Cognitive-Behavioural Treatment of Panic Disorder During Pregnancy and Lactation* LYNNE ROBINSON, Ph.D.', JOHN
R. WALKER, Ph.D. 2 AND DONNA ANDERSON, M.D. 3
the clinician-patient relationship. Mogul (2) suggests that pregnancy increases a woman's concerns about pharmacological treatment. A pregnant woman is also bombarded by warnings about many substances. If the alternatives to medication are not adequately explained, she may feel guilt and anxiety about risks to her child. Moreover, patients increasingly demand the right to be informed about available treatments and the risks and benefits of each. A clinician may be caught in the middle of these conflicting emotions. Once the patient's initial preferences and awareness of the situation have been evaluated, a joint discussion of alternatives will allow the clinician to respond to the patient's concerns, ensuring a better therapist-patient rapport and a more positive outcome. Little is known about the effects of psychotropic medication on the fetus or on breast-feeding infants, or the effects of acute or chronic episodes of anxiety on the fetus or child or on the mother-child relationship. However, patients with panic disorder are at risk of developing major depression and chemical dependency, including alcohol abuse. If the disorder is left untreated, it may interfere with a successful transition to parenthood because of a diminished appetite from anxiety, unnecessary fears about the birth and motherhood, self-medication, or restriction of activities. Cowley and Roy-Byrne (3) give a more detailed discussion of panic disorder during pregnancy. There are valid reasons for avoiding psychotropic medications (4) or leaving panic disorder untreated during pregnancy and lactation. It is generally accepted that alprazolam, imipramine, and phenelzine are effective in treating panic disorder (5). Cognitive-behavioural therapy is also a well accepted and evaluated treatment for a variety of psychiatric problems and is now being evaluated specifically for treating panic disorder. A recent study (6) using a double-blind procedure indicated that cognitive-behavioural therapy was significantly superior to either placebo or no therapy and at least as effective as alprazolam in treating panic disorder, although it may not be as immediately effective (7). We have found that the patient feels significant relief after the initial interview and from keeping a diary of anxiety and panic attacks, once the patient knows that treatment will be beginning soon. Alprazolam has a few side-effects (8) and is relatively well accepted by patients (7). Ballenger et al (7), in their literature review, found that up to one-third of patients using tricyclic antidepressants or monoamine oxidase (MAO) inhibitors experience intensified anxiety at the beginning of treatment and many continued to experience anticipatory anxiety. The use of MAO inhibitors requires dietary restrictions. Klosko et al
The treatment of panic disorder during pregnancy and lactation poses special problems. It is important that both the practitioner and patient consider a number of issues to find the most appropriate treatment for the patient. New cognitive-behavioural treatment options often circumvent the problems of pharmacotherapy for pregnant or lactating women while providing therapeutic benefits which are at least equivalent.
P
anic disorder is a common problem. Panic disorder associated with agoraphobia, is more common among women and typically begins in the late 20s (I), the peak childbearing years. Thus, it is to be expected that a significant number of women who suffer from panic disorder will be pregnant or lactating during treatment. Panic disorder is diagnosed on the basis of the occurrence of panic attacks accompanied by a number of somatic symptoms and/or fears and in the exclusion of other major functional or organic illness (1). Psychiatrists are often reluctant to prescribe medication, an effective treatment for panic disorder, during pregnancy, and many patients are reluctant to take it. Cognitivebehavioural therapy should be considered as an alternative treatment for panic disorder.
