Cognitive Behaviour Therapy Vol 31, No 5, pp. 41–47, 2002
Extension and Replication of an Internet-Based Treatment Program for Panic Disorder Jeffrey C. Richards and Marlies E. Alvarenga University of Ballarat, Ballarat, Victoria, Australia Abstract. This study describes an internet-based intervention for people with panic disorder that consisted of a 5-module program. Participants accessed the program for 5–8 weeks and were then re-assessed 3 months later. Use of the program was associated with reductions in severity of panic disorder and in catastrophic misinterpretation of ambiguous panic body sensations in 9 people with this anxiety disorder. There were also non-significant trends for body vigilance to decrease over the course of the study. Further investigations of the efficacy of this medium for the treatment of panic disorder and the associated mechanisms of change are warranted. Key words: internet-based treatment; panic disorder; symptom misinterpretation. Received July 7, 2001; Accepted October 18, 2001 Correspondence address: Jeffrey C. Richards, School of Behavioural & Social Science and Humanities, University of Ballarat, PO Box 663, Ballarat, VIC 3353, Australia. Tel: ‡61 3 5327 9620. Fax: 61 5327 9840. E-mail:
[email protected] u
A recent survey of the mental health of Australians (Henderson, Andrews, & Hall, 2000) found that in any 12-month period, 9.7% of the population have a diagnosable anxiety disorder, with 2.4% having panic disorder, with or without agoraphobia. These data are consistent with similar surveys in other industrialized countries (Weissman & Merikangas, 1986). The Australian study showed that only 28% of people with an anxiety disorder sought professional assistance and that people outside of the major urban centres have restricted access to specialist mental health services (Parslow & Jorm, 2000). A major challenge is therefore to increase the accessibility and affordability of evidence-based treatments for panic and anxiety disorders (Walker, Norton, & Ross, 1991), as well as for other mental health disorders. By reducing the need for multiple face-to-face sessions, the integration of computer technology into treatment for anxiety disorders (Newman, Consoli, & Taylor, 1997) offers promise for people unable easily to access specialized mental health assistance. For example, Newman, Kenardy, Herman, and Taylor (1997) found a therapist-assisted 4-session palm-top computer cognitive behavioural program was as effective as 12 sessions of individual treatment at a 6-month followup, although the cost of the palm-top computers would have been prohibitive for many people. Increasingly, people are assessing their mental health status through the internet, and accessing internet-based mental health treatment (Rabasca, 2000). Treatment via the internet may take the form of therapy by email, access to chat groups or access to a detailed online information program. There are however, few controlled studies of the use of the internet in treating panic disorder. Carlbring, Westling, Ljungstrand, Ekselius, and Andersson (2001) found that internet-based treatment incorporating limited therapist assistance via email resulted in improvements on panic disorder dimensions compared with a waiting-list condition. Klein and Richards (2001) also found that a brief, 2-module internet-based treatment program for panic disorder reduced panic frequency, anticipatory fear of panic, general anxiety and excessive body vigilance in comparison with a selfmonitoring control condition. As with other successful self-help treatments for panic disorder, there was limited therapist assistance by telephone over the course of this study (Marrs, 1995).
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The present study represented a development of that by Klein and Richards (2001), in that the longer-term effects of a more comprehensive internet-based treatment program for panic disorder were evaluated on a greater number of panic-related variables. The program was based upon cognitive behavioural principles because this approach has consistently been shown to be the treatment of choice for panic disorder (Clark et al., 1994; Craske, Brown, & Barlow, 1991; Margraf, Barlow, Clark, & Telch, 1991). Although the usual CBT program involves both interoceptive exposure and cognitive therapy (Barlow, 1988), our program did not include the former component because it may be that interoceptive exposure is best used with a degree of therapist control not available through the internet. Despite evidence that the addition of interoceptive exposure enhances the effects of cognitive therapy (Gould, Otto, & Pollack, 1995), it has also been suggested that cognitively based procedures alone may produce good results even when exposure to fear sensations is not included (Brown, Beck, Newman, Beck, & Tran, 1997; Salkovskis, Clark, & Hackman, 1991). Moreover, Sokol, Beck, Greenburg, Wright, and Berchick (1989) found a substantial decrease in panic frequency that was maintained at a 2-year follow-up when using only cognitive therapy as treatment.
