set of seven guidelines for training clinical psychologists
in empirically supported treatments. Their recommen-
dations for training can be applied differentially at the
predoctoral, internship, postdoctoral, and continuing
education levels.94 A promising new way of improving
dissemination may also be to provide treatments that
are shorter and more accessible and that incorporate
technological innovations.27,81
In order for patients to make a choice between these
highly effective (but underutilized) treatment options,
CBT needs to be more available in a variety of locales,
and disseminated effectively to a variety of provi-
ders.80–89 Innovations in the treatment of PDA with
CBT include briefer versions of therapy for PDA, self-
directed treatments, and computer and virtual reality
applications which may further lower cost and increase
access.95–98 Initial attempts to test the effectiveness of
briefer versions of PCT have demonstrated success.
Craske et al. compared a four-session PCT protocol with
a four-session nondirective supportive psychotherapy
(NST) protocol.18 The PCT protocol consisted of one ses-
sion each of psychoeducation, cognitive restructuring,
and interoceptive exposure; the fourth session reviewed
the concepts and skills that had been introduced during
the preceding three sessions. Participants were given
written summaries of each session and were assigned
between-session practices of these skills. NST consisted
of one session of psychoeducation and three sessions of
non-directive discussion of panic and anxiety symptoms
with a psychiatrist. The brief PCT was found to be sig-
nificantly more effective than nondirective supportive
psychotherapy on measures of panic frequency, degree
of worry about panic, and level of phobic fear, but the
authors noted that the outcome was less than what is
typically achieved from 12–16 weeks of CBT. Botella
and Garcia-Palacios determined that CBT is still an
effective treatment for PDA when therapist contact is
reduced and the length of therapy is shortened.99 They
found that a reduced therapist contact program sup-
ported by self-help materials produced significant
July 2004 219
 COGNITIVE-BEHAVIORAL TREATMENT FOR PANIC DISORDER
improvements at 12-month follow-up and outcomes
were similar to those obtained in a standard CBT pro-
gram. Stein et al. found that 80% of patients receiving
very brief CBT, administered in one initial 45-minute
session and one subsequent 30-minute session, plus an
SSRI (paroxetine) were panic-free when compared with
25% who received this very brief CBT treatment plus a
placebo. This would suggest that a total of 75 minutes of
CBT is not sufficient.100 The CBT sessions in this study
were delivered at weeks 5 and 7, out of 10 weekly ses-
sions. During the first very brief treatment session, a
self-help book, titled “Coping with Panic,” was provided
along with a relaxation tape and instructions for daily
reading and relaxation practice.101,102 The therapist
focused on the symptoms experienced during panic
attacks and coping strategies such as cognitive restruc-
turing and breathing control. Participants kept a diary
of relaxation practice and time spent reading the self-
help book. At week 7, the reading assignment, coping
strategies, and relaxation practices were discussed, with
encouragement to continue work in these areas. Graded
exposure assignments were planned with the goal of
overcoming phobic avoidance of external situations and
bodily sensations related to panic episodes.
If shorter treatments do work, it would be helpful to
clinicians to know which elements of the treatment
approach appear to be less important. Unfortunately, we
do not yet know the precise mechanisms of action of
CBT; the treatment may work through several different
avenues that need to be elucidated by more comprehen-
sive research.
Self-directed treatment, an intervention that does not
require the presence of a therapist, is an accessible and
possibly effective alternative to professionally delivered
psychological treatment, at least for some patients. The
long history of excellent results with manual-driven self-
help behavioral treatment provides a precedent for self-
directed PCT. There is growing evidence that CBT
presented via a self-help manual may be a viable
approach for treating PDA, at least for patients with less
severe symptoms. Several studies have found that a
manual alone is as effective as eight sessions of group or
individual CBT.102,103 Hecker et al. compared self- and
therapist-directed approaches to utilizing the MAP
Manual10 over 12 weeks in 16 patients with PDA.104 In
the self-directed condition, clients were instructed to
work through the workbook on their own. In week 1,
they were given the workbook, general instructions
about its use, and assigned the first four chapters. In
weeks 4 and 8 they met with their therapists who
answered questions about the material covered so far,
220 July 2004
provided an overview of the next set of readings, and
assigned these chapters. No therapeutic interventions
were delivered during these meetings. Participants were
asked to mail in the self-assessment questions from each
chapter when they completed them. In the therapist-
directed treatment, clients met with therapists (a
licensed psychologist and three graduate students in
clinical psychology) for 12 weekly sessions during which
the therapist and client worked through the material
covered in the MAP workbook. The authors found that
participants in both conditions improved with treatment
and maintained their gains at 6-month follow up, with
40% of self-directed and 28.6% of therapist-directed par-
ticipants meeting conservative criteria for high end-
state functioning. To explain this surprising finding,
Hecker et al. suggested that perhaps the self-directed
intervention used in the present study was not truly self-
directed, since the clients met with their therapists on
four occasions. They also note that there was a high rate
of dropout (38%) in the self-directed condition (0% in the
therapist-directed condition), indicating that the sample
size was reduced and the equivalence found for the two
treatments may have been due to low statistical power.