Differential Therapeutics To determine the appropriate treatment for a pregnant woman with panic disorder, the clinician should review four major issues with the patient: the patient's preferences, the effects of withholding treatment, the effects of treatment on the child, and the effectiveness and availability of treatments. Pregnancy is a time of great stress for many women. New fears and anxieties may emerge, including fears of losing control, which can be either exacerbated or ameliorated by "Manuscript received November 1990, revised July 1991. IDepartment of Psychology, Simon Fraser University, Burnaby, British Columbia. 2Associate Professor, Department of Psychiatry, University of Manitoba; Coordinator, Anxiety Disorders Clinic, Department of Psychiatry, St. Boniface General Hospital, Winnipeg, Manitoba. 3Private Psychiatric Practice; formerly, Assistant Professor, Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba. Address reprint requests to: John Walker, Ph.D., M4 - Department of Psychiatry, St. Boniface General Hospital, 409 Tache Avenue, Winnipeg, ManitobaR2H2A6
Can. J. Psychiatry Vol. 37, November 1992
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624
CANADIAN JOURNAL OF PSYCHIATRY
(6) report that improvement is maintained at one and two year follow-up with cognitive-behavioural therapy. Withdrawal effects and relapse have been found with discontinuance of alprazolam (6). Fyer et al (8) estimate the relapse rate to be nearly 30% with tricyclic antidepressants and much higher with MAO inhibitors. Other forms of non pharmacological treatment are available to the pregnant or lactating woman. Arange ofbehavioural and other therapies have been used to treat panic disorder. Several reviews have found that treatment is most successful when it is focused specifically on panic attacks rather than simply on exposure to feared situations (9,10). Supportive therapy or reassurance or any of a variety of social supports in the community may be provided. By itself, such support may not alleviate the symptoms of panic disorder sufficiently to ensure the well-being of the mother and baby. The patient may be hospitalized, but this is extremely costly and may interfere with the marital relationship and the couple's preparation for parenthood. These interventions are probably most useful when combined with more specific treatment. In general, since no treatment is clearly superior overall, all treatment options should be considered in order to choose the best one for the patient.
Case Report The patient was a 26 year old bank clerk who was happily married. She presented with panic attacks four months before the delivery of her first baby and met the DSM-III-R (1) criteria for panic disorder. She experienced her first panic attack about two and one-half years prior to treatment at our clinic. During the initial interview, it became clear to the patient that the panic attacks had begun several months after a high school friend had committed suicide. The patient expressed many concerns about losing control, harming herself (for example, stabbing herself with a knife) and feared that she might be crazy. When she was feeling anxious, she experienced gastro-intestinal distress and nausea, heart palpitations, choking and dizziness. She also experienced maladaptive thoughts, such as "I might never get over these panic attacks," "I will not be able to control myself," and "I am going to throw up," as well as negative images, that of dropping a birthday cake in front of a crowd. Cognitivebehavioural therapy led her to discover that panic attacks were usually preceded by the thought "What if I dry heave?" The panic attacks had increased in frequency during the year prior to treatment. They occurred, with no precipitants that were evident to the patient, approximately 1.5 times per week. The patient expressed many concerns about the effect of her panic disorder on parturition and child-rearing. She reported having always had a fear of vomiting and eating in public. These fears had diminished with time, suggesting an additional diagnosis of social phobia. There were no other psychiatric symptoms, and there was no history of serious medical problems. Data on the patient's anxiety, degree of phobic avoidance and panic attacks were collected during all phases of treatment, using a daily diary, a panic diary, and weekly adminis-
Vol. 37, No.9
tration of the Fear Questionnaire (11). Baseline data were collected for three weeks prior to initiation of treatment. Treatment took place over a six week period, with one hourlong session per week. Follow-up data were recorded for nine weeks. There were additional follow-up contacts 34, 39 and 100 weeks after the data collection began.
