Applied Relaxation vs JPMR in Panic Disorder (PDF)

APPLIED RELAXATION VS PROGRESSIVE RELAXATION IN THE TREATMENT OF PANIC DISORDER Psychiatric Research Center, Uileriker Hospital, S-750 17 Uppsala, Sweden Summary-The present study investigated the e&acy of a copin~-t~~~~~~e. applied retaxation (AR),...

APPLIED RELAXATION VS PROGRESSIVE RELAXATION IN THE TREATMENT OF PANIC DISORDER Psychiatric Research Center, Uileriker Hospital, S-750 17 Uppsala, Sweden Summary-The present study investigated the e&acy of a copin~-t~~~~~~e. applied retaxation (AR), and that of a traditional behavioral method, progressive retaxation (PRf. in the treatment of panic disorder. Eighteen outpatients were assessed with clinical ratings, self-report scales. and self-observation of panic attacks/general anxiety before and after treatment, and at follow-up 6-29 months (mean 19) later. Patients were treated individually for 14 weekly sessions. The results showed that both treatments yielded very large improvements, which were maintained, or furthered at follow-up. The between-group comparisons showed that AR was significantly better than PR on 6111 measures at post-treatment, and on all measures at follow-up. The proportian of ciinicaily improved patients (according to stringent criteria) was 38% for PR and 75% for AR at post-treatment, and 25% vs 100% at follow-up. The tentative conclusion that can be drawn is that AR is an effective treatment for patients with panic disorder. INTRODUCTION Controtfed studies using behavioral methods in treating panic disorder (PD) and/or generalized anxiety disorder (GAD) and few, if the prevafence of these disorders are taken into consideration. Different ep~demioIogi~a~ studies reviewed by Marks (1986) suggest that the prevaience of PD and GAD together varies between 2.9 and 7.6%, with an average of 5.3%, while the phobias have an average prevalence of 5.5%. Thus, it seems that GADjPD in the general population is as prevalent as phobias. However, a review of controlled clinical studies (&t and Jansson, 1987) showed that between 1966 and 1984, 77 studies on phobias (excluding those concerning small animal phobia) and only 16 on GADjPD had been published. Since 1985 another four studies on GADjPD using behavioral methods have been published, making a total of 20 studies. There may be different reasons for this relative lack of controlled studies on GAD/PD. One is the reluctance of behavior therapists to accept the concept of non-situational, general anxiety [e.g. Wofpe’s (1976) view of GAD as a large number of conditioned anxiety reactions to both external and internal stimufi]. In the early-mid-198~s behaviorists began to present behaviorat models and analyses of GADjPD (Hare and Levis, 198f; Stampfer, t982; Jacob and Rapport, 1984; Suinn, 1984; Clark, 1986a). Another reason might be discouragement from the modest effects obtained in the early behavioral studies in this area, compared to what is usually obtained with phobics (ast, 1982; Jansson and &t, 1982). The majority of the studies have had a rather traditional, passive view of the anxiety patient. The researchers seem to conceive of the therapy as a course of treatment that the patient will go through, after which some beneficial tonic change supposedly has taken pface. Examples of these treatments are EMG-biofeedback (Canter, Kondo and Knott, 1975; Townsend, House and Addario, 1975; LaValEe, Lamontagne, Pinard, Annable and T&treat&, 1977; LeBoeuf and Lodge, 1980; Raskin, Bali and Peeke, 1980), HR-biofeedback (Rupert and Holmes, I978), and Progressive Relaxation (Canter et a!., 1975; Lehrer, 1978; LeBouef and Lodge, 1980; Raskin et af., 1980; Taylor, Kenigsberg and Robinson, 1982a; Lehrer, Wootfolk, Rooney, McCann and Cartington, 1983). The fact that the patients did not Ieam an effective method that was useful when anxiety/panic occurred is sometimes noted with surprise in these articles, e.g. Raskin et al. (1980): “Unfortunately, relaxation treatments appear to be insufficient in the treatment of most chronically anxious subjects. The relaxation response is of siow onset, particularly when the individual is tense or anxious. Thus the response, no matter how well learned, appears to be of limited value in inhibiting anxiety... Subjects reported that attempts to relax in the face of anxiety, or even prior to expected anxiety were usually unsuccessful” (p. 97). I3 14 LARS-G~RAS C)ST This conceptualization of treatment can be contrasted with the idea behind the coping-techniques [see Barrios and Shigetomi (1979) for an early review]. These attempt to teach the patient a skill for coping with the anxiety reaction, i.e. to recognize anxiety/panic at an early stage and to handle it, instead of being overwhelmed by it. Applying relaxation is also a way to counteract escape from the phobic situation, leading to extinction of the conditioned reactions. The earliest, albeit not particularly successful, trials of coping-techniques for GAD,‘PD came in the early 1980s (Woodward and Jones, 1980; Ramm, Marks, Yuksel and Stern, 1981). There has, however, been a further development of the coping-techniques in studies by Jannoun, Oppenheimer and Gelder (1982), Barlow, Cohen, Waddell, Vermilyea, Klosko, Blanchard and DiNardo (1984). Eayrs, Rowan and Harvey (1984), and the latest study by Butler, Cullington, Hibbert, Klimes and Gelder (1987) showed very good results for Anxiety Management Training. A comparison of per cent improvement (pre-post-treatment) on the Spielberger State-Trait Anxiety Inventory (State form) yielded a mean of 28% for the traditional methods and 38% for the coping-techniques. The corresponding figures for STAI-Trait form were 16 and 29%, respectively. Thus, there is a strong tendency for coping-techniques to yield better results than traditional behavioral methods in the treatment of GAD/PD, even if they have not yet reached the level of the best behavioral methods for phobias. The purpose of the present study was to compare the efficacy of a coping-technique, Applied Relaxation (AR), with a traditional behavioral method, Progressive Relaxation (PR), in the treatment of GAD/PD. Applied relaxation has been found as effective, or more effective than other behavioral methods with which it was compared in the treatment of phobias, headache, epilepsy. and tinnitus. ijst (1987) reviewed 18 controlled outcome studies and found that the mean per cent improvement on the most central measure of each study was 57 at post-assessment and 69 at follow-up (mean 11 months). Given the record of AR, and the above comparison of traditional methods and coping- techniques, it was predicted that AR would be more effective than PR, and that this difference would be more pronounced at follow-up when a longer period of application, and thus extinction of the anxiety reactions, had passed. METHOD Subjects and design The patients for this study were outpatients at Ulleraker Mental Hospital. They were referrals from psychiatrists and general practitioners in Uppsala county, or recruited by advertisements in the local newspaper. In order to be included in the study the patients had to fulfil the following criteria: (1) DSM-III criteria for panic disorder or generalized anxiety disorder (APA, 1980); (2) not have any other psychiatric disorder in immediate need of treatment; (3) not suffer from primary depression; (4) be between 20 and 60 years of age; (5) a duration of the anxiety disorder of at least 1 year; (6) agree to take part in the study for 18 weeks, including pre- and post-treatment assessments (7) if on drugs, agree to keep the dosage constant throughout the study. The patient applying for treatment went through a screening interview during which the Anxiety Disorders Interview Schedule (ADIS; DiNardo, O’Brien, Barlow, Waddell and Blanchard, 1983) was used. This gives information for making the DSM-III diagnosis and to differentiate between anxiety disorders and other disorders with similar symptomatology. Eighteen patients (14 PD and 4 GAD) fulfilled the criteria and took part in the study. There were 14 females and 4 males; their mean age was 37.5 years (range 22-58) and mean duration of their anxiety disorder was 9.0 years (range 2-33). Ten of the patients were married, 6 were single and 2 were divorced. Fifteen worked part- or full-time, 2 were on sick-leave, and 1 was a housewife. Fourteen of the patients had obtained psychiatric treatment for their anxiety disorder previously (13 pharmacological and 1 psychodynamic therapy), while 4 had not. Half of the patients were taking some kind of psychotropic drugs at the start of treatment. Five had bensodiazepines  Applied relaxation vs progressive relaxation in the treatment of panic disorder 15 (oxazepam and diazepam), 2 had antidepressives (clomipramine and maprotiline), while 2 had propranolol (combined with bensodiazepines). Of the altogether 12 drugs prescribed for this group of 9 patients, 5 prescriptions were on a when-needed basis only, while 7 concerned regular