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This article, condensed from Chapter 14 of A Guide to the Standard EMDR Protocols for Clinicians, Supervisors, and Consultants (Leeds, 2009), examines applying eye movement desensitization and reprocessing (EMDR) to treating individuals with panic disorder (PD) and PD with agoraphobia (PDA). The literature on effective treatments for PD and PDA is reviewed focusing on cognitive and behavioral therapies, pharmacotherapy, and EMDR. Case reports and controlled studies of EMDR treatment of PD and PDA are examined for lessons to guide EMDR clinicians. Two model EMDR treatment plans are presented: one for cases of simple PD without agoraphobia or other co-occurring disorders and the other for cases of PDA or PD with co-occurring anxiety or Axis II disorders. A more extensive literature discussion, detailed treatment guidelines, and client education resources can be found in the original chapter.
Keywords: agoraphobia; CBT; EMDR; panic; pharmacotherapy; review
Individuals with panic disorder (PD) experience periods of extreme anxiety accompanied by intense somatic and cognitive distress. These episodes can be as brief as 1 to 5 minutes, but more commonly increase over a period of about 10 minutes. Some individuals experience episodes of panic that can wax and wane over an hour or longer. The symptoms of panic include palpitations, sweating, trembling or shaking, sensations of shortness of breath, sensations of choking, chest pain or discomfort, nausea or abdominal distress, dizziness or lightheadedness, derealization or depersonalization, fear of losing control or "going crazy," fear of dying, tingling, and chills or hot flushes. Initial episodes of panic are frequently perceived as just as life- threatening as other experiences that meet Criterion A for posttraumatic stress disorder (PTSD; American Psychiatric Association [APA], 2000).
To meet criteria for PD, panic attacks must recur and initially be unexpected rather than being linked to a specific situation as in specific phobia or social phobia. Subsequently, individuals may come to expect panic attacks in settings where they have occurred previously. This expectation may lead to avoidance of those settings and thus is associated with the development of agoraphobia-the fear of having panic in situations from which escape may be difficult. These settings include bridges, public transportation, crowds, and lines of people. In extreme agoraphobia, individuals become unwilling to leave their place of residence. PD is experienced by 2.7% of individuals older than the age of 18 each year (Kessler, Chiu, Demler, Merikangas & Walters, 2005). One in three of those with PD in the general population develop agoraphobia (National Institute of Mental Health, 2008). In clinical settings, the rate of agoraphobia is considerably higher (APA, 2000).
Treatments for Panic Disorder
Research on treatments for PD, with or without agoraphobia, has focused on pharmacological and cognitive behavioral therapy (CBT) approaches, both of which are generally considered effective treatments (American Psychiatric Association, 1998; Sturpe & Weissman, 2002). Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and benzodiazepines appear roughly equivalent in their efficacy (Campbell-Sills & Stein, 2006). CBT is as effective as first-line pharmacotherapies (Campbell- Sills & Stein, 2006). Both interoceptive exposure- deliberately inducing physiological symptoms of panic-and cognitive therapy appear to be equally effective for treating PD without agoraphobia (Arntz, 2002). Both panic-control treatment and in vivo exposure have been shown to reduce panic-related fears and agoraphobia (Craske et al., 2002).
Limitations of Existing Treatments
A 5-year follow-up of pharmacotherapy studies indicated that only 45% of those treated achieved full remission (Woodman, Noyes Jr, Black, Schlosser, & Yagla, 1999). Ost, Thulin, and Ramnerö (2004) note, "only 60% of the [panic disorder with agoraphobia] patients treated in RCTs published since 1990 have achieved a clinically significant improvement" (p. 1106). Dropout rates are reported as high as 24% for exposure (Marks et al., 2004) and 26% for CBT (Bakker, van Dyck, Spinhoven, & van Balkom, 1999). Research also suggests that those who are more severely affected by PDA are more likely to refuse or drop out of these treatments (Hunt, 2000).