Cognitive-Behavioural Treatment The cognitive-behavioural treatment consisted of information-giving, self-monitoring, cognitive restructuring, in vivo exposure and follow-up. Adjustments in the style of implementing the treatment may be necessary in order to limit the anxiety experienced during therapy. Information-giving is rated by patients as an important component of treatment. The patient was given written information on panic disorder and explicit reassurance about her fears. Self-monitoring consists of recording episodes of anxiety, the events and thoughts which precede and follow the episodes, and, during treatment, the effects of the coping techniques being taught. This serves several purposes. First, it allows the therapist and patient to see the connections between thoughts, situations and body sensations and the experience of anxiety or panic, suggesting to the patient that cognitive changes can be made. Observing the occasions and thoughts which precipitated anxiety allows the patient to understand their effects on panic attacks. For example, feelings of nausea often led to fear of having a panic attack. On several occasions, after careful examination of the situation, the patient found that the nausea was secondary to overeating, a normal experience which she had misinterpreted. Second, the self-monitoring record permits a more accurate comparison of symptoms before, during, and after treatment, providing an assessment of the effectiveness of treatment and allowing us to fine-tune treatment. Initial progress gave the patient a sense of control over her symptoms, which she had experienced as long term and debilitating, and this progress improved her commitment to therapy. Cognitive restructuring includes a variety of techniques directed toward changing the patient's thoughts. Examination of self-monitoring records reveals the thoughts and images which may increase feelings of anxiety, often by misinterpretation of normal or anxiety-related body sensations as threatening or catastrophic events (12). Treatment may focus on recognizing this connection through self-monitoring (as in our patient's experience of nausea) or through therapeutic manipulations which illustrate the connection between unpleasant body sensations and catastrophic thoughts. Hyperventilation is often used in this way, but there are concerns about its effects on the fetus during pregnancy; this technique was not used with our patient. "Reframing," or describing a situation in different terms can be used to change the meaning of an event for the patient. Panic attacks were reframed for this patient as new opportunities to practise her skills rather than as failures. Patients may learn to use thoughts which act to "neutralize" anxiety-provoking thoughts. The patient found that using the thought "so what?" was effective in
November, 1992
625
PANIC DISORDER DURING PREGNANCY AND LACTATION
counteracting the effects of anxiety-inducing thoughts, such as "I might leave my baby crying while I have a panic attack." In vivo exposure consists of actually experiencing the situations which have been feared and avoided. This allows patients to discover that the situation is not as catastrophic as feared, to practise these skills and to observe and influence their own responses. For example, the patient had previously avoided dinner parties but agreed to schedule them in order to practise neutralizing her thoughts. Follow-up is important to ensure that the acquired skills continue to be effective and to manage any sequelae of treatment termination. We contacted the patient 18 weeks after therapy was terminated, after delivery of her baby, and she was doing well. Several weeks later she asked for a follow-up appointment. At that session she stated that she had experienced some anxiety during the summer and she had experienced debilitating anxiety during the previous several summers. She had the anxiety-producing thought "What if I am slipping back?" However she was able to write out her thoughts and a!' a result saw them as "silly". Moreover, whereas in previous summers she had lost weight and been unable to do her shopping, she recognized that this summer she was anxious at times, 'but the anxiety was well under her control by the time she was able to meet with the therapist. This incident highlights the importance of follow-up contact which is used to give the patient the message that some periods of "slipping back" are to be expected and are not failures or catastrophies, but are opportunities for further practice of her new-found skills. Follow-up to ensure that treatment effects are maintained becomes even more important after childbirth, given the stress of that event, possible hormonal effects on anxiety and the risks of post-partum depression, Results of Treatment Panic attacks declined from 1.5 per week during the baseline period to 0.33 per week during the treatment period (during cognitive restructuring and planned exposure to feared situations); 0.33 attacks occurred per week during the first nine weeks of follow-up, and 0.06 times during the following 16 