THE ROLE OF CLIENT-CENTRED PSYCHOTHERAPY IN THE MANAGEMENT OF PANIC DISORDER

UNIVERSITY OF MEDICINE AND PHARMACY OF CRAIOVA FACULTY OF MEDICINE PhD Thesis Abstract THE ROLE OF CLIENT-CENTRED PSYCHOTHERAPY IN THE MANAGEMENT OF PANIC DISORDER PHD COORDINATOR: Prof. Univ. Dr. Tudor UDRIȘTOIU, M.D., PHD PHD POSTGRADUATE: Oana Dana PANAIT, M.D. CRAIOVA, ROMANIA 21

I. General part TABLE OF CONTENTS II. Objectives and method of the study III. Results and discussions IV. Conclusions V. References Key words: panic disorder, client centered psychotherapy, treatment management, selective serotonin re-uptake inhibitors, social functioning. I. GENERAL PART Panic disorder has a twelve-month prevalence of 2.7% and a lifetime prevalence of 4.7%, with higher incidence in females (Kessler et al, 2). The essential feature of panic disorder, according to DSM-IV (American Psychiatric Association), is the presence of recurrent, unexpected panic attacks. There is no specification of the precise frequency of panic attacks to fulfil the criteria for panic disorder in DSM-IV. At least one of the attacks has to be followed by one month or more of the following: persistent concern about having another attack, worry about the consequences of having an attack or a significant change in behaviour. There may also be unfocused anxiety present between the attacks. Panic disorder is generally considered to be a chronic condition; although most patients improve, few seem to achieve full remission (Keller et al 1994, Roy-Byrne and Cowley 1994/9, Pollack and Otto 1997). It is estimated that only one third of the patients remain in full remission, the others have a chronic evolution (episodic course or persistent course) (Katschnig et al 199). The course and outcome of panic disorder are influenced by many factors. Women are twice likely to have recurrence of the disease, after remission (Yonkers et al 1998). Panic disorder patients experience severe social and health consequences, which are comparable in severity and sometimes bigger than those seen in depressed patients. Social and marital functions were significantly impaired, and panic disorder was associated with financial dependency. Panic disorder patients subjectively experienced poor physical and emotional health. There was an increased risk of suicide, alcohol and drug abuse, as well as use of psychotropic medication (such as tranquillizers) (Markowitz et al 1989). These patients appear to be more severely impaired than patients with other anxiety disorders. Disability in relation to work is also extensive. Panic disorder patients are more likely to be unemployed or to earn less than normal people who do the same jobs. Therefore, understanding the extent to which panic disorder affects patients lives as a whole is a key issue when it comes to treatment. Several psychopharmacological agents are available for the treatment of panic disorder, among them the selective serotonin reuptake inhibitors (SSRIs) are the first-line drugs. Their efficacy has been proven in many controlled studies, and they are considered to be first-line drugs for this disorder. Psychotherapy has proven to be effective and client centred therapy is one method to be considered. II. OBJECTIVES AND METHOD OF THE STUDY 2.1.Objective The main objective: the comparative evaluation of two groups of patients with panic disorder, along 48 weeks, one of them treated with SSRI and the other one with SSRI and client centred therapy. Secondary objectives: The global evaluation of therapy. The evaluation of the social and professional functioning. 2

2.2. Methodological background Prospective study of patients diagnosed with panic disorder, treated only with SSRI (group A) and with SSRI and client centred therapy (group B). The study was 48 weeks long, between February 24-February 26. 2.3. Inclusion criteria Diagnostic of panic disorder with/without agoraphobia according to DSM-IV Age of 18 at least Able to understand the instructions from the scales and to accept psychotherapy. COVI score at least 9 at screening CGI-S score at least 4 la at screening. 2.4. Exclusion criteria: Without important co-morbidities, or therapeutic-controlled co-morbidities. Without psychiatric co-morbidities. No substances dependency in the last 6 months. 2.. Recorded characteristics Age:2-29 years, 3-39 years and 4-49 years; Residence: rural, urban; Educational background: elementary, college, university. Alcohol consumption: abstinence, occasionally (1-2 times/week), chronic (more than 3 times/week). Years from the beginning of the disorder. 2.6. Scales of evaluation COVI scale Panic and Agoraphobia Scale (PAS). Panic and Agoraphobia Scale-patient questionnaire. Clinical Global Impression Severity Scale. Index of anxiety R-IMA-36. Sheehan Disability Scale (SDS). 2.7. Study design The subjects were evaluated along seven visits S, S4, S8 within 4 weeks, and S12, S24, S36 and S48 within 12 weeks. Visit S- after signing the inform consent: Inclusion and exclusion criteria Medical history Psychiatric history Previous treatments Demographic data Employment Level of education Residence: rural/urban Clinic general examination COVI PAS PAS-patient questionnaire R-IMA-36 CGI-S SDS 3