Research on EMDR Treatment of Panic Disorder
Research on EMDR treatment of PD and panic disorder with agoraphobia (PDA) is considerably more limited than for EMDR treatment of PTSD. There is an early case series, (Goldstein & Feske, 1994), four individual case reports (Fernandez & Faretta, 2007; Goldstein, 1995; Nadler, 1996; Shapiro & Forrest, 1997), and two controlled studies (Feske & Goldstein, 1997; Goldstein, de Beurs, Chambless, & Wilson, 2000).
The First Panic Disorder Case Series by Goldstein and Feske (1994)
Goldstein and Feske published the first case series on seven cases of PD in 1994. Five patients also met criteria for agoraphobia. Standard EMDR reprocessing was applied to targets such as the first and worst episodes of panic attacks, life events related to panic, and anticipated panic attacks. All seven patients experienced decreased fear of panic attacks and behavioral gains with an absence of or decreased frequency of panic attacks.
Breaking Through the Barriers to Recovery-Goldstein (1995)
In 1995, Goldstein published a key paper exploring the limitations of existing cognitive-behavioral treatments for PD and PDA. He cited a review by Chambless and Gillis (1994) indicating an average improvement rate of 58%, with only 27% of exposure participants ending treatment with little or no residual agoraphobic behavior.
Panic Attacks That Can Persist for Hours. First, Goldstein observes that these patients seem to have disconnected or disassociated the formative experiences from the affective component of the maladaptive memory network. When the maladaptive memory network of these formative experiences is triggered, patients can go into a state similar to a panic attack that goes on for hours. Patients with PDA "attribute these feelings to insanity, a biochemical disorder or signs of some disease" (Goldstein, 1995, p. 87). Second, clinicians may be unable to tolerate the intensity of affect generated when patients with PDA access their central issues. Finally, Goldstein proposes that the formative experiences of this maladaptive memory network involve an early "parent-child role reversal" frequently reported by PDA patients (Goldstein, 1995, p. 87). Goldstein directs his readers to the work of John Bowlby (1973) for a discussion of the role of attachment issues in the development of agoraphobia.
Goldstein's description of the lack of association between PDA patients' prolonged states of anguish, dread, and fear of loneliness, and their childhood experiences of parent-child role reversal, as dissociation suggests that we might view PDA through the lens of the model of structural dissociation just as van der Hart, Nijenhuis, and Steele (2006) suggest we view PTSD. This formulation strengthens the conceptualization that a prolonged exposure to misattunement in early childhood with insecure or disorganized attachment should be considered a contributory foundation for cases of complex PDA. This leads to the rationale for considering EMDR as an approach in cases of complex PDA. Goldstein illustrated his formulation of complex PDA with a case report on Ms. C. It is unclear from the session summaries to what degree treatment gains were the result of exposure, EMDR reprocessing, assertiveness training, or the therapeutic relationship since these different treatment elements overlapped and alternated.
Psychodynamically Informed EMDR Treatment of Panic Disorder
Nadler (1996) presented a single case report of a woman in her late 20s whom he refers to as "Sarah." Two sessions of EMDR reprocessing appeared to alleviate Sarah's panic attacks and reduced her anticipatory anxiety.
Shapiro and Forrest: Panic Disorder in a Case of Unresolved Traumatic Loss
Shapiro and Forrest (1997, pp. 74-88) described the case of Susan, a woman with a lifelong fear of storms, who had her first panic attack while sitting at home with her second husband, listening to a blizzard outside just 6 years after the tragic death of her first husband in a tornado. This vivid, narrative case report suggests that brief treatment with EMDR for PD can be successful, but provides no standardized measures or follow-up information on stability of treatment effects.
Fernandez and Faretta (2007): Resolving Separation Anxiety in a Case of Panic Disorder With Agoraphobia
Fernandez and Faretta (2007) described a case of a 32-year-old woman, Adriana, treated with EMDR for PDA that had started when she was 20 years old. Adriana's panic attacks occurred when driving alone and led to an avoidance of driving alone. Eventually, she became afraid to be alone, even at home, and had to have a companion at all times. Her history revealed several early contributory and recent etiological events that were addressed in the comprehensive treatment plan.