weeks. Two of the three attacks during the first nine weeks of follow-up occurred on the day when she went into labour, she felt the panic attacks were fairly natural under the circumstances. At the end of follow-up, the patient felt that she was able to handle any episodes of anxiety which arose. Her ratings of distress due to "fear of having a panic attack" also declined steadily from a high of "extremely distressing" during baseline and at the beginning of treatment, through "slightly distressing" during follow-up, to a final follow-up rating of "not at all distressing" two years after treatment. There were similar patterns of improvement in the patient's ratings of anxiety/depression and avoidance of eating in public. The improvements were documented (using the Fear Questionnaire). The patient provided low ratings in all areas by the end of treatment, and these changes were maintained over the follow-up periods. George et al (13) have suggested on the basis of three retrospective case studies, that
pregnancy itself may ameliorate the symptoms of panic disorder. This is unlikely our case, since the patient's pregnancy was well advanced when therapy was initiated, which was for an exacerbation rather than an amelioration of her symptoms. The reduction in her symptoms matched the progress of therapy, and the reduction in anxiety was maintained postpartum and at follow-up (unlike the cases reported by George et al). Cowley and Roy-Byrne (3) reported improvement in the majority of the women they studied with panic disorder who became pregnant, but worsening of symptoms in two of the women. Conclusions Cognitive-behavioural treatment has been found effective, and now larger scale studies are being conducted to compare it with the pharmacological treatment of panic disorder. Initial results suggest that these techniques are at least as effective as treatment with alprazolam, and while they may be less immediately efficacious, they may have greater long term effects and do not result in deterioration or relapse when treatment is terminated (6). However, patients with limited intellectual ability, psychological insight or cooperation may not do as well with cognitive-behavioural treatment. Medication is currently the most accessible form of treatment for panic disorder. However, there are therapists familiar with cognitive-behavioural therapy in most large centres. When the issues outlined in the introductory section are considered, cognitive-behavioural therapy may well be the treatment of choice for many women who are or who may become pregnant. Further information on cognitive-behavioural treatment of panic disorder has been published in an article by Barlow and Cerny (14). References 1. Diagnostic and statistical manual of mental disorders, third edition, revised. Washington DC: American Psychiatric Press, Inc., 1987. 2. Mogul KM. Psychological considerations in the use of psychotropic drugs with women patients. Hosp Community Psychiatry 1985; 36: 1080-1085. 3. Cowley OS, Roy-Byrne PP. Panic disorder during pregnancy. Journal of Psychosomatic Obstetrics Gynaecology 1989; 10: 193-210. 4. Mortola JF. The use of psychotropic agents in pregnancy and lactation. Psychiatr Clin North Am 1989; 12: 69-87. 5. Roy-Byrne P, Katon W. An update on treatment of the anxiety disorders. Hosp Community Psychiatry 1987; 38: 835-843. 6. Klosko JS, Barlow DH, Tassinari RB, et al. A comparison of alprazolam and cognitive behavior therapy in the treatment of panic disorder. J Consult Clin Psychol 1990; 58: 77-84. 7. Ballenger JC, Burrows GO, DuPont RL, et al. Alprazolam in panic disorder and agoraphobia: results from a multicenter trial. Arch Gen Psychiatry 1988; 45: 413-422. 8. Fyer AJ, Sandberg 0, Klein OF. Pharmacological treatment of panic disorder and agoraphobia. In: Walker JR, Norton GR, Ross CA, eds. Panic disorder and agoraphobia: a comprehensive guide for the practitioner. Pacific Grove CA: Brooks/Cole, 1991. 9. Clum GA. Psychological interventions vs drugs in the treatment of panic. Behavior Therapy 1989; 20: 429-457.
626
Vol. 37, No.9
CANADIAN JOURNAL OF PSYCHIATRY
10. Pecknold JC. Behavioral and combined therapy in panic states. Prog Neuropsychopharmacol Bioi Psychiatry 1987; II: 97-
104.
11. Marks 1M, Mathews AM. Brief standard self-rating for phobic patients. Behav Res Ther 1979; 17: 263-267. 12. Clark DM. A cognitive approach to panic. Behav Res Ther 1986; 24: 461-470. 13. George D, Ladenheim J, Nutt D. Effect of pregnancy on panic attacks. Am J Psychiatry 1987; 144: 1078-1079. 14. Barlow DH, Cerny JA. Psychological treatment of panic. New York: The Guilford Press, 1988.
Resume Le traitement du trouble de panique durant la grossesse et la lactation pose des problemes particuliers. Il est important que Ie medecin et la malade examinent plusieurs questions afin de choisir le traitement qui convient le mieux. Des nouvelles options therapeutiques, les therapies cognitives et comportementales, permettent souvent de contourner Ie probleme que pose la pharmacotherapie pour la femme enceinte au en lactation en donnant des resultats au mains equivalents.