Researchers are beginning to demonstrate that self-
help for PDA can be enhanced by the use of a comput-
er. Kenwright et al. compared pre- and post-treatment
ratings of patients who had six sessions of computer
guided self-help using cognitive-behavioral principles
(from a system called Fear Fighter) with those of out-
patients with somewhat more severe phobia/panic who
received the same treatment guided by a clinician.105
The Fear Fighter system was located at a self-care cen-
ter run by two clinical nurse specialists. Patients were
introduced to the Fear Fighter system and shown how
to use it, including how to print out information along
with homework diaries and graphs of progress to take
home. The system teaches information in nine steps,
which basically consist of the rationale for self-expo-
sure therapy, instructions for recruitment of a “co-ther-
apist,” identification of triggers for panic, suggestions
for individualized exposures, and advice on coping
strategies to remain in panic-evoking situations. At
each visit to the center, patients spent the first 10 min-
utes with the nurse, reviewing progress and exposure
homework. For the next 40 minutes, they worked on the
computer, and they then spent the final 10 minutes
with the nurse discussing further homework, solving
problems, and setting up the next appointment. An
intent-to-treat analysis demonstrated that both groups
showed comparable improvement. Computer-guided
patients spent 86% less time with a clinician than did
Journal of Psychiatric Practice Vol. 10, No. 4
 COGNITIVE-BEHAVIORAL TREATMENT FOR PANIC DISORDER
clinician-guided patients, who had no access to the com-
puter system.105
Klein and Richards took the use of computers a step
further. They compared an Internet-based self-help
treatment program that incorporated principles of cog-
nitive therapy via two modules (psychoeducation about
PDA, explaining errors in thinking) with a self-monitor-
ing control condition.106 The Internet-based program
was placed on the website of a university where partici-
pants could access it with a password. The program
involved the use of color, animation, hyperlinks, and
self-assessment quizzes that provided immediate feed-
back. It consisted of two modules that contained infor-
mation about the nature of panic and the causes of
panic and its effects. The study took place over 3 weeks
and consisted of 1 week of self-monitoring and 1 week of
accessing the program, followed by 1 week of post-inter-
vention assessment. Results suggested that this
Internet-based treatment program was an effective
intervention for individuals with PDA, at least in the
short-term (participants improved on all measures
except anxiety sensitivity). Richards and Alvarenga
examined the long-term benefit of this program, extend-
ed to 5-modules (without instructions for interoceptive
or in vivo exposure strategies).107 The additional three
modules covered the components of panic, information
on negative and self-defeating cognitions (such as prob-
ability overestimation and catastrophizing) and how to
change them, and information about non-helpful and
helpful strategies for coping with panic attacks. The pro-
gram also contained quizzes at the end of sections,
which enabled participants to self-assess their under-
standing of the material they had just covered. The
authors found that panic frequency and distress during
panic attacks, but not other measures, improved signif-
icantly following the intervention (the post-assessment
was conducted 3 months after completion of the pro-
gram.) The attrition rates in these studies106,107 and in
the Kenwright et al. study105 were higher than those
found with face-to-face treatment. Preliminary evidence
thus suggests that computer-guided self-help may be a
feasible approach for individuals with less severe PDA
and may be more affordable and accessible than clini-
cian-guided treatment.107
Newman et al.95 have made headway with computer
applications in the treatment of PDA in a clinical set-
ting. They used a palmtop computer to reinforce the
systematic use of cognitive-behavioral procedures and
to help patients engage in active coping at all times
over a period of 8 weeks following 4 weekly sessions
with a therapist. This condition was compared with 12
Journal of Psychiatric Practice Vol. 10, No. 4
weeks of therapist-directed CBT in which the computer
was used only for self-monitoring. Participants in both
treatments used a Casio PB-1000 palmtop computer
that has a small keyboard, a touch-sensitive screen,
and weighs 15 oz. Participants in the 12-week condition
used the computer in “diary only” mode, which contains
a prompt for clients to report their average level of anx-
iety and number of panic attacks at 9 P.M. each day.
Participants in the 4-week condition used this mode as
well as the “treatment plus diary” mode. The treatment
mode adds three modules: a self-statement and expo-
sure module that displays a series of statements to help
clients alter their thinking and remain in the present
situation, a symptom control module that prompts
clients to practice breathing retraining, and a “postpan-
ic” module that presents self-reinforcing and re-evalua-
tion statements to help clients objectively re-assess
their fears 30 minutes after each computer interaction.