use (l-3 times/day). The patients were randomly assigned to two treatments, applied relaxation or progressive relaxation, and the study used a basic two-group design with assessment pre- and post-treatment and at follow-up, on the average 19 months (range 6-29) after the end of treatment. Assessments Clinical ratings. As an integrated part of ADIS, the Hamilton Anxiety and Depression Scales (Hamilton, 1959, 1960) are administrated. Before treatment this was done by the psychologist doing the screening interview, and at post-treatment and follow-up assessment by the author who was kept blind to the treatment the patients had received. Self-report scales. State-Trait Anxiety Inventory is one of the most widely used self-report scales for general anxiety (Spielberger, Gorsuch and Lushene, 1970). Both the State and the Trait forms were used. These give self-ratings of the degree of anxiety experienced at the moment of filling out the scale (State form), and how one usually feels (Trait form). As a complement the Zung Self-rating Anxiety Scale (Zung, i971) was used. Finally, the Beck Depression Inventory (Beck, 1967) was used to obtain a self-rating of depression. Self-observation. Since panic attacks and generalized anxiety basically are subjective phenomena it is necessary to let the patient make continuous self-monitoring and recording of their occurrence. Two forms, developed for and used in our clinical practice for some years were used. The form for panic attacks consists of the following columns: date, situation, intensity (l-5), duration (in minutes), and medicine intake (if any). By carefully going through and discussing the panic attacks of the last 2 weeks before the start of the study, and defining what is needed before an attack is counted as such, it was possible to obtain records of attacks fulfilling the DSM-III criteria (i.e. at least 4 of the 12 symptoms). From the form used, which the patient gave the therapist at each weekly session, the mean frequency of panic attacks per week, the mean intensity, and the mean duration of these attacks were calculated. At least 2 weeks of self-observation pre- and post-treatment and at follow-up were obtained from each of the PD-patients and two of the GAD-patients (the other two had no panic attacks). Regarding generalized anxiety all patients recorded 6 times a day (at 9, 12, 15, 18, 2 1, and at bedtime) whether they had experienced any anxiety during the preceding 3-hr period. If this was the case they were to rate the intensity on a l-5 scale, and if not record a 0. The measures obtained from this self-observation were mean number of periods with anxiety/week (maximum = 42) and mean intensity during these periods. Treatments General aspects. The therapy sessions lasted 45-60 min and were scheduled once a week. Between each session the patients had as homework assignments to practice, twice a day, the form of relaxation that was demonstrated during the previous session, and record the training on specific forms. Progressire relaxation. The Bernstein and Borkovec (1973) manual for PR was used. Session 1 was devoted to a brief behavior analysis, an individual goal formulation, and a description of the method and its rationale. Briefly, the rationale said that the most plausible reason for the patient’s panic attacks was that his/her general tension level of the body was too high, and that relatively small and innocuous stressors may trigger a panic attack. The purpose of the treatment was to reduce the general tension level through long and frequent relaxation practice, and thus achieve a bodily state in which these stressors had no panic eliciting effect. The practice of PR using tension-release was started at session 2 with the 16 muscle groups format. This was continued at sessions 3 and 4. A reduction to 7 muscle groups was introduced at session 5, and repeated at session 6. A further reduction to 4 muscle groups started at session 7 and continued at session 8. During session 9-10 release-only of 4 muscle groups were practiced, and this was followed by self-relaxation during sesions 11-12. The final two sessions (13-14) were 16 LAM-GijRAN c)ST used for a review of the results obtained so far and development of a maintenance program as described by Jansson, Jerremalm and &t (1984). Applied relaxation. The manual described by ijst (1987) was followed. During session 1 a short behavior analysis was done, followed by an individual goal formulation. description of AR and its rationale. The