David F. Tolin, Ph.D. Institute of Living and Yale University School of Medicine

Transcription

1 David F. Tolin, Ph.D. Institute of Living and Yale University School of Medicine

2 Research funding from Palo Alto Health Sciences, Inc.

3 Exaggerated upper thoracic movements Minimal use of the diaphragm Erratic and irregular breathing pattern Wide variations in rate and rhythm of breathing Frequent sighs Forced, audible expiration Cluff RA. J. R. Soc. Med. 1984;77(10):

4 Respiratory rate (RR) or depth (tidal volume: TV) in excess of metabolic needs CO 2 production usually in equilibrium with O 2 consumption Normal: arterial CO 2 (PaCO 2 ) mmhg Increased RR or TV rapidly decreases PaCO 2 Hypocapnia/hypocarbia

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6 Tight throat, difficulty swallowing, intestinal cramps Lightheadedness, dizziness Cold hands and feet Weakness, fatigue, twitching Heart palpitations, rapid pulse Chest pain Muscle tension Peripheral tingling or numbness Fear of death Depersonalization or derealization Gilbert, C. Acc Emerg Nurs 1997;7:

7 Hyperventilation (High RR or TV) Low PaCO 2 Physical sensations

8 Hyperventilation (High RR or TV) Low PaCO 2 Physical sensations

9 TV Panic GAD Control 250 Min 0-10 Min Min Wilhelm et al., Biol Psychiatry 2001;49:

10 Panic Disorder Subject Healthy Control Subject Abelseon et al., Biol Psychiatry 2001;49:

11 Normal = 16 Meuret et al., Biol Psychiatry 2011;70:

12 Hyperventilation (High RR or TV) Low PaCO 2 Physical sensations

13 P ET CO Panic GAD Control Baseline Serial 7s Recovery Hegel & Ferguson, Psychosom Med 1997;59:

14 Normal = 40 Meuret et al., Biol Psychiatry 2011;70:

15 Mean item probability Class 1 Class Roberson-Nay & Kendler, Psychol Med 2011;41:

16 41 40 P ET CO Resp-PD NonResp-PD GAD Control Hegel & Ferguson, Psychosom Med 1997;59:

17 Ley s Hyperventilation Theory Hyperventilation and low PaCO 2 are the direct cause of panic attacks Klein s Suffocation False Alarm Theory People with PD are highly sensitive to CO 2 fluctuations Biopsychological Theory Hyperventilation leads to the detection of aversive physiological sensations Cognitive misappraisals of symptoms Ley R. Clin. Psychol. Rev. 1985;5: Klein DF. Arch. Gen. Psychiatry. 1993;50: Clark et al., J Behav Ther Exp Psychiatry 1985;16:23-30 Margraf J. Adv Behav Res Ther. 1993;15:49-74

18 Slow respiration rate Decrease TV Increase P ET CO 2

19 Panic attacks per week Panic attacks per week Baseline BR Situational Non-Situational Weeks Months Clark et al., J Behav Ther Exp Psychiatry 1985;16:23-30

20 4 weekly treatment sessions (1 hour) Homework twice daily (17 min) Baseline (2 min) Pacing (10 min) Transfer (5 min) Frequency of breathing P ET CO 2 Meuret et al., J Psychiatr Res. 2008;42:

21 CART WL CART WL 29 Pre Post 2FU 12FU 0 Pre Post 2FU 12FU P ET CO 2 PDSS (0-4) Meuret et al., J Psychiatr Res. 2008;42:

22 Changes in P ET CO 2 mediate changes in anxiety sensitivity Changes in RR do not mediate changes in anxiety sensitivity Changes in P ET CO 2 mediate changes in RR Changes in anxiety sensitivity do not mediate changes in P ET CO 2 CART P ET CO 2 ASI RR Meuret et al., J Psychiatr Res. 2009;43:

23 Effect size (d) CART CT PETCO2 RR ASI/BSQ ACQ Meuret et al., J. Consult. Clin. Psychol. 2010;78:

24 20 CT + BR + In Vivo 100% CT + Interoceptive + In Vivo 15 CT + Interoceptive + In Vivo 80% CT + BR + In Vivo 60% 10 40% 5 20% 0 0% Pre Post Panic Free Recovery Panic Attacks/Mo Normal Functioning Craske et al., Br J Clin Psychol 1997;36:85-99

25 Recovered at 12 Mo 60% 50% 40% 30% 20% 10% 0% CBT CBT + BR Schmidt et al. J. Consult. Clin. Psychol. 2000;68:

26 Use of breathing retraining as a safety behavior Exercises "applied to anxiety-producing situations Absence of capnometry biofeedback or paced breathing

27 Raise C02 Lower CO2 Wait List Pre 1 Mo FU 6 Mo FU 80% Raise C02 70% Lower CO2 60% 50% 40% 30% 20% 10% 0% PDSS (0-4) Panic Free at 6 Mo Kim et al. J. Clin. Psychiatry. 2012;73:

28 Something other than P ET CO 2 is the mechanism of change Interoceptive exposure to altered breathing Improved sense of control over physiology Training was for TV only RR fixed rate Patients reported raising CO 2 to be more difficult than lowering it

29 Panic disorder is characterized by chronic respiratory abnormality Increased RR Decreased PaCO 2 Decreased PaCO 2 produces panic-like symptoms Increased respiratory abnormality precedes panic attacks

30 Breathing retraining appears to be a viable treatment for panic disorder Train patients to decrease RR and increase P ET CO 2 Normalization of PaCO 2 appears to be the mediating factor The integration of breathing retraining and exposure therapy is problematic The fact that instructions to lower P ET CO 2 are also helpful raises difficult questions

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