Fernandez and Faretta (2007) indicated that Adriana received a total of 30 treatment sessions. Six sessions were devoted to history taking and preparation. This initial phase was followed by 12 sessions of EMDR reprocessing of targets selected from past events and triggers. Then three sessions were devoted to EMDR reprocessing of rehearsal of future behaviors. Finally, there were nine additional sessions reviewing results from the active treatment phase. Follow-up data was collected posttreatment at 3 months, 6 months, and 1 year. Follow-up data confirmed that Adriana achieved the following: elimination of anxiety, panic attacks, and avoidance behaviors; establishment of the ability to be alone and drive; resolution of agoraphobic symptoms; insight about symptoms and secondary gains; establishment of a new self-perception; and return to normal daily life functioning.
Fernandez and Faretta (2007) emphasized the importance when treating agoraphobia of providing an extended preparation phase, and contrasted the six sessions of history taking, alliance building, and psychoeducation offered Adriana with the single session of history and preparation provided in the controlled study by Goldstein et al., (2000)- reviewed in the next section. They emphasized the ability of EMDR reprocessing to assist the uncovering and resolving of key contributory and etiological events and maladaptive learning experiences. Like Goldstein (1995) and Nadler (1996), they drew attention to the need to identify and apply EMDR reprocessing to attachment related issues (Fernandez & Faretta, 2007, p. 50).
Controlled Research: Feske and Goldstein (1997)
In 1997, Feske and Goldstein published the first controlled study of EMDR treatment for PD. All but two participants also met criteria for agoraphobia. They randomly assigned 43 outpatients with PD to a waiting list, to receive six sessions of EMDR reprocessing, or six sessions of an EMDR-like treatment without eye movements called "eye fixation exposure and reprocessing" (EFER). Subtitled "A Controlled Outcome and Partial Dismantling Study," the research design focused on the question of the extent to which eye movements contribute to treatment effectiveness without adequately considering the question of what constitutes an adequate trial for EMDR treatment of PDA itself.
In the active treatment groups, participants received one history-taking session followed by five EMDR or EFER sessions (one 2-hour and four 90-minute sessions) over 3 weeks. Participants were offered no other preparation or treatment interventions such as the calm-place, relaxation or breathing exercises, or in vivo exposure. Deliberate targeting of current stimuli, such as unpleasant body sensations, was excluded to avoid procedures similar to in vivo exposure. No specific effort was made to identify or target early adverse childhood experiences of separations, traumas, or stressful parental interactions.
Feske and Goldstein (1997) found EMDR to be more effective in alleviating panic and panic-related symptoms than the waiting-list procedure at posttest. Compared with EFER, EMDR led to greater improvement on two of five primary outcome measures at posttest. However, at the 3-month follow-up, EFER and EMDR showed statistically equivalent results. Although Feske and Goldstein provided good evidence for procedural fidelity within their EMDR reprocessing sessions, it appears that the overall treatment plan and number of sessions offered failed to meet the standards set by the authors of the successful single case reports and suggested by EMDR's developer (Shapiro, 2001).
Goldstein, de Beurs, Chambless, and Wilson (2000)
In 2000, Goldstein et al. published a controlled study of PDA essentially replicating Feske and Goldstein (1997). They randomly assigned 46 participants to a wait-list, EMDR or an alternate condition, but they replaced the eye fixation condition (EFER) with a credible placebo-controlled condition known to be ineffective for PDA. At the end of the waiting period, wait-list participants were randomly assigned to one of the two treatment conditions. The credible placebo-controlled treatment, referred to as " association and relaxation therapy" (ART), consisted of 30-45 minutes of progressive muscle relaxation training followed by 30-45 minutes of association therapy. Given the positive initial findings from both the uncontrolled case series in Goldstein and Feske (1994) and from the randomized controlled study by Feske and Goldstein (1997), a more useful study would have directly compared EMDR to a credible alternate known effective treatment such as cognitive therapy or exposure.