Visits S4-S48: Maintaining the inform consent COVI PAS PAS-patient questionnaire R-IMA-36 CGI-S SDS Possible adverse events Paroxetine treatment Alprazolam treatment Participation in the therapy sessions for the group B patients. The results were processed separately for each group, related to the recorded characteristics, and comparative, looking for the evolution in time of the scores on all the scales, at each visit 2.8. Study groups Group A: 41 patients: 1 male and 26 de female Age 21-49 years, with an average mean of 33.+/-7.1 Treatment with paroxetine 2-4 mg/day for 48 weeks Treatment with alprazolam,.2-.mg/day for a short period No psychotherapy. Group B: 3 patients: 9 males and 21 females Age 24-43 years with an average mean of 33+/- 6,6 Treatment with paroxetine 2-4 mg/day for 36 weeks Treatment with alprazolam,.2-.mg/day for a short period Client centred psychotherapy for 48 weeks. III. RESULTS AND DISCUSSIONS The patients age from both groups is situated between 3-39, namely 3% from group B and 44% from group A. Group A (treated only with SSRI) has a uniform distribution, while 86% from group B patients (treated with SSRI and client centred therapy) are under 39 years of age. The sex distribution was the same in both groups; the share of female is almost double. Regarding the level of instruction, in group A prevail the patients which graduated from highschool, and in the other group the university graduated patients. The majority of both groups (9% from A and 1% from B) have urban residence, the disorder has a history of at least years in both groups. In general, there were no significant differences regarding the demography of both groups. 3.1. Comparative evolution of the groups COVI scale The COVI scores have a descendent trend for both groups, demonstrating the symptoms remission and treatment s efficacy (Fig. nr. 1). The scores were almost equal in the beginning of the study 13.1 for group A and 12.82 for group B. At a global assessment, group A has a more constant evolution along the 48 study weeks, with a slower rhythm in the first 24 weeks; the B group has a marked improvement of the panic symptoms in the first 24 weeks, the majority of the patients have similar scores as the normal people at week 36. This demonstrates that client centred therapy had an important role in the therapeutic management of panic disorder. 4

Media aritmetică ponderată Media aritmetică ponderată 14 12 1 8 6 4 2 13,1 12,829 11,33 1 1,973 9,33 7,267 8,39 4,6 6,22 4,439 3,433 3,1 3,634 S S4 S8 S12 S24 S36 S48 Fig. nr. 1. COVI score evolution in the two groups In a comparative study from 21, Teusch shows that both treatment methods are effective in diminishing both panic and anxiety and avoidance behaviour. The differences between the two groups consisted from the personality scales: the degree of autonomy was bigger in the patients with combined treatment (SSRI and client centred therapy), the patients felt more independent, less stressed, with fewer somatic complaints (Teusch and al. 21). PAS scale The scores on this scale have a more constant evolution for group A; the most important changes for all the patients are in the first 12 weeks of treatment, when the symptoms have a significant improvement (%) and then the rhythm decreases. The symptoms diminishing is bigger between week 12-24 for group B, the scores average improving by 26.6% (only by 2% for group A), and between week 36-48 for group A (Fig. nr. 2). 3 3 2 2 1 1 3,146 29,133 26,19 22 23,733 17,76 19,67 14, 11,8 4,878 6,167,78 1,,3 S S4 S8 S12 S24 S36 S48 Fig. nr. 2. PAS score evolution in the two groups In general, both groups have a clear improvement of panic symptoms along the study; in group A the improvement rhythm is constant and the treatment efficacy is better if the period of administration is at least 12 months (Ballenger, 24). The evolution of group B patients is more rapid, at week 36 they have normal PAS scores; the psychotherapy is helping them to master the anxiety symptoms and the avoidance behaviour.