The 4-week condition consisted of individual weekly
sessions in which therapists adhered to a very brief ver-
sion of the MAP manual re-written for four sessions
(including cognitive restructuring, breathing retrain-
ing, and exposure to interoceptive cues and feared situ-
ations).10,70 After the fourth session, clients continued
using the computer for 8 weeks without therapist con-
tact. CBT-12 was found to be superior in lowering panic
frequency at post-treatment compared with 4 weeks of
therapy supplemented with the computer, but these dif-
ferences disappeared at follow-up, suggesting that the
computer approach was acceptable to patients. These
findings are promising, as the palmtop computer is less
expensive (about $500 each) and certainly more
portable than desktop computers, making it well-suited
for therapeutic applications. Moreover, because CBT is
structured and systematic, it is compatible with the use
of interactive computer software and may even increase
compliance with self-monitoring while increasing
access to treatment. Kenardy et al. have replicated and
extended these findings in their comparison of 6 (CBT6)
and 12 (CBT12) sessions of therapist-delivered CBT, 6
sessions of CBT augmented by a palmtop computer
(CBT6-CA), and a wait-list control.108 The CBT6-CA
approach consisted of a condensed version of the stan-
dard CBT regimen, delivering the same content as this
regimen (as well as supplementary handouts) over six
weekly 1-hour individual sessions with a therapist. The
computer, a Hewlett Packard 200LX, included a self-
statement module, a breathing control module, and a
new exposure module incorporating both situational
exposure and interoceptive exposure. The computer
was programmed to signal the subjects five times daily
July 2004 221
 COGNITIVE-BEHAVIORAL TREATMENT FOR PANIC DISORDER
to prompt practice of the therapy components. Patients
continued to carry the palmtop computer for 6 addi-
tional weeks, after which it was returned. Although the
computer provided some benefits immediately follow-
ing treatment, the active treatments did not differ sta-
tistically at 6-month follow-up, suggesting that use of
computers did not confer any additional benefits.108
An exciting direction in the treatment of PDA
involves new protocols that make use of virtual reality
and videoconferencing to teach patients cognitive-
behavioral principles. A pilot outcome study in Canada
examined the effectiveness of 12 sessions of telepsy-
chotherapy for PDA, in which trained therapists deliv-
ered CBT via videoconference according to a
standardized treatment manual.109,110 The remote site
was equipped with a Tandberg 2000 videoconference
system and a fax, and the information was relayed via a
camera and television, a codec (coder/decoder), and links
between the two sites. Participants were seated in a psy-
chologist’s office in a mental health clinic (local site).
They recorded panic attacks and panic apprehension on
diaries and were provided with written handouts
describing key information. The investigators found
that this approach demonstrated statistically and clini-
cally significant improvements on measures of target
symptoms (frequency of panic attacks, panic apprehen-
sion, severity of PDA, perceived self-efficacy) in eight
patients (all of whom completed the program), with 63%
panic-free after treatment. The authors noted that a
good therapeutic alliance was formed after the first ses-
sion, suggesting that CBT can be delivered through
videoconferencing systems to patients suffering from
PDA and that this strategy merits further investiga-
tion.109 In their discussion of the treatment process, the
authors did note that the use of videoconferencing has
some limits, such as the inability to shake hands, to
bend over to offer tissues to a crying patient, or to make
direct eye contact. However, they reported that the ther-
apists in the study forgot that they were talking
through a camera to someone kilometers away, and felt
completely involved in the therapy. Future research
needs to determine whether telepresence, the impres-
sion of being “in psychotherapy,” is a predictor of treat-
ment acceptability and success.109
Experiential-Cognitive Therapy (ECT) is another
new protocol that integrates the use of virtual reality
(VR) with a CBT treatment strategy.111 The treatment
is composed of eight sessions and of booster sessions for
6 months after the therapy, and is delivered by the
Virtual Environments for Panic Disorder (VEPD) virtu-
al reality system, developed by Vincelli and Riva. In
222 July 2004
session 1, the patient is introduced to the etiologic
model of PDA and the ECT program. In the following
session, the patient is exposed to each of four virtual
environments (an elevator, a supermarket, a subway
ride, and a large square) and is asked to evaluate the
experience on a subjective units of distress scale. In this
way, the therapist obtains a hierarchy of virtual envi-
ronments from the least anxiety provoking to the most,
which will be used in later sessions. Within each envi-
ronment, there are various levels of difficulty (e.g., in
the supermarket, the increase in difficulty may be
obtained by increasing the number of persons present).
After the hierarchy is constructed, graded exposure to
virtual environments is introduced along with cognitive
restructuring and homework that includes scheduling
of in vivo self-exposure assignments. Interoceptive
exposure is introduced in sessions 5–7 and is assisted
through continued graded exposure to virtual environ-
ments. The eighth and final session consists of relapse
prevention. A controlled study using this approach (12
sessions) showed that both CBT and ECT could signifi-
cantly reduce the number of panic attacks, level of
depression, and both state and trait anxiety in the sam-
ple studied. The authors suggested that ECT may be
more cost-effective than therapist-delivered CBT, since
these results were obtained in 33% fewer sessions than
CBT.111
Predictors of Outcome for CBT
Researchers are beginning to examine factors that
enhance the outcome of CBT for PDA and investigate
which components of the treatment are most effective.