R. WALKER, Ph.D. 2 AND DONNA ANDERSON, M.D. 3
the clinician-patient relationship. Mogul (2) suggests that pregnancy increases a woman's concerns about pharmacological treatment. A pregnant woman is also bombarded by warnings about many substances. If the alternatives to medication are not adequately explained, she may feel guilt and anxiety about risks to her child. Moreover, patients increasingly demand the right to be informed about available treatments and the risks and benefits of each. A clinician may be caught in the middle of these conflicting emotions. Once the patient's initial preferences and awareness of the situation have been evaluated, a joint discussion of alternatives will allow the clinician to respond to the patient's concerns, ensuring a better therapist-patient rapport and a more positive outcome. Little is known about the effects of psychotropic medication on the fetus or on breast-feeding infants, or the effects of acute or chronic episodes of anxiety on the fetus or child or on the mother-child relationship. However, patients with panic disorder are at risk of developing major depression and chemical dependency, including alcohol abuse. If the disorder is left untreated, it may interfere with a successful transition to parenthood because of a diminished appetite from anxiety, unnecessary fears about the birth and motherhood, self-medication, or restriction of activities. Cowley and Roy-Byrne (3) give a more detailed discussion of panic disorder during pregnancy. There are valid reasons for avoiding psychotropic medications (4) or leaving panic disorder untreated during pregnancy and lactation. It is generally accepted that alprazolam, imipramine, and phenelzine are effective in treating panic disorder (5). Cognitive-behavioural therapy is also a well accepted and evaluated treatment for a variety of psychiatric problems and is now being evaluated specifically for treating panic disorder. A recent study (6) using a double-blind procedure indicated that cognitive-behavioural therapy was significantly superior to either placebo or no therapy and at least as effective as alprazolam in treating panic disorder, although it may not be as immediately effective (7). We have found that the patient feels significant relief after the initial interview and from keeping a diary of anxiety and panic attacks, once the patient knows that treatment will be beginning soon. Alprazolam has a few side-effects (8) and is relatively well accepted by patients (7). Ballenger et al (7), in their literature review, found that up to one-third of patients using tricyclic antidepressants or monoamine oxidase (MAO) inhibitors experience intensified anxiety at the beginning of treatment and many continued to experience anticipatory anxiety. The use of MAO inhibitors requires dietary restrictions. Klosko et al
The treatment of panic disorder during pregnancy and lactation poses special problems. It is important that both the practitioner and patient consider a number of issues to find the most appropriate treatment for the patient. New cognitive-behavioural treatment options often circumvent the problems of pharmacotherapy for pregnant or lactating women while providing therapeutic benefits which are at least equivalent.
P
anic disorder is a common problem. Panic disorder associated with agoraphobia, is more common among women and typically begins in the late 20s (I), the peak childbearing years. Thus, it is to be expected that a significant number of women who suffer from panic disorder will be pregnant or lactating during treatment. Panic disorder is diagnosed on the basis of the occurrence of panic attacks accompanied by a number of somatic symptoms and/or fears and in the exclusion of other major functional or organic illness (1). Psychiatrists are often reluctant to prescribe medication, an effective treatment for panic disorder, during pregnancy, and many patients are reluctant to take it. Cognitivebehavioural therapy should be considered as an alternative treatment for panic disorder.