Method Participants
Participants were recruited through short articles published in newspapers in regional Victoria, which called for volunteers who had experienced at least 1 panic attack in the past 12 months. To be eligible for entry into the study, participants had to meet the DSM-IV criteria (American Psychiatric Association, 1994) for a primary diagnosis of panic disorder. Thirty people initially inquired about the study, but 18 were excluded because they did not have panic disorder, they had another primary mental disorder or they had significant medical conditions, which were contributing to the panics. Fourteen people with a primary diagnosis of panic disorder were included in the study and commenced the internet-based treatment program. Nine of the 14 people completed the treatment program and provided post-intervention data. Of the remaining 5, 2 discontinued their involvement because of dislike of this form of intervention, 1 lost contact with the researchers after going overseas, and 2 appeared to complete the program but did not return their post-intervention questionnaires. All 5 participants (4 females and 1 male) were non-completers and so their pre-intervention data were excluded. The attrition rate was therefore 36%. Of the 9 participants included in the study, 5 were female and 4 were male. The women’s average age was 30.6 years (SD = 7.3) and the men’s was 41.5 years (SD = 15.2). Participants were requested not to take part in any other type of treatment for their panic attacks during the course of the study. All participants reported no contact with any mental health professional or relaxation-based therapy over the course of the study. Criteria for inclusion were a primary diagnosis of panic disorder and absence of any significant physical health problems. All participants had experienced spontaneous panic attacks in the past 12 months and reported at least 1 of the following: fear of future panics, worry about the consequences of panic attacks, or a significant change in behaviour as a consequence of the attacks. At the initial assessment, the 9 people who completed the study reported an average of 4.4 panic attacks over the preceding 4 weeks. Three reported they did not actively avoid panic sensations, 2 had mild panic sensation avoidance, 2 moderate avoidance and 2 reported severe avoidance. One did not report any agoraphobic avoidance, 4 were mildly agoraphobic, 1 moderately so and 3 were severely agoraphobic. Initially, prospective participants were assessed by a structured clinical interview using the Prime-MD (Spitzer, Williams, Kroenke, Linzer, & DeGruy, 1994). For those prospective participants where there was some doubt about a primary diagnosis of panic disorder (8 of the initial 14 people), a more thorough clinical assessment using the Anxiety Disorders Interview
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Schedule for DSM-IV (Brown, Di Nardo, & Barlow, 1994) was conducted. All participants were also administered the Panic Disorder Severity Scale (Shear et al., 1997) by interview to confirm the diagnosis of panic disorder. All assessments, including questionnaire completions, were conducted on a face-to-face basis. Of the 9 people who completed the study, 1 had a secondary diagnosis of post-traumatic stress disorder, 1 a secondary diagnosis of generalized anxiety disorder and 1 had a major depressive episode. The remaining 6 had no detectable comorbidity. Three of the 5 who discontinued the study had a secondary diagnosis of generalized anxiety disorder. In all cases however, panic disorder was the primary diagnosis.
Measures
Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Brown et al., 1994). This structured clinical interview is reliable and enables an accurate Axis 1 DSM-IV diagnosis to be made. Prime-MD (Spitzer et al., 1994). The Prime-MD was used to assess potential participants for panic disorder and to screen out those with other primary mental disorders. This is a brief structured interview intended for the diagnosis of anxiety disorders, mood disorders, somatoform disorders, eating disorders and alcohol abuse/dependence as defined in the DSM-IV. It has been shown to have good validity when matched against more lengthy clinical interviews conducted by mental health practitioners. All modules of the Prime-MD were administered by the second author, a doctoral psychology student, who had been trained by the first author in the administration of this instrument. Panic Disorder Severity Scale (Shear et al., 1997). This instrument measures panic frequency, distress associated with panic, worry about future panics, avoidance of panic sensations and situations associated with panic, and impairment in occupational and social functioning. An overall panic severity score is derived. Anxiety Sensitivity Index (ASI) (Riess et al., 1986). This 16-item self-report scale reliably measures fear of autonomic arousal symptoms (Maller & Reiss, 1992). Body Vigilance Scale (BVS) (Schmidt, Lerew, & Trakowski, 1997). A total body vigilance score is derived from items measuring amount of attentional focus on bodily sensations, perceived sensitivity of changes regarding bodily sensations, amount of time spent scanning for bodily sensations and experience of panic symptomatology. Body Sensations Interpretation Questionnaire (BSIQ; Clark et al., 1997). The BSIQ measures a participant’s interpretations of written descriptions of ambiguous events that can be interpreted as threatening. The 4 classes of ambiguous events are Panic Body Sensations, Social Events, General Events and Other Body Sensations (non-panic related). For each ambiguous event, participants rank ordered 3 possible explanations as to their likelihood of being the correct interpretation. One of the provided interpretations conveyed threat, with the other 2 being neutral and/or positive.