Participants received just five 90-minute sessions of treatment with either EMDR reprocessing or ART. Neither group received the kind of extended preparation or treatment, described as important in the earlier report by Goldstein (1995) or in the later report by Fernandez and Faretta (2007). Indeed, "Throughout treatment, therapists in both conditions were prohibited from using interventions outside the realm of the protocol such as anxiety management training, cognitive restructuring, in vivo exposure, and exploration of intrapsychic issues" (Goldstein et al., 2000, p. 949). Results showed less benefit from EMDR treatment than in the earlier study by Feske and Goldstein (1997). The authors cited several reasons that these weaker results could not be due to poor methodology. Their conclusion was that, "In light of the availability of treatments with solid efficacy evidence, the results of this investigation do not support the use of EMDR for treatment of panic disorder with agoraphobia" (Goldstein et al., 2000, p. 955).
This study suffers from the same treatment design issues as the study done 3 years earlier by Feske and Goldstein (1997). These include (a) not offering the number of sessions needed for preparation and development of rapport; (b) not uncovering and reprocessing maladaptive memory networks related to adverse, attachment-related childhood experiences or traumas; (c) not reprocessing current stimuli and triggers including unpleasant physical sensations associated with panic attacks-on the grounds that this would involve in vivo exposure; and (d) not helping participants prepare for future situations.
Contrasting Good Fidelity in Single Sessions With an Adequate Treatment Plan
It is entirely possible to have good fidelity to the standard EMDR procedural steps when reprocessing each selected target and fail to offer an adequate treatment plan. In the study by Goldstein et al. (2000), 13 participants also met the criteria for generalized anxiety disorder (GAD), social phobia, or obsessive-compulsive disorder, and 7 of the participants also met the criteria for obsessive-compulsive personality disorder or avoidant personality disorder. Based on the individual PDA case reports cited in this article and other reports on the application of EMDR to the treatment of Axis II disorders (Manfield, 2003) and GAD (Gauvreau & Bouchard, 2008), a significantly more comprehensive and longer treatment plan would be needed to successfully treat patients with these comorbid conditions.
A Spectrum of Cases From PD to PDA to Panic Secondary to PTSD
In simpler cases, most commonly in PD without agoraphobia, EMDR reprocessing of memories of first, worst, or recent occurrences of panic attacks leads to simple associations within the memory of the panic experiences without associations to deeper feelings of dread of loneliness and without recall of distressing childhood attachment-related memories. In more complex cases of PDA, to achieve successful resolution of the affective avoidance that underlies the agoraphobia, EMDR reprocessing of memories of panic attacks eventually leads to the uncovering of associations to childhood memories of parental separations, strict parenting, superficial parenting without "mindsight" (Siegel, 1999, p. 140), parental illness, neglect, or to experiences of parent-child role reversals. These maladaptive memory networks can include preverbal material for which patients have no defined memories but which evokes intense affective states as well as later experiences for which patients have discrete childhood memories.
A treatment plan that initially targets these earliest life events for EMDR reprocessing may expose the patient to the full intensity of deep feelings of dread, loneliness, hurt, anger, or grief for which some patients may not feel adequately prepared. Instead, these patients need a structured approach that combines reassurance with a treatment plan that begins with concrete anxiety management skills, resource development and installation for self-soothing and affect tolerance, and then initially targets their panic attacks. These patients first need to achieve a sense of mastery and greater confidence in EMDR reprocessing and an adequate sense of trust in the therapeutic alliance through successfully completed, within-session reprocessing of memories of first, worst, and most recent panic attacks. Only after some initial gains are these patients ready to address the central contributory memories holding the core painful affects that underlie their panic attacks and agoraphobia.