Differential Therapeutics To determine the appropriate treatment for a pregnant woman with panic disorder, the clinician should review four major issues with the patient: the patient's preferences, the effects of withholding treatment, the effects of treatment on the child, and the effectiveness and availability of treatments. Pregnancy is a time of great stress for many women. New fears and anxieties may emerge, including fears of losing control, which can be either exacerbated or ameliorated by "Manuscript received November 1990, revised July 1991. IDepartment of Psychology, Simon Fraser University, Burnaby, British Columbia. 2Associate Professor, Department of Psychiatry, University of Manitoba; Coordinator, Anxiety Disorders Clinic, Department of Psychiatry, St. Boniface General Hospital, Winnipeg, Manitoba. 3Private Psychiatric Practice; formerly, Assistant Professor, Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba. Address reprint requests to: John Walker, Ph.D., M4 - Department of Psychiatry, St. Boniface General Hospital, 409 Tache Avenue, Winnipeg, ManitobaR2H2A6
Can. J. Psychiatry Vol. 37, November 1992
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624
CANADIAN JOURNAL OF PSYCHIATRY
(6) report that improvement is maintained at one and two year follow-up with cognitive-behavioural therapy. Withdrawal effects and relapse have been found with discontinuance of alprazolam (6). Fyer et al (8) estimate the relapse rate to be nearly 30% with tricyclic antidepressants and much higher with MAO inhibitors. Other forms of non pharmacological treatment are available to the pregnant or lactating woman. Arange ofbehavioural and other therapies have been used to treat panic disorder. Several reviews have found that treatment is most successful when it is focused specifically on panic attacks rather than simply on exposure to feared situations (9,10). Supportive therapy or reassurance or any of a variety of social supports in the community may be provided. By itself, such support may not alleviate the symptoms of panic disorder sufficiently to ensure the well-being of the mother and baby. The patient may be hospitalized, but this is extremely costly and may interfere with the marital relationship and the couple's preparation for parenthood. These interventions are probably most useful when combined with more specific treatment. In general, since no treatment is clearly superior overall, all treatment options should be considered in order to choose the best one for the patient.
Case Report The patient was a 26 year old bank clerk who was happily married. She presented with panic attacks four months before the delivery of her first baby and met the DSM-III-R (1) criteria for panic disorder. She experienced her first panic attack about two and one-half years prior to treatment at our clinic. During the initial interview, it became clear to the patient that the panic attacks had begun several months after a high school friend had committed suicide. The patient expressed many concerns about losing control, harming herself (for example, stabbing herself with a knife) and feared that she might be crazy. When she was feeling anxious, she experienced gastro-intestinal distress and nausea, heart palpitations, choking and dizziness. She also experienced maladaptive thoughts, such as "I might never get over these panic attacks," "I will not be able to control myself," and "I am going to throw up," as well as negative images, that of dropping a birthday cake in front of a crowd. Cognitivebehavioural therapy led her to discover that panic attacks were usually preceded by the thought "What if I dry heave?" The panic attacks had increased in frequency during the year prior to treatment. They occurred, with no precipitants that were evident to the patient, approximately 1.5 times per week. The patient expressed many concerns about the effect of her panic disorder on parturition and child-rearing. She reported having always had a fear of vomiting and eating in public. These fears had diminished with time, suggesting an additional diagnosis of social phobia. There were no other psychiatric symptoms, and there was no history of serious medical problems. Data on the patient's anxiety, degree of phobic avoidance and panic attacks were collected during all phases of treatment, using a daily diary, a panic diary, and weekly adminis-
Vol. 37, No.9
tration of the Fear Questionnaire (11). Baseline data were collected for three weeks prior to initiation of treatment. Treatment took place over a six week period, with one hourlong session per week. Follow-up data were recorded for nine weeks. There were additional follow-up contacts 34, 39 and 100 weeks after the data collection began.