Schmidt and Woolaway-Bickel evaluated the effects of
patient compliance with treatment.112 They found that
therapist ratings of homework compliance were signifi-
cantly associated with most outcome measures, whereas
patient estimates of compliance were not. Interestingly,
the authors reported that the quality of treatment-relat-
ed assignments was more closely related to clinical
improvement than the quantity of the participants’
work, suggesting that patient motivation enhances the
outcome of CBT for PDA. Analysis of demographic vari-
ables revealed that subjects who were older and unem-
ployed produced higher quality work. Formal mediation
analyses that examine the mechanisms of action of CBT
for PDA in future research studies should clarify the
impact of specific factors on the efficacy of this psycho-
logical approach. Such investigations should form the
next stage of ongoing research on effective treatments
for panic disorder.112
Journal of Psychiatric Practice Vol. 10, No. 4
 COGNITIVE-BEHAVIORAL TREATMENT FOR PANIC DISORDER
Conclusion
Data from research clinics provide an empirical basis
for the use of CBT in the treatment of PDA. On average,
40%–90% of patients treated with CBT are panic-free at
the end of treatment,29,113,114 with most studies finding
rates at the higher end of the spectrum. Unfortunately,
panic-free status utilized in most early psychosocial and
drug treatment studies is not the most comprehensive
outcome measure115 and more broad assessment meas-
ures are needed to capture the true rate of substantial
improvement, which may be closer to 50%–60%.
However, the treatment effects of CBT do seem to
endure. At follow-up intervals ranging from 6 months to
2 years, 75%–87% of patients who received CBT
remained panic free.25,116 Assessment of transportabili-
ty suggests that CBT can be effectively used by trained
clinicians to treat patients in CMHCs, outpatient clin-
ics, hospitals, and primary care settings, whether in an
individual or group-therapy format,69,71,73 and brief
forms of CBT also appear superior to alternative psy-
chosocial interventions.18 CBT has also been used suc-
cessfully to treat PDA in adolescents.
Nevertheless, there remains much room for improve-
ment in the robustness of these procedures since a sub-
stantial percentage of patients (approximately 40%) do
not achieve a fully satisfactory response29 and we need
to discover predictors of success in individual patients.
Research is also needed on ways to improve the dis-
semination to and utilization of these treatments by
community clinicians. Clinical investigators are evalu-
ating more user-friendly approaches that are amenable
to a wider range of practice settings, including the use
of briefer therapist-assisted structured manuals and
technology to lower costs and enhance treatment effec-
tiveness.
References
1. Klerman GL, Weissman MM, Oullette R, et al. Panic attacks in
the community: Social morbidity and health care utilization.
JAMA 1991;265:742–6.
2. U.S. Department of Health and Human Services. Public
Health Service National Center for Health Statistics,
National Medical Care Utilization and Expenditure Survey
(NMCUES). Washington, DC: US Government Printing Office;
1985.
3. Edlund MJ, Swann AC. The economic and social costs of panic
disorder. Hosp Community Psychiatry 1987;38:1277–79, 1288.
4. Markowitz JS, Weissman MM, Oullette R, et al. Quality of life
in panic disorder. Arch Gen Psychiatry 1989;46:984–92.
5. Agras WS, Leitenberg H, Barlow DH. Social reinforcement in
Journal of Psychiatric Practice Vol. 10, No. 4
the modification of agoraphobia. Arch Gen Psychiatry 1968;
19:423–7.
6. Barlow, DH. Anxiety and its disorders: The nature and treat-
ment of anxiety and panic. New York: Guilford; 1988.
7. Barlow DH, Cohen AS, Waddell M, et al. Panic and generalized
anxiety disorders: Nature and treatment. Behav Ther
1984;15:431–49.
8. Clark DM. A cognitive approach to panic. Behav Res Ther
1986;24:461–70.
9. Barlow DH, Cerny J. Psychological treatment of panic. New
York: Guilford; 1988.
10. Barlow DH, Craske MG. Mastery of your anxiety and panic
(MAP-3). San Antonio, TX: Graywind Publications/The
Psychological Corporation; 2000.
11. Beck AT, Emery G. Anxiety disorders and phobias: A cognitive
perspective. New York: Basic Books; 1985.
12. Klosko JS, Barlow DH, Tassinari R, et al. A comparison of
alprazolam and behavior therapy in treatment of panic disor-
der. J Consult Clin Psychol 1990;58:77–84.
13. Barlow DH, Brown TA. Correction to Klosko et al. J Consult
Clin Psychol. 1995;63:830.
14. Clark DM, Salkovskis PM, Hackmann A, et al. A comparison of
cognitive therapy, applied relaxation and imipramine in the
treatment of panic disorder. Br J Psychiatry 1994;164:759–69.