Media aritmetică ponderată Media aritmetică ponderată PAS-patient questionnaire For all the patients the scores on this scale are dropping by % in the first 12 weeks. For the group B patients the improvement of the symptoms is by 3% between weeks 12-24, and for group A is 33%. In the next 12 weeks the difference is the same (% for the group A and 69% for the group B), the role of client centred therapy is shown in the fact that the patients feel more social accepted, more independent in all the activities out their secure environment, with fewer somatic complaints (Mitte, 2). In the last 12 weeks the ratio changes: 7% for group A and 3% for group B (Fig. nr. 3). 3 3 2 2 1 1 31,24 27,244 28,933 22,91 23,667 19,267 18,488 14,933 12,341 6,433,366 1,22 1,967,6 S S4 S8 S12 S24 S36 S48 Fig. nr. 3. PAS patient questionnaire score evolution in the two groups R-IMA-36 scale In general, the group A has a more constant evolution along the 48 weeks; for this patients the scores average drops in the first 12 weeks by 3%, while in group B it drops by %. The intensity of panic attacks and of the somatic complaints continues to diminish for these patients by % in the next 12 weeks, but for the group A the decrease is only by 31%. Between week 24-36 the difference is the same (% for group A and 6% for group B), the therapeutical intervention has an important role in the disappearance of panic attacks and agoraphobia (Mitte, 2). In the last 12 weeks the R-IMA-36 score diminishes by % for both groups (Fig.4). 3 3 2 2 1 1 32,22 3,2 27,91 24,4 23,488 19,171 17,833 13,171 13,467 7,6 7,98 3,488 2,967 1,467 S S4 S8 S12 S24 S36 S48 Fig. nr. 4. R-IMA-36 evolution in the two groups 6

Media aritmetică ponderată Media aritmetică ponderată CGI-S Panic disorder is a chronic disorder which needs treatment, but, under these conditions, its prognosis is good (Andersch and Hetta, 23). The clinical global assessment shows the symptoms improvement in both groups, with a descendent course for all patients (Fig. nr. ). 6 4 3 2 1,293,1 3,41 3,267 3 2,77 2,7 2,98 2,267 1,667 1,488 1,267 1,24 1,24 S S4 S8 S12 S24 S36 S48 Fig. nr.. CGI-S score evolution in the two groups In general, both groups have a similar evolution in the 48 study weeks. For all the patients the scores drop by % in the first 12 weeks, more for the group B, proving that client centred therapy is favourable. In the last 12 weeks group A has a better improvement (33% and group B only 23%). The group B patients have a more rapid course, they report the disappearance of panic attacks and the avoidance behaviour and the somatic complaints (Teusch, 21). SDS The evaluation of the social, professional and familial impact of the disorder on the SDS shows the improvement of these items in both groups (Fig.6). 3 2 2 1 1 24,97 24,3 21,82 2, 18,82 16,6 16,31 13,8 11,39 8,43 6,41 4,2 4,6 2,9 S S4 S8 S12 S24 S36 S48 Fig. nr. 6. SDS score evolution in the two groups We see that the level of disability decreases, so the social functioning is increasing in both groups the first 12 weeks, by 33% for the A patients and by 4% for the patients benefiting from therapy. The same course is seen in the next 24 weeks; in the last 12 weeks the rhythm is more rapid for group A-37% and only 3% for group B. 7