Cognitive-Behavioural Treatment The cognitive-behavioural treatment consisted of information-giving, self-monitoring, cognitive restructuring, in vivo exposure and follow-up. Adjustments in the style of implementing the treatment may be necessary in order to limit the anxiety experienced during therapy. Information-giving is rated by patients as an important component of treatment. The patient was given written information on panic disorder and explicit reassurance about her fears. Self-monitoring consists of recording episodes of anxiety, the events and thoughts which precede and follow the episodes, and, during treatment, the effects of the coping techniques being taught. This serves several purposes. First, it allows the therapist and patient to see the connections between thoughts, situations and body sensations and the experience of anxiety or panic, suggesting to the patient that cognitive changes can be made. Observing the occasions and thoughts which precipitated anxiety allows the patient to understand their effects on panic attacks. For example, feelings of nausea often led to fear of having a panic attack. On several occasions, after careful examination of the situation, the patient found that the nausea was secondary to overeating, a normal experience which she had misinterpreted. Second, the self-monitoring record permits a more accurate comparison of symptoms before, during, and after treatment, providing an assessment of the effectiveness of treatment and allowing us to fine-tune treatment. Initial progress gave the patient a sense of control over her symptoms, which she had experienced as long term and debilitating, and this progress improved her commitment to therapy. Cognitive restructuring includes a variety of techniques directed toward changing the patient's thoughts. Examination of self-monitoring records reveals the thoughts and images which may increase feelings of anxiety, often by misinterpretation of normal or anxiety-related body sensations as threatening or catastrophic events (12). Treatment may focus on recognizing this connection through self-monitoring (as in our patient's experience of nausea) or through therapeutic manipulations which illustrate the connection between unpleasant body sensations and catastrophic thoughts. Hyperventilation is often used in this way, but there are concerns about its effects on the fetus during pregnancy; this technique was not used with our patient. "Reframing," or describing a situation in different terms can be used to change the meaning of an event for the patient. Panic attacks were reframed for this patient as new opportunities to practise her skills rather than as failures. Patients may learn to use thoughts which act to "neutralize" anxiety-provoking thoughts. The patient found that using the thought "so what?" was effective in
November, 1992
625
PANIC DISORDER DURING PREGNANCY AND LACTATION
counteracting the effects of anxiety-inducing thoughts, such as "I might leave my baby crying while I have a panic attack." In vivo exposure consists of actually experiencing the situations which have been feared and avoided. This allows patients to discover that the situation is not as catastrophic as feared, to practise these skills and to observe and influence their own responses. For example, the patient had previously avoided dinner parties but agreed to schedule them in order to practise neutralizing her thoughts. Follow-up is important to ensure that the acquired skills continue to be effective and to manage any sequelae of treatment termination. We contacted the patient 18 weeks after therapy was terminated, after delivery of her baby, and she was doing well. Several weeks later she asked for a follow-up appointment. At that session she stated that she had experienced some anxiety during the summer and she had experienced debilitating anxiety during the previous several summers. She had the anxiety-producing thought "What if I am slipping back?" However she was able to write out her thoughts and a!' a result saw them as "silly". Moreover, whereas in previous summers she had lost weight and been unable to do her shopping, she recognized that this summer she was anxious at times, 'but the anxiety was well under her control by the time she was able to meet with the therapist. This incident highlights the importance of follow-up contact which is used to give the patient the message that some periods of "slipping back" are to be expected and are not failures or catastrophies, but are opportunities for further practice of her new-found skills. Follow-up to ensure that treatment effects are maintained becomes even more important after childbirth, given the stress of that event, possible hormonal effects on anxiety and the risks of post-partum depression, Results of Treatment Panic attacks declined from 1.5 per week during the baseline period to 0.33 per week during the treatment period (during cognitive restructuring and planned exposure to feared situations); 0.33 attacks occurred per week during the first nine weeks of follow-up, and 0.06 times during the following 16 