This approach bears similarities to the "inverted protocol" described by Dr. Arne Hofmann (2004, 2005) for treatment of complex PTSD in which the sequence of targets selected for reprocessing inverts the standard "past, present, and future" treatment planning sequence proposed by Shapiro (1995, 2001). Many patients with PDA also meet the proposed criteria set for disorders of extreme stress not otherwise specified (DESNOS) or complex PTSD (Herman, 1992; Pelcovitz et al., 1997). The treatment plans described in this article are generally not sufficiently comprehensive to adequately meet the clinical needs of these patients. This can seem mysterious to patients and even to some referring clinicians less familiar with the adaptive information processing (AIP; Shapiro, 2001) model and the literature on DESNOS who tend to view a condition like PD or PDA as a discrete set of symptoms that can be considered and treated separately from the overall life experience of the patient.
Phase 1: History Taking and Treatment Planning Issues
It is important to consider potential medical and lifestyle factors that can contribute to the onset, frequency, and severity of panic attacks. Excess consumption of caffeinated beverages and over-the-counter medications can create anxiety states that make panic attacks more likely. Sleep deprivation can be a significant factor in anxiety states as well. A thorough screening should check on sleep hygiene (Foldvary- Schaefer, 2006).
Screening for Formative Experiences That Preceded the Onset of Panic Attacks
Both a thorough history and comprehensive clinical assessment, which considers comorbid conditions, are essential to the formulation of the treatment plan in cases of PDA. Even when PDA patients can identify formative maladaptive experiences from childhood early in the treatment planning process, they may dissociate or minimize the relationship between these events and their panic attacks.
Screening for Impaired Caregivers and Experiences of Parent-Child Role Reversals
History taking needs to consider adverse life events- both those that meet Criterion A for PTSD as well as those that do not meet Criterion A (APA, 2000) such as early life exposures to perceived and actual abandonments and impaired caregivers, especially in the first few years of life. Early experiences of persistent parental misattunement can create recurrent states of abandonment terror and episodes of disorientation and dissociation. When chronic, these experiences lead to insecure attachment and an increased vulnerability to adolescent and adult psychiatric disorders (Schore, 1996, 1997). Clinicians should not start from an assumption that formative life experiences involving impaired caregivers or parental misattunement are invariably involved in the etiology of PD or PDA. Until there are widely accepted tests for genetic vulnerability to PD (Philibert et al., 2007), clinicians have to rely on careful psychosocial assessment and history taking.
Phase 2: Preparation Phase Issues
In order for patients with PDA or PD with co-occurring GAD, DESNOS, or an Axis II disorder to be able to make informed consent to treatment they need to know that formative childhood experiences may need to be addressed later in the treatment plan. First, provide basic psychoeducation on panic attacks, the physiological symptoms they experience, and clarify that, while distressing, they pose no threat to their physical health. Next, patients need to learn and practice self-control and anxiety management procedures to gain some control over their background anxiety states. If they experience depersonalization episodes, they need education about these experiences and how to gain control over them (see Leeds, 2009, Chapter 6.) Finally, patients need to be provided basic information about EMDR reprocessing itself and the likely sequence and stages of their treatment plan.
Phase 3: Assessment of the Target
When treating a patient with PD or PDA, the procedural steps for the assessment of targets selected for reprocessing are identical to those used for treatment of PTSD. These are described in detail in Chapter 7 (Leeds, 2009, pp. 129-142). When treating memories of past panic attacks, it is more likely you will find negative self-appraisals reflecting the perception of extreme danger-"I am not safe" or "I am going to die"-or a lack of control-"I am helpless" or "I am not in control." However, if attention later shifts to contributory experiences from childhood involving parent-child role reversals you may find negative selfappraisals reflecting a lack of self-worth such as "I am worthless," or "My feelings do not matter," or "I am invisible."
Phase 4: Reprocessing Requires Decisions on When to Move to Core Material
Procedures for reprocessing of targets for PD and PDA are essentially identical to those for PTSD (see Leeds, 2009, Chapters 8, 9, and 10). Clinicians need to be prepared to make decisions on when to follow associations to earlier contributory experiences based on an appraisal of the patient's sense of trust and selfcapacities for affect tolerance.