Both groups show an improvement of the social functioning in the 48 study weeks, improvement which is more rapid in group B patients. The rapid recovery is important because the specific panic disorders disabilities are related to the quality of life decreasing (Rubin and al. 2). A cost/efficacy study in two groups of panic disorder patients treated one group with monotherapy (SSRI or psychotherapy) and the other with combined therapy showed that monotherapy is more effective in the acute phase, and the combined treatment in the long-term treatment (McHugh and al. 27). IV. CONCLUSIONS 1. The symptoms improvement (both panic attacks and anxiety) of the group B patients from group B were more rapid. The considerable differences between the two groups, in the group B favour, support the scales conclusions, proving the superiority of the combined therapy in the treatment of panic disorder. 2. Patients treated with SSRI and client centred therapy have a rapid improvement of the social functioning. 3. In the management of panic disorder it has to be considered the association of psychotherapy and pharmacotherapy, because the therapeutic response is quicker and the time of administration of SSRI is shorter. 4. The superiority of combined therapy regarding patients functionality suggests that in the therapeutic management of panic disorder we have to consider beyond the clinical efficacy, the improvement of the social and familial functioning.. Panic disorder responded both to the SSRI treatment and to the combined therapy. 6. Regarding the global social functioning, we see a balance between familial and social dysfunction in both groups, with an important impact on quality of life. 7. Patients functioning is a basic aspect to evaluate, and it is an important marker for adequate therapeutic intervention in panic disorder. V. REFERENCES 1. APA. 2. Diagnostic and statistical manual of mintal disorderrs. 4th ed. Text Revision ( DSM-IV-TR). Washington, DC: American Psychiatric Press. 2. Ballenger JC. 24. Remission rates in patients with anxiety disorder treated with paroxetine. J Clin Psychiatry 6:1696-177. 3. Bandelow B, Seidler-Brandler U, Becker A, Wedekind D, Ruther E. 27a. Meta-analysis of randomized controlled comparaisons of psychopharmacological and psychological treatments for anxiety disorders. World J Biol Psychiatry 8: 17-187 4. Gendlin ET. Experiential psychotherapy. 1973. In R. Corsini(Ed.), Current psyvhotherapies Itasca, IL: Peacock.. Greenberg PE, Sisitsky T, Kessler RC, Finkelsteien SN, Berndt ER, Davidson JRT, Ballenger JC, Fyer AJ. 1999. The economic burden of anxiety disorders in the 199s. J Clin Psychiatry 6:427-43. 6. Kasper S, Resinger E. 21. Panic disorder: the place of bezodiazepines and selective serotonin reuptake inhibitors. Eur Neurolpsychopharmacol 11:37-321. 7. Lecrubier Y, Judge R. 1997. Long-term evaluation of paroxetine, clomipramine and placebo in panic disorder. Collaborative Paroxetine Panic Study Investigation. Acta Psychiatr Scand 9:13-16. 8. Lietaer G. Unconditional positive regard: a controversial basic attitude in client-centerd therapy. 1984. In R. E. Levant and J. M Shilen(Eds), Client-Centered Therapy and the Person-Centered Approach: New Directions in Theory, Research and Practice. New York: Prager. 9. Mitte K. 2. A meta-analysis of the efficacy of psycho- and pharmacotherapy in panic disorder with and without agoraphobia. J Affect Disord 88:28-287. 8

1. Nutt DJ, Cowen PJ. 1987. Diazepam alters brain -HT function in man: implications for the acute and chronic effects of benzodiazepines. Psychol Med 17:61-67. 11. Oehrberg S, Christiansen PE, Behnke K, Borup AL, Severin B, Soegaard J, et al. 199. Paroxetine in the treatment of panic disorder. A randomized, Double-blind, placebocontrolled study. Br J Psychiatry 167:374-379. 12. Rogers CR. Client-Centered Therapy. Boston: Houghton Mifflin, 191. 13. Rogers CR. 197. The necessary and sufficient for therapeutic personality change. Journal of Consulting Psychology 21: 9-13. 14. Reiman EM, Raichle ME, Robins E et al. 1989b. Neuroanatomical correlates of a lactateinduced anxiety attack. Arch Gen Psychiatry 46: 493-. 1. Simon NM, Otto MW, Smits JA, Nicolau DC, Reese HE, Pollack MH. 24. Changes in anxiety sensitivity with pharmacotherapy for panic disorder. J Psychiatr Res 38:491-49. 16. Shear MK, Cooper AM, Klerman GL et al. 1993. A psychodynamic model of panic disorder. Am J Psychiatry 1: 89-866. 17. Stein MB, Walker JR, Anderson G et al. 1996. Childhood phisical abuse in patints with anxiety disorders and in a community sample. Am J Psychiatry 13: 27-277. 18. Teusch L, Bohme H, Finke J. 21. Conflict-centered individual therapy or integration of psychotherapy methods. Process of change in client-centered psychotherapy wit hand without behavioral exposure therapy in agoraphobia with panic disorder. Nervenarzt 72:31-39. 19. Wittchen HU. 22. Generalized anxiety disorder: prevalence, burden and cost to society. Depress Anxiety 16:162-171. CURRICULUM VITAE PERSONAL INFORMATION Name: Dr. Oana Dana Panait Nationality: Romanian Date of birth: June 19-th, 1968 Marital status: Married Contact: 4 723 313 898; oana.panait19@gmail.com Language: Romanian, English, French. EDUCATION: 1986 1993- University of Craiova Faculty of Medicine, Romania 199 2-resident in psychiatry, University Clinic of Psychiatry, Craiova 2-present-psychiatry specialist, University Clinic of Psychiatry, Craiova 1999-24-training in client centred therapy, The Austrian Client-Centred Psychotherapy Association WORKING EXPERIENCE: 1993-1994-Emergency Hospital, Craiova 199-present-University Clinic of Psychiatry, Craiova 9