weeks. Two of the three attacks during the first nine weeks of follow-up occurred on the day when she went into labour, she felt the panic attacks were fairly natural under the circumstances. At the end of follow-up, the patient felt that she was able to handle any episodes of anxiety which arose. Her ratings of distress due to "fear of having a panic attack" also declined steadily from a high of "extremely distressing" during baseline and at the beginning of treatment, through "slightly distressing" during follow-up, to a final follow-up rating of "not at all distressing" two years after treatment. There were similar patterns of improvement in the patient's ratings of anxiety/depression and avoidance of eating in public. The improvements were documented (using the Fear Questionnaire). The patient provided low ratings in all areas by the end of treatment, and these changes were maintained over the follow-up periods. George et al (13) have suggested on the basis of three retrospective case studies, that
pregnancy itself may ameliorate the symptoms of panic disorder. This is unlikely our case, since the patient's pregnancy was well advanced when therapy was initiated, which was for an exacerbation rather than an amelioration of her symptoms. The reduction in her symptoms matched the progress of therapy, and the reduction in anxiety was maintained postpartum and at follow-up (unlike the cases reported by George et al). Cowley and Roy-Byrne (3) reported improvement in the majority of the women they studied with panic disorder who became pregnant, but worsening of symptoms in two of the women. Conclusions Cognitive-behavioural treatment has been found effective, and now larger scale studies are being conducted to compare it with the pharmacological treatment of panic disorder. Initial results suggest that these techniques are at least as effective as treatment with alprazolam, and while they may be less immediately efficacious, they may have greater long term effects and do not result in deterioration or relapse when treatment is terminated (6). However, patients with limited intellectual ability, psychological insight or cooperation may not do as well with cognitive-behavioural treatment. Medication is currently the most accessible form of treatment for panic disorder. However, there are therapists familiar with cognitive-behavioural therapy in most large centres. When the issues outlined in the introductory section are considered, cognitive-behavioural therapy may well be the treatment of choice for many women who are or who may become pregnant. Further information on cognitive-behavioural treatment of panic disorder has been published in an article by Barlow and Cerny (14). References 1. Diagnostic and statistical manual of mental disorders, third edition, revised. Washington DC: American Psychiatric Press, Inc., 1987. 2. Mogul KM. Psychological considerations in the use of psychotropic drugs with women patients. Hosp Community Psychiatry 1985; 36: 1080-1085. 3. Cowley OS, Roy-Byrne PP. Panic disorder during pregnancy. Journal of Psychosomatic Obstetrics Gynaecology 1989; 10: 193-210. 4. Mortola JF. The use of psychotropic agents in pregnancy and lactation. Psychiatr Clin North Am 1989; 12: 69-87. 5. Roy-Byrne P, Katon W. An update on treatment of the anxiety disorders. Hosp Community Psychiatry 1987; 38: 835-843. 6. Klosko JS, Barlow DH, Tassinari RB, et al. A comparison of alprazolam and cognitive behavior therapy in the treatment of panic disorder. J Consult Clin Psychol 1990; 58: 77-84. 7. Ballenger JC, Burrows GO, DuPont RL, et al. Alprazolam in panic disorder and agoraphobia: results from a multicenter trial. Arch Gen Psychiatry 1988; 45: 413-422. 8. Fyer AJ, Sandberg 0, Klein OF. Pharmacological treatment of panic disorder and agoraphobia. In: Walker JR, Norton GR, Ross CA, eds. Panic disorder and agoraphobia: a comprehensive guide for the practitioner. Pacific Grove CA: Brooks/Cole, 1991. 9. Clum GA. Psychological interventions vs drugs in the treatment of panic. Behavior Therapy 1989; 20: 429-457.
626
Vol. 37, No.9
CANADIAN JOURNAL OF PSYCHIATRY
10. Pecknold JC. Behavioral and combined therapy in panic states. Prog Neuropsychopharmacol Bioi Psychiatry 1987; II: 97-
104.
11. Marks 1M, Mathews AM. Brief standard self-rating for phobic patients. Behav Res Ther 1979; 17: 263-267. 12. Clark DM. A cognitive approach to panic. Behav Res Ther 1986; 24: 461-470. 13. George D, Ladenheim J, Nutt D. Effect of pregnancy on panic attacks. Am J Psychiatry 1987; 144: 1078-1079. 14. Barlow DH, Cerny JA. Psychological treatment of panic. New York: The Guilford Press, 1988.
Resume Le traitement du trouble de panique durant la grossesse et la lactation pose des problemes particuliers. Il est important que Ie medecin et la malade examinent plusieurs questions afin de choisir le traitement qui convient le mieux. Des nouvelles options therapeutiques, les therapies cognitives et comportementales, permettent souvent de contourner Ie probleme que pose la pharmacotherapie pour la femme enceinte au en lactation en donnant des resultats au mains equivalents.