15. Beck AT, Sokol L, Clark DA, et al. A crossover study of focused
cognitive therapy for panic disorder. Am J Psychiatry
1992;149:778–83.
16. Black DW, Wesner R, Bowers W, et al. A comparison of fluvox-
amine, cognitive therapy and placebo in the treatment of
panic disorder. Arch Gen Psychiatry 1993;50;44–50.
17. Telch M, Lucas JA, Schmidt NB, et al. Group cognitive behav-
ioral treatment of panic disorder. Behav Res Ther 1993;
31:279–87.
18. Craske MG, Maidenberg E, Bystritsky A. Brief cognitive-
behavioral versus non-directive therapy for panic disorder. J
Behav Ther Exp Psychiatry 1995;26:113–20.
19. Margraf J, Schneider S. Outcome and active ingredients of cog-
nitive behavioral treatment for panic disorder. Presented at
the annual meeting of the Association for Advancement of
Behavior Therapy, New York, 1991.
20. Shear MK, Pilkanis PA, Cloitre M, et al. Cognitive behavioral
treatment compared with nonprescriptive treatment of panic
disorder. Arch Gen Psychiatry 1994;51:395–401.
21. Newman CF, Beck JS, Beck AT. Efficacy of cognitive therapy in
reducing panic attacks and medication. Presented at the
annual meeting of the Association for Advancement of
Behavior Therapy, San Francisco, 1990.
22. Ost MW, Westling BE, Hellstrom K. Applied relaxation, expo-
sure in vivo and cognitive methods in the treatment of panic
disorder with agoraphobia. Behav Res Ther 1993;31:383–95.
23. Cote C, Gauthier J, Laberge B, et al. Reduced therapist contact
in the cognitive-behavioral treatment of panic disorder. Behav
Ther 1994;25:123–145.
24. Barlow DH, Gorman JM, Shear MK, et al. Cognitive-behav-
ioral therapy, imipramine, or their combination for panic dis-
order: A randomized control trial. JAMA 2000;283:2529–36.
25. Craske MG, Brown TA, Barlow DH. Behavioral treatment of
panic disorder: A two-year follow up. Behav Ther 1991;22:
289–304.
26. Shear MK, Houck P, Greeno C, et al. Emotion-focused psy-
chotherapy for patients with panic disorder. Am J Psychiatry
July 2004 223
 COGNITIVE-BEHAVIORAL TREATMENT FOR PANIC DISORDER
2001;158:1993-9.
27. Barlow DH, Lehman C. Advances in the psychosocial treat-
ment of anxiety disorders: Implications for national health
care. Arch Gen Psychiatry 1996;53:727–35.
28. Barlow DH, Craske MG, Cerny JA, et al. Behavioral treatment
of panic disorder. Behav Ther 1989;20:261–82.
29. Barlow, DH, ed. Anxiety and its disorders: The nature and
treatment of anxiety and panic, 2nd edition. New York:
Guilford; 2002.
30. Gould RA, Otto MW, Pollack MH. A meta-analysis of treatment
outcome for panic disorder. Clin Psychol Rev 1995;15:819–44.
31 Milrod, B, Busch F, Leon AC, et al. A pilot open trial of brief
psychodynamic psychotherapy for panic disorder. J Psycho-
ther Pract Res.2001;10:239–45
32. Meuret AE, Wilhelm FH, Roth WT. Respiratory feedback for
treating panic disorder. J Consult Clin Psychol 2004;
60:197–207.
33. Craske MG, Zucker BG. Consideration of APA Practice
Guideline for the Treatment of Patients with Panic Disorder:
Strengths and limitations for behavior therapy. Behav Res
Ther 2001;32:259–81.
34. Wardle J. Behavior therapy and benzodiazepines: Allies or
antagonists? Br J Psychiatry 1990;156:163–8.
35. Wolkowitz OM, Pickar D. Benzodiazepines in the treatment of
schizophrenia: A review and reappraisal. Am J Psychiatry
1991;148:714–26.
36. Glass RM. Panic disorder—It’s real and it’s treatable. JAMA
2000;283:2573–4.
37. Rosenbaum JF, Pollock RA, Jordan SK, et al. The pharma-
cotherapy of panic disorder. Bull Menninger Clin 1996;2(suppl
A):A54–A71.
38. Biondi M, Picardi A. Increased probability of remaining in
remission from panic disorder with agoraphobia after drug
treatments in patients who received concurrent cognitive
behavioural therapy: A follow-up study. Psychother
Psychosom 2003;72:34–42.
39. Otto MW, Pollack MH, Penava SJ, et al. Group cognitive-
behavior therapy for patients failing to respond to pharma-
cotherapy for panic disorder: A clinical case series. Behav Res
Ther 1999;37:763–70.
40. Spiegel DA, Bruce TJ, Gregg SF, et al. Does cognitive behavior
therapy assist slow-taper alprazolam discontinuation in panic
disorder? Am J Psychiatry 1994;151:876–88.
