Behavior Therapy For Panic Disorder Research Articles

Relationships between depressive symptoms and panic disorder symptoms during guided internet-delivered cognitive behavior therapy for panic disorder

Aims: The current study explore the relationship between the trajectories of primary panic disorder symptoms and secondary depressive symptoms during guided internet-delivered cognitive behaviour therapy for panic disorder.Materials and methods: The patients (N=143) were recruited from an ongoing effectiveness study in secondary mental health outpatient services in Norway. Weekly self-reported primary panic disorder symptoms and secondary depressive symptoms were analysed.Results: primary panic disorder symptoms and secondary depressive symptoms improved significantly during the course of treatment, and at six months follow-up. Parallel process latent growth curve modelling showed that the trajectory of depressive symptoms and trajectory of panic disorder symptoms were significantly related. A supplementary analysis with cross-lagged panel modelling showed that (1) pre-treatment depressive symptoms predicted a positive effect of panic disorder symptoms early in treatment; (2) high early treatment panic disorder symptoms predicted low depressive symptoms at post-treatment.Conclusions: Guided ICBT for panic disorder is effective for both primary panic disorder symptoms and secondary depressive symptoms. Patients with high pre-treatment secondary depressive symptoms may constitute a vulnerable subgroup. A high level of panic disorder symptoms early in treatment seems beneficiary for depressive symptoms outcome. A time-dependent model may be necessary to describe the relationship between PAD symptoms and depressive symptoms during the course of treatment.

The implementation of guided Internet-based cognitive behaviour therapy for panic disorder in a routine-care setting: effectiveness and implementation efforts

Panic disorder is a common mental disorder. Guided Internet-based cognitive behavioural therapy (Guided Internet-based cognitive behaviour therapy (ICBT)) is a promising approach to reach more people in need of help. In the present effectiveness study, we investigated the outcome of guided ICBT for panic disorder after implementation in routine care. A total of 124 patients were included in the study, of which 114 started the treatment. Large within-group effect sizes were observed on the primary panic disorder symptoms (post-treatment: d = 1.24; 6-month follow-up: d = 1.39) and moderate and large effects on secondary panic disorder symptoms and depressive symptoms at post-treatment and follow-up (d = .55–1.13). More than half (56.1%) of the patients who started treatment recovered or improved at post-treatment. Among treatment takers (completed at least five of the nine modules), 69.9% recovered or improved. The effectiveness reported in the present trial is in line with previous effectiveness and efficacy trials of guided ICBT for panic disorder. This provides additional support for guided ICBT as a treatment alternative in routine care.

Stepped care versus face-to–face cognitive behavior therapy for panic disorder and social anxiety disorder: Predictors and moderators of outcome

ObjectiveTo investigate predictors and moderators of treatment outcome by comparing immediate face-to-face cognitive behavioral therapy (FtF-CBT) to a Stepped Care treatment model comprising three steps: Psychoeducation, Internet-delivered CBT, and FtF-CBT for panic disorder (PD) and social anxiety disorder (SAD). MethodPatients (N = 173) were recruited from nine public mental health out-patient clinics and randomized to immediate FtF-CBT or Stepped Care treatment. Characteristics related to social functioning, impairment from the anxiety disorder, and comorbidity was investigated as predictors and moderators by treatment format and diagnosis in multiple regression analyses. ResultsLower social functioning, higher impairment from the anxiety disorder, and a comorbid cluster C personality disorder were associated with significantly less improvement, particularly among patients with PD. Furthermore, having a comorbid anxiety disorder was associated with a better treatment outcome among patients with PD but not patients with SAD. Patients with a comorbid depression had similar outcomes from the different treatments, but patients without comorbid depression had better outcomes from immediate FtF-CBT compared to guided self-help. ConclusionsIn general, the same patient characteristics appear to be associated with the treatment outcome for CBT provided in low- and high-intensity formats when treated in public mental health care clinics. The findings suggest that patients with lower social functioning and higher impairment from their anxiety disorder benefit less from these treatments and may require more adapted and extensive treatment. ClinicalTrials.govIdentifier: NCT00619138.

Predictors and Moderators of Internet- and Group-Based Cognitive Behaviour Therapy for Panic Disorder

Internet-based cognitive behaviour therapy (ICBT) can be equally effective as traditional face-to-face cognitive behaviour therapy (CBT) for treating panic disorder (PD). However, little is known about the predictors and moderators of outcome of ICBT when delivered in psychiatric outpatient settings. This study investigated a selection of outcome predictors and moderators of ICBT for panic disorder based on data from a randomised controlled trial where therapist-guided ICBT was compared with group CBT (GCBT) for panic disorder. Participants (N = 104) received 10 weeks of ICBT or GCBT and were assessed before and after treatment, and after six months. Multiple regression analyses were used to test for significant predictors of treatment outcome. Predictors of positive treatment response for both modalities were having low levels of symptom severity and work impairment. In addition, anxiety sensitivity was found to have a small negative relationship with treatment outcome, suggesting that anxiety sensitivity may slightly enhance treatment response. Treatment modality had a moderating effect on the relationship between domestic impairment and outcome and on the relationship between initial age of onset of panic symptoms and treatment outcome, favouring ICBT for patients having had an early onset of PD symptoms and for patients having a high domestic functional impairment. These results suggest that both ICBT and GCBT are effective treatment modalities for PD and that it is possible to predict a significant proportion of the long-term outcome variance based on clinical variables.