Procedures
The 5-module program constructed for the present study was a development of that described by Klein and Richards (2001), which contained 2 modules. The first module contained information about the nature of panic; the second about the causes of panic and its effects; the third about the cognitive, physiologica l and behavioural components of panic and how these interact with each other; the fourth contained specific information on negative and self-defeating cognitions (such as probability over-estimations and catastrophizing) and how to change them; and the fifth component contained information about non-helpful and helpful strategies for coping with panic attacks. Although the program did not contain any instructions on interoceptive or in vivo exposure strategies, some participants engaged in their own exposure exercises during the program but information about this was not systematically gathered.
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The program contained quizzes at the end of sections, which enabled participants to self-assess their understanding of the material they had just covered. These quizzes provided immediate feedback as to the correctness or otherwise of their answers. The program was placed on the website of the University of Ballarat, which allowed participants to access it via a password. It included liberal use of colour, animated illustrations and hyperlinks between sections of the text. Participants were initially assessed in a face-to-face interview by the second author using the instruments described above. Subsequently, each participant was instructed on how to access the internet-based program, and how to navigate it. This assessment and instruction session was conducted at the University of Ballarat. Subsequently, all participants completed all 5 modules from their own terminal source in 5–8 weeks. During this time the second author contacted each participant on a weekly basis by telephone to monitor progress and answer any questions, which may have arisen. Post-intervention assessment using the PDSS, ASI, BVS and the BSIQ was conducted by the second author at a face-to-face session 3 months after the participant had said s/he had completed all modules. The second author had an average of 5 hours contact with each participant, which included assessment time.
Results Panic Disorder Severity
Table 1 shows Panic Disorder Severity data before and after the intervention. Results from ANOVA conducted on the data summed across the 7 subscales showed a significant reduction in average panic disorder severity from pre-intervention to post-intervention, F(1,16) = 6.42, p < 0.05. Effect size was 0.29 and power was 0.66. Bartlett’s test of sphericity showed that scores on the 7 subscales of the PDSS did not share common variance and so before and after differences on each of these subscales were analysed with a series of t tests. Only panic frequency (t (10.28) = 4.72, p < 0.01) and distress during panic attacks (t (16) = 2.50, p < 0.05) improved significantly following intervention. No changes in the group data for anticipatory worry over panic, avoidance of panic sensations, agoraphobic avoidance, or impairment/interference in work and social functioning were found.
Anxiety Sensitivity and Body Vigilance
These are shown in Table 1. Anxiety Sensitivity scores showed no significant change from preTable 1. Means (and standard deviations) of panic disorder severity, anxiety sensitivity, body vigilance and misinterpretation ranks at pre- and post-intervention. Variable
Pre-intervention
Post-intervention
PDSS ASI BVS BSIQ Panic Body Sensations Social Events External Events Other Body Sensations
14.78 (3.90) 27.67 (9.86) 24.24 (7.70)
10.38 (3.46) 31.67 (15.31) 17.33 (6.87)
1.89 1.72 1.65 1.59
(0.47) (0.59) (0.29) (0.62)
1.43 1.42 1.54 1.33
(0.47) (0.61) (0.63) (0.40)
PDSS = Panic Disorder Severity Scale; ASI = Anxiety Sensitivity Index; BVS = Body Vigilance Scale; BSIQ = Body Sensations Interpretation Questionnaire . For PDSS, ASI and BVS lower scores mean less of the variable in question. For BSIQ higher scores denote more negative interpretations.
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intervention to post-intervention, F(1,16) = 0.43, p > 0.05. Effect size was 0.03 and power was 0.10. Body Vigilance scores showed a non-significant trend towards improvement from preintervention to post-intervention, F(1,16) = 4.03, p = 0.06, with an effect size of 0.20 and power of 0.47. Pre-post changes in body vigilance were correlated with pre-post changes in panic disorder severity to give a Pearson’s correlation coefficient = ‡0.19, which was not significant.