41. Schmidt NB, Wolloway-Bickel K, Trakowski JH, et al.
Antidepressant discontinuation in the context of cognitive
behavioral treatment for panic disorder. Behav Res Ther
2002;40:67–73.
42. Whittal ML, Otto MW, Hong JJ. Cognitive-behavior therapy
for discontinuation of SSRI treatment of panic disorder: A
case series. Behav Res Ther 2001;39:939–45.
43. Levitt J, Hoffman EC, Grisham JR, et al. Empirically support-
ed treatments for panic disorder. Psychiatr Ann 2001;31:1–12.
44. Clark DM, Salkovitz PM, Hackmann A, et al. Brief cognitive
therapy for panic disorder. A randomized control trial. J
Consult Clin Psychol 1999;67:583–9.
45. Gelder MG. Combined pharmacotherapy and cognitive behav-
ior therapy in the treatment of panic disorder. J Clin
Pharmacol. 1998;J8(suppl 12):2–5.
46. Telch MJ, Lucas JA. Combined pharmacological and psychoso-
cial treatment for panic disorder: Current status and future
directions. In: Wolfe BE, Maser JD, eds. Treatment of panic
224 July 2004
disorder: A consensus development conference. Washington,
DC: American Psychiatric Press; 1994:177–97.
47. Kampmnan M, Keijsers GP, Hoogduin CA, et al. A randomized,
double-blind, placebo controlled study of the effects of adjunc-
tive paroxetine in panic disorder patients unsuccessfully
treated with cognitive behavioral therapy alone. J Clin Psych-
iatry 2002;63:772–7.
48. Kearney CA, Albano AM, Eisen AR, et al. The phenomenology
of panic disorder in youngsters: An empirical study of a clini-
cal sample. J Anxiety Disord 1997;11:49–62.
49. Ollendick TH, Mattis SG, King NJ. Panic in children and ado-
lescents: A review. J Child Psychol Psychiatry 1994;35:
113–34.
50. Nelles WB, Barlow DH. Do children panic? Clin Psychol Rev
1988;146:1059–60.
51. Hayward C, Killen JD, Taylor CB. Panic attacks in young ado-
lescents. J Am Acad Child Adolesc Psychiatry 1989;146:
1061–2.
52. King NJ, Guillone B, Tonge BJ, et al. Self-reports of panic and
manifest anxiety in adolescents. Behav Res Ther 1993;31:
111–6.
53. King NJ, Ollendick TH, Mattis SG, et al. Nonclinical panic
attacks in adolescents: Prevalence, symptomatology, and asso-
ciated features. Behav Change 1997;13:171–83.
54. Lau JJ, Calamari JE, Waraczynski M. Panic attack sympto-
matology and anxiety sensitivity in adolescents. J Anxiety
Disord 1996;10:355–64.
55. Macaulay JL, Kleinknecht RA. Panic and panic attacks in ado-
lescents. J Anxiety Disord 1989;3:221–41.
56. Barlow DH, Pincus DB, Heinrichs N, et al. Anxiety disorders.
In: Stricker GS, Widiger TA, eds. Handbook of psychology, Vol.
8: Clinical psychology. New York: John Wiley & Sons; 2003:
119–47.
57. Mattis SG, Ollendick TH. Children’s cognitive responses to the
somatic symptoms of panic. J Abnormal Child Psychol 1997;
25:47–57.
58. Ollendick TH. Cognitive behavioral treatment of panic disor-
der with agoraphobia in adolescents: A multiple baseline
design. Behav Ther 1995;26:517–31.
59. Hoffman EC, Mattis SG. A developmental adaptation of panic
control treatment for panic disorder in adolescence. Cognitive
and Behavioral Practice 2000;7:253–61.
60. Zaubler TS, Katon W. Panic disorder and medical comorbidity:
A review of the medical and psychiatric literature. Bull
Mennininger Clin 1996;Suppl A60:A12–A33.
61. Venturello S, Berzega G, Maina G, et al. Premorbid conditions
and precipitating events in early onset panic disorder. Compr
Psychiatry 2002;43:28–36.
62. Marshall JR. Comorbidity and its effects on panic disorder.
Bull Menninger Clinic 1996; 60:A39–A53.
63. Ball S, Otto M, Pollack M, et al. Predicting prospective
episodes of depression in patients with panic disorder. J
Consult Clin Psychol 1994;62:359–65.
64. Breier A, Charney DS, Heninger GR. Major depression in
patients with agoraphobia and panic disorder. Arch Gen
Psychiatry 1984;41:1129–35.
65. Brown TA, Barlow DH. Comorbidity among anxiety disorders:
Implications for treatment and DSM-IV. J Consult Clin
Psychol 1992;60:835–44.
66. Rapaport MH, Cantor JJ. Panic disorder in a managed care
environment. J Clin Psychiatry 1997;58(Suppl 2):51–8.