AR rationale said that panic attacks can start as a small and insignificant change in some physiological parameter. This is noticed by the patient who might have a negative thought concerning it, which is followed by further physiological arousal, and so on in a vicious circle. The purpose of AR is to teach the patient to observe the very first signs of a panic attack and to apply a rapid and effective relaxation technique to cope with, and eventually abort these symptoms before they have developed into a full-blown panic attack. Sessions 2-4 were devoted to the condensed version of progressive relaxation presented by Wolpe and Lazarus (1966), gradually increasing the number of muscle groups that was worked with. During session 5 release-only relaxation was practiced, and cue-controlled relaxation was intro- duced in session 6. Sessions 7-8 were devoted to differential relaxation, teaching the patient to relax while sitting in an ordinary chair, sitting at a desk writing, while standing and walking. Rapid relaxation was started at session 9 with the purpose of teaching the patient to relax quickly (in 20-30 set) in natural, but not anxiety-arousing, situations. In session 10 there was either a rehearsal of rapid relaxation, or the start of application training, which continued in sessions I l-l 2. For most patients it was enough to give careful instructions on how to apply AR in anxiety,panic attack situations, but a few needed application training in the therapy session. For these hyperventilation for 2min (30 breaths/min), physical exercise (running up and down the stairs), or imagery of previously anxiety-arousing situations were used with the purpose of eliciting anxiety,‘panic and practicing to apply AR to extinguish it. Sessions 13-14 concerned a review of results obtained for the patient and development of a maintenance program. Therapist A female therapist with a 2-year training in behavior therapy and 2 years of subsequent clinical experience served as therapist for both groups. She was continuously supervised by the author during the time of the study. Statistical methods Student’s t-test was used to compare the pre-treatment means for the groups. In case of a significant pre-treatment difference, analysis of covariance was used to compare the groups at post- and follow-up assessment, and when the groups were equivalent at pre-treatment t-test was used. Since the a priori hypothesis predicted AR to be better than PR one-tailed tests were used. RESULTS Attrition Two patients, one in the PR- and one in the AR-group, dropped out at an early stage of treatment due to scheduling difficulties. Pre-treatment differences There were only two significant differences between the groups at the pre-treatment assessment. The PR-group had a higher BDI-score than the AR-group, and the latter had higher panic attack intensity ratings. Besides these differences the groups were approximately equal on the dependent variables at the start of treatment. Clinical ratings The results on the clinical ratings are presented in Table 1. On the Hamilton Anxiety Scale the PR-group showed a 54% reduction of its mean from pre- to post-assessment, and 69% from pre-treatment to follow-up. However, the AR-patients displayed a larger improvement, 75 and 86%, respectively. The between-group comparison showed that the AR-group was significantly better than PR both at post-treatment and at follow-up.  Applied relaxation vs progressive relaxation in the treatment of panic disorder 17 Table I. Means (S.D,s) on clinical ratings and self-report scales for progressive relaxation (PR) and applied relaxatton (AR) pre- and post-treatment and at follow-up Measure Pre-treatment Post-treatment Follow-up PR 23.5 (5.2) 10.7 (6.0) 7.3 (4.5) Hamilton Anxiety Scale Hamilton I AR f PR 22.8 (5.2) 0.29 17.8 (6.0) 5.6 (5.0) 1.83. 7.9 (3.8) 3.1 (2.9) ?.l6** 5.8 (3.6) Depression AR 16. t (7.0) 3.4(2.0) 1.9(1.0) Scale { t 0.50 2.97**= 2.92”‘ PR 59.8 (5.8) 46.5 (9.1) 42.6 (IO. I) STAI-Trait AR 56.5 (6.1) 35.6 (7.9) 30.9 (7.3) I I 1.09 2.55** 2.67”’ PR 56.5(12.5) 38.0 (I 2.0) 35. I (5.2) STAI-State AR 54.6 (9.7) 32.0 (8.5) 27.3(&l) I t 0.33 I.15 LIE** PR 53.0 (7.4) 38.9 (6.9) 38.5 (5.6) Self-rating AR 49.1 (3.5) 32.9(4.8) 30.5 (5.7) Anxiety Scale 1 I I.34 2.02’ 2.83”’ PR 24.1 (4.2) 12.3(4.3) 9.8 (4.9) Beck Depression AR 20.0 (2.3) 5.5 (3.5) 3.0 (I.9) Inventory I 2.40. PR: 10.5” PR: 9.4” AR: 7.3’ AR: 3.4” F 3.88. f 7.039. ‘Adjusted for pretreatment means. lP < 0.05. **P < 0.025. l**P