Phase 5: Installation Phase
Normally, you continue the desensitization phase until the SUD is reported to be stable at a zero before proceeding to the installation phase. However, with some patients with PDA you may elect to offer a modified form of installation of a modified positive cognition (PC) when the desensitization phase remains incomplete and the SUD has only dropped to a 2, 3, or 4. In this situation, it is important not to press the patient to continue to a Validity of Cognition (V°C) rating of 7. Simply offer two or three standard sets of BLS checking the V°C on the modified PC after each set. Also, you would not go on to do the body scan phase because this would clearly be an incomplete session (see Leeds, 2009, Chapter 10, for procedures for closure of an incomplete session and for Phase 6, Body Scan Phase).
Phase 7: Closure Procedures
During the closure phase, clinicians should be alert to counter-transference urges to rescue PD and PDA patients from feelings that they are actually capable of tolerating. However, when patients want or need assistance to feel calmer and more in control at the end of an intense EMDR reprocessing session, offer assistance with the calm place, guided imagery, breathing, and other interventions that have been found to be most helpful in the preparation phase. It is helpful after completing extended closure interventions to allow additional time for patients to mentalize (Allen, 2003; Fonagy, Gergely, Jurist, & Target, 2002) about their experiences in the session.
Phase 8: Re-Evaluation
Standard re-evaluation steps are described in detail in Leeds, 2009, Chapter 11. In cases of simple PD without agoraphobia or any other co-occurring anxiety disorder or an Axis II disorder, clinicians will generally find that the model I treatment plan-described in Figure 1-will be sufficient. In cases of PDA or PD with a co-occurring anxiety disorder or an Axis II disorder, the two-layered model II treatment plan will generally be necessary. The model II treatment plan requires clinicians to assess emerging patient readiness based on treatment gains before making a transition from selecting targets based directly on panic attacks themselves to targets based on contributory memories from childhood.
Incorporating the Future Template
When, after resolving contributory childhood experience, past memories of panic and current cues, patients continue to experience anticipatory anxiety over the possible recurrence of certain interoceptive sensations or avoid certain situations because of residual anxiety, it can be helpful to incorporate reprocessing future templates. During reprocessing with the future template, patients rehearse reexperiencing the interoceptive sensations that they still fear or imagine being in the feared situations to help further resolve associated anxiety.
Evaluating and Responding to Feedback From In Vivo Exposure
The only way to be completely certain that treatment has been successful is when patients expand their activities without reexperiencing symptoms of panic. At some point, patients need to make specific plans for in vivo exposure. In vivo exposure assures patients achieve their treatment goals by providing opportunities both for identifying residual targets that need further reprocessing and for mastery experiences that represent consolidation of their gains in treatment.
Summary
While existing cognitive, behavioral, and pharmacotherapy treatments for PD and PDA are generally considered effective, a significant percentage of patients receiving these treatments either drop out or fail to achieve clinical goals. Published case reports suggest EMDR treatment of PD and PDA can help eliminate symptoms of panic and agoraphobia. Controlled EMDR treatment outcome studies of PDA have failed to show the same gains as the individual case reports. This may be due to the need to provide extended preparation phase interventions and apply the model II approach with a gradual transition to reprocessing contributory events. It is hoped that future controlled research will compare EMDR treatment of PDA with cognitive behavioral treatment and will incorporate the model II approach outlined here (and described in detail in Leeds, 2009, Chapter 14). Published case reports of EMDR treatment of simple PD without agoraphobia or other co-occurring disorders suggest it can be effective in a small number of sessions and that EMDR treatment of PDA can be effective when the model II approach is employed. Clinicians need to keep in mind the importance of offering sufficient preparation and trust building when treating cases of PDA or PD with other co-occurring anxiety or Axis II disorders.
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Andrew M. Leeds
Sonoma Psychotherapy Training Institute, Santa Rosa, CA
Correspondence regarding this article should be directed to Andrew M. Leeds, 1049 Fourth St., Suite G, Santa Rosa, CA 95404-4345. E-mail: [email protected]
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