Journal of Psychiatric Practice Vol. 10, No. 4
 COGNITIVE-BEHAVIORAL TREATMENT FOR PANIC DISORDER
67. Tsao JC, Mystkowski JL, Zucker BG, et al. Effects of cognitive-
behavioral therapy for panic disorder on comorbid conditions:
Replication and extension. Behav Ther 2002;33:493–509.
68. Schmidt NB, McCreary BT, Trakowski JJ, et al. Effects of cog-
nitive-behavioral treatment on physical health status in
patients with panic disorder. Behav Ther 2003;34:49–64.
69. Wade WA, Treat TA, Stuart GL. Transporting an empirically
supported treatment for panic disorder to a service clinic set-
ting: A benchmarking strategy. J Consult Clin Psychol
1998;66:231–9.
70. Barlow DH, Craske MG. Mastery of your anxiety and panic
(MAP-3): Client workbook for anxiety and panic, 3rd edition.
San Antonio, TX: Graywind/Psychological Corporation; 2000.
71. Stuart GL, Treat TA, Wade WA. Effectiveness of an empirical-
ly based treatment of panic disorder delivered in a service
clinic setting: 1 year follow up. J Consult Clin Psychol
2000;68:506–12.
72. Garcia-Palacios A, Botella C, Robert C, et al. Clinical utility of
cognitive-behavioural treatment for panic disorder. Results
obtained in different settings: A research centre and a public
mental health unit. Clin Psychol Psychother 2002;9:373–83.
73. Penava SJ, Otto MW, Maki KW, et al. Rate of improvement
during cognitive-behavioral group treatment for panic disor-
der. Behav Res Ther 1998;36:664–73.
74. Ballenger JC. Panic disorder in the medical setting. J Clin
Psychiatry 1997;58(suppl 2):13–7.
75. Craske MG, Stein MB, Donald-Sherbourne C, et al. Treating
panic disorder in primary care: A collaborative care interven-
tion. Gen Hosp Psychiatry 2002;24:148–55
76. Liberman M, Reicher B, Maoz A, et al. A profile of patients who
do not comply with referrals for psychiatric counseling.
Primary Care Psychiatry 1997;3:25–30.
77. Sharp DM, Power KG. Psychologist, patient, and general prac-
titioner ratings of outcome of pharmacological and psycholog-
ical treatments for panic disorder and agoraphobia in primary
care. Behavioural and Cognitive Psychotherapy 1998;26:
13–27.
78. Heldt E, Manfro GG, Kipper L, et al. Treating medication-
resistant panic disorder: Predictors and outcome of cognitive-
behavior therapy in a Brazilian public hospital. Psychother
Psychosom 2003;72:43–8.
79. Sanderson WC, Raue PJ, Wetzler S. The generalizability of
cognitive behavior therapy for panic disorder. Journal of
Cognitive Psychotherapy 1998;12:323–30.
80. Otto MW, Pollack MH, Maki MW. Empirically supported treat-
ments for panic disorder: Costs, benefits, and stepped care. J
Consult Clin Psychol 2000;4:556–63.
81. Hofmann, SG, Spiegel, DA. Panic control treatment and its
applications. J Psychother Pract Res 1999;8:3–11.
82. Wilson TG. Behavior therapy at century close. Behav Ther
1997;28:449–57.
83. Breier A, Charney DS, Henninger GR. Agoraphobia with panic
attacks: Development, diagnostic stability, and course of ill-
ness. Arch Gen Psychiatry 1986;43:1029–36.
84. Taylor CB, King R, Margraf J, et al. Use of medication and in
vivo exposure in volunteers for panic disorder research. Am J
Psychiatry 1989;146:1423–6.
85. Goisman RM, Rogers MP, Steketee GS, et al. Utilization of
behavioral methods in a multicenter anxiety disorders study.
J Clin Psychiatry 1993;54:213–8.
86. Swinson RP, Cox BJ, Kerr SA, et al. A survey of anxiety disor-
Journal of Psychiatric Practice Vol. 10, No. 4
ders clinics in Canadian hospitals. Can J Psychiatry 1992;
37:188–91.
87. Taylor S, Cox BJ. An expanded Anxiety Sensitivity Index:
Evidence for a hierarchical structure in a clinical sample. J
Anxiety Disord 1998;12:463–83.
88. National Institutes of Health. Treatment of panic disorder.
NIH Consensus Development Conference Consensus
Statement (Volume 9); 1991.
89. Barlow DH, Hofmann SG. Efficacy and dissemination of psy-
chosocial treatment expertise. In: Clark DM, Fairburn CG,
eds. Science and practice of cognitive behaviour therapy.
London: Oxford University Press; 1997:95–117.
90. Katerndahl DA, Realini JP. Where do panic sufferers seek
care? J Fam Pract 1995;40:237–43.