Interpretation of ambiguous events
Table 1 also shows the changes in mean rank scores on Panic Body Sensations, Social Events, External Events and Other Body Sensations. Univariate analysis showed a marginally significant decrease in scores on Panic Body Sensations from pre- to post-intervention, F(1,16) = 4.30, p = 0.055, with an effect size of 0.21 and power of 0.49. The results of univariate analyses conducted on the other 3 sets of interpretation data failed to show significant changes for Social Events, F(1,16) = 1.13, p > 0.05, General Events, F(1,16) = 0.21, p > 0.05, and Other Body Sensations, F(1,16) = 1.10, p > 0.05. The Pearson’s correlation coefficient of pre-post changes in interpretation of Panic Body Sensations with pre-post changes in total panic severity scores (from the PDSS) was 0.03. The Panic Body Sensation pre-post change scores were also correlated with changes in each of the 7 PDSS scales but again none of the resulting Pearson’s coefficients were significant.
Discussion Our results showed significant overall reductions in panic disorder severity subsequent to participants using the internet-based information program. These changes were specifically confined to reductions in panic frequency and distress during panic attacks. However, inspection of the individual data from the PDSS suggested that 2 of the 9 participants after intervention no longer met DSM-IV criteria for panic disorder. The size of the effect related to the overall reduction in panic disorder severity was moderate, although it may have been larger if the program had included interoceptive exposure instructions (Gould et al., 1995). Participants were somewhat less inclined to interpret ambiguous bodily sensations associated with panic as harm-related after intervention, given marginal statistical significance and a moderate effect size. Use of the internet-based program therefore was probably associated with a reduction in this cognitive bias. However, there was no evidence that changes in severity of panic disorder were related to less catastrophic interpretations of ambiguous panic body stimuli. Anxiety sensitivity scores did not change significantly over the course of the study, which was consistent with our earlier results with the 2-module program (Klein & Richards, 2001). Anxiety sensitivity appears to be a relatively stable individual difference characteristic, which may require more intensive modification to change (Cox et al., 1995). There were strong non-significant trends for body vigilance to decrease over the intervention period, which is consistent with other studies showing that decreases in exaggerated levels of body vigilance are associated with positive treatment outcomes (Borden, Clum, & Salmon, 1991; Schmidt et al., 1997) although we did not find a significant correlation between this variable and panic disorder severity. Because of the absence of a control condition, it was not possible to attribute changes in panic disorder severity and cognitive misinterpretation specifically to the internet-based program. However, our post-intervention assessment took place 3 months after participants said they had completed the program, which should be sufficient time for many of the demand and non-specific treatment effects to dissipate. Nevertheless, participants may still have been continuing to use the program when they were re-assessed. That there were not significant changes on the measures of interpretation of the other types of ambiguous events (particularly other body sensations not associated with panic) adds some support to the notion that our program had specific effects on misinterpretation of ambiguous panic body sensations.
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Another significant limitation to the present study was the small number of participants who completed the program. This meant that although the effect sizes obtained for body vigilance and misinterpretation of panic body sensations were moderate, low power made it difficult to obtain statistical significance. Notable was the fact that the attrition rate in this study was 36%. This figure is high when compared with face-to-face treatment (typically of the order of 10%), but is not very different from the 56% attrition found by Strom, Pettersson and Andersson (2000) in their internet-based treatment for recurrent headaches. Our attrition rate is also consistent with other studies utilizing self-help treatments for panic disorder (e.g. Febbraro et al., 1999). Unlike Febbraro et al. (1999) however, the present study included intermittent telephone contact with the therapist, which has been shown to reduce attrition in other studies (e.g. Marrs, 1995). In our study it appeared that one significant reason for attrition was dislike of, or unfamiliarity and discomfort with computer technology. The influence of this variable on the adoption of computer-based interventions needs further investigation. Although no conclusions can be drawn due to the small numbers of participants, 3 of the 5 people who discontinued their involvement in the program had a co-morbid diagnosis of generalized anxiety disorder. This issue of comorbidity might be investigated further. In summary, this study suggests that an internet-based program, incorporating the principles of cognitive therapy may be efficacious in reducing the severity of panic disorder, at least in relation to panic frequency and distress during panics. Our internet-based treatment also tended to be associated with reductions in bias towards harm-related interpretations of ambiguous interoceptive stimuli, which is presumed to underlie the development and maintenance of panic disorder. Although panic disorder severity was reduced over the course of the study, no attempt was made to measure the effects of the intervention on broader variables such as endstate functioning (Brown & Barlow, 1995) and quality of life (Rapaport, Pollack, Wolkow, Mardekian, & Clary, 2000), which should be done in future studies on the efficacy of internet-based treatment for panic disorder.
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