91. Swinson RP, Soulios C, Cox BJ, et al. Brief treatment of emer-
gency room patients with panic attacks. Am J Psychiatry
1992;33:465–9.
92. Task Force on Promotion and Dissemination of Psychological
Procedures. Training in and dissemination of empirically-val-
idated psychological treatments: Report and recommenda-
tions. The Clinical Psychologist 1995;48:3–24.
93. Huppert JD, Baker-Morissette SL. Beyond the manual: An
insider’s guide to panic control treatment. Cog Behav Pract
2003;10:2–13.
94. Calhoun KS, Moras K, Pilkonis P, et al. Empirically supported
treatments: Implications for training. J Consult Clin Psychol
1998;66:151–62.
95. Newman MG, Kenardy J, Herman S, et al. Comparison of cog-
nitive-behavioral treatment of panic disorder with computer-
assisted brief cognitive behavior treatment. J Consult Clin
Psychol 1997;65:178–83.
96. Otto MW. New tools for anxiety disorders: A clinical commen-
tary on treatment innovations. Cognitive and Behavioral
Practice 1999;6:263–6.
97. Pollard AC. Comments on innovations in cognitive behavioral
treatments of anxiety disorders. Cognitive and Behavioral
Practice 1999;6: 267–9.
98. Heimberg RC, Coles ME. Reflections on innovations in cogni-
tive behavioral treatments of anxiety disorders. Cognitive and
Behavioral Practice 1999;6:258–63.
99. Botella C, Garcia-Palacios A. The possibility of reducing thera-
pist contact and total length of therapy in the treatment of
panic disorder. Behavioural and Cognitive Psychotherapy
1999;27:231–47.
100. Stein MB, Ron Norton G, Walker JR, et al. Do selective sero-
tonin re-uptake inhibitors enhance the efficacy of very brief
cognitive behavioral therapy for panic disorder? A pilot study.
Psychiatry Res 2000;94:191–200.
101. Clum, G. Coping with panic. Pacific Grove, CA: Brooks/Cole
Publishing; 1990.
102. Lidren DM, Watkins PL, Gould RA, et al. A comparison of bib-
liotherapy and group therapy in the treatment of panic disor-
der. J Consult Clin Psychol 1994;62:865–9.
103. Ghosh A, Marks IM. Self-treatment of agoraphobia by expo-
sure. Behav Ther 1987;18:3–16.
104. Hecker JE, Losee MC, Fritzler BS, et al. Self-directed versus
therapist directed cognitive behavioral treatment for panic
disorder. J Anxiety Disord 1996;4:253–65.
105. Kenwright M, Liness S, Marks I. Reducing demands on clini-
cians by offering computer-aided self-help for phobia/panic. Br
J Psychiatry 2001;179:456–9.
July 2004 225
 COGNITIVE-BEHAVIORAL TREATMENT FOR PANIC DISORDER
106. Klein B, Richard JC. A brief internet-based treatment for panic
disorder. Behavioural and Cognitive Psychotherapy 2001;29:
113–7.
107. Richards JC, Alvarenga ME. Extension and replication of an
internet-based treatment for panic disorder. Cogn Behav Ther
2002;31:41–7.
108. Kenardy JA, Dow MG, Johnston DW, et al. A comparison of
delivery methods of cognitive behavioral therapy for panic dis-
order: An international multi-center trial. J Consult Clin
Psychol 2003;71:1068–75.
109. Bouchard S, Payeur R, Rivard V, et al. Cognitive behavior ther-
apy for panic disorder with agoraphobia in videoconference:
Preliminary results. CyberPsychol Behav 2000;3:999–1007.
110. Clark DM, Salkovskis PM. Cognitive treatment for panic
attacks: Therapist manual. Oxford: Warneford Hospital; 1987.
111. Vincelli F, Annolli L, Bouchard S, et al. Experiential cognitive
226 July 2004
therapy in the treatment of panic disorders with agoraphobia:
A controlled study. CyberPsychol Behav 2003;6:321–7.
112. Schmidt NB, Woolaway-Bickel K. The effects of treatment com-
pliance on outcome in cognitive-behavioral therapy for panic
disorder: Quality versus quantity. J Consult Clin Psychol
2000;68:13–8.
113. Clum GA, Clum GA, Surls R. A meta-analysis of treatments for
panic disorder. J Consult Clin Psychol 1993;61:317–26.
114. Chambless DL, Gillis MM. Cognitive therapy of anxiety disor-
ders. J Consult Clin Psychol 1993;61:248–60.
115. Pollack MH, Otto MW. Long-term course and outcome in panic
disorder. J Clin Psychiatry 1997;58(suppl 2):57–60.
116. Brown TA, Barlow DH. Long-term outcome in cognitive-behav-
ioral treatment of panic disorder: Clinical predictors and alter-
native strategies for assessment. J Consult Clin Psychol
1995;63:754–65.
Journal of Psychiatric Practice Vol. 10, No. 4