Mechanisms of change in cognitive behaviour therapy for panic disorder: The role of panic self-efficacy and catastrophic misinterpretations

The efficacy of cognitive behavioural therapy (CBT) for panic disorder with or without agoraphobia (PD) is well-established; however, little is known about the underlying change processes of clinical improvement during therapy. According to cognitive theories, CBT for PD primarily works by changing catastrophic misinterpretations of bodily symptoms and panic attacks. However, panic self-efficacy, i.e. the perceived ability to cope with panic attacks, has also been suggested as an important change mechanism in CBT for PD. The aim of the study was to investigate if change in catastrophic misinterpretations and panic self-efficacy mediated change in the level of anxiety during the course of thirteen sessions of group CBT for PD. Forty-five participants completed weekly self-report measures of the possible cognitive mediators and the level of anxiety throughout therapy. The results indicated that within-person change in panic self-efficacy in one session, but not in catastrophic misinterpretations, predicted within-person level of anxiety symptoms the following week. However, in a reversed analysis, prior change in level of anxiety symptoms also predicted change in panic self-efficacy the following session. These results support panic self-efficacy as a mediator of change in CBT for PD, although a reciprocal causal relationship between panic self-efficacy and level of anxiety seems to be implied.

Effectiveness of Group Cognitive Behavior Therapies for Panic Disorder: Systematic Review and Meta-analysis

Although cognitive behavior therapies are vastly studied treatments for panic disorder, reviews on the subject usually don’t discriminate between individual and group settings. This article aims to evaluate, through meta-analytical techniques, the effectiveness of group cognitive behavior therapy for panic disorder. A literature search on LILACS, PsycINFO, ISI Web of Knowledge and Pubmed was conducted. Intra-group Hedges (g) effect size calculations were made for symptoms of panic and anxiety, agoraphobia, and depression. A random effects model was used to estimate the summary effect sizes and the publication bias was calculated. The search identified 22 articles from 14 different studies. Summary effect sizes were large for symptoms of panic and anxiety (g=1,39), moderate for symptoms of depression (g=0,79) and large for agoraphobic symptoms (g=0,92). These results suggest that these therapies in group are effective for panic disorder and constitute an interesting alternative of treatment.

Efetividade de Terapias Cognitivo-Comportamentais em Grupo para o Transtorno de Pânico: Revisão Sistemática e Meta-análise

Embora as terapias cognitivo-comportamentais sejam estudadas para o transtorno de pânico, geralmente as revisões sobre o assunto agrupam indiscriminadamente modalidades individuais e em grupo. O presente estudo objetivou avaliar, por meio de técnicas de meta-análise, a efetividade das terapias cognitivo-comportamentais em grupo para o transtorno de pânico. Foram feitas buscas bibliográficas em LILACS, PsycINFO, ISI e Pubmed. Foram calculados tamanhos de efeito de Hedges (g) intragrupos em sintomas de pânico e ansiedade, agorafobia e depressão. Utilizou-se um modelo de efeitos aleatórios para estimar os tamanhos de efeito sumários e o viés de publicação foi calculado. A busca resultou em 22 artigos de 14 estudos diferentes. Encontraram-se tamanhos de efeito sumário grande para sintomas de pânico e ansiedade (g=1,39), moderado para sintomas depressivos (g=0,79) e grande para sintomas agorafóbicos (g=0,92). Os resultados sugerem que essas terapias são efetivas para o transtorno de pânico e se constituem em uma alternativa interessante de tratamento

Effectiveness of Internet-based cognitive behaviour therapy for panic disorder in routine psychiatric care

Guided Internet-based cognitive behaviour therapy (ICBT) for panic disorder has been shown to be efficacious in several randomized controlled trials. However, the effectiveness of the treatment when delivered within routine psychiatric care has not been studied. The aim of this study was to investigate the effectiveness of ICBT for panic disorder within the context of routine psychiatric care. We conducted a cohort study investigating all patients (n = 570) who had received guided ICBT for panic disorder between 2007 and 2012 in a routine care setting at an out-patient psychiatric clinic providing Internet-based treatment. The primary outcome measure was the Panic Disorder Severity Scale-Self-report (PDSS-SR). Participants made large improvements from screening and pretreatment assessments to posttreatment (Cohen's d range on the PDSS-SR = 1.07-1.55). Improvements were sustained at 6-month follow-up. This study suggests that ICBT for panic disorder is as effective when delivered in a routine care context as in the previously published randomized controlled trials.

The COMTval158met polymorphism is associated with symptom relief during exposure-based cognitive-behavioral treatment in panic disorder

BackgroundCognitive behavioral therapy (CBT) represents a learning process leading to symptom relief and resulting in long-term changes in behavior. CBT for panic disorder is based on exposure and exposure-based processes can be studied in the laboratory as extinction of experimentally acquired fear responses. We have recently demonstrated that the ability to extinguish learned fear responses is associated with a functional genetic polymorphism (COMTval158met) in the COMT gene and this study was aimed at transferring the experimental results on the COMTval158met polymorphism on extinction into a clinical setting.MethodsWe tested a possible effect of the COMTval158met polymorphism on the efficacy of CBT, in particular exposure-based treatment modules, in a sample of 69 panic disorder patients.ResultsWe present evidence that panic patients with the COMTval158met met/met genotype may profit less from (exposure-based) CBT treatment methods as compared to patients carrying at least one val-allele. No association was found with the 5-HTTLPR/rs25531 genotypes which is presented as additional material.ConclusionsWe were thus able to transfer findings on the effect of the COMTval158met polymorphism from an experimental extinction study obtained using healthy subjects to a clinical setting. Furthermore patients carrying a COMT val-allele tend to report more anxiety and more depression symptoms as compared to those with the met/met genotype. Limitations of the study as well as possible clinical implications are discussed.Trial registrationClinical Trial Registry name: Internet-Versus Group-Administered Cognitive Behavior Therapy for Panic Disorder (IP2). Registration Identification number: NCT00845260, http://www.clinicaltrials.gov/ct2/show/NCT00845260

Internet-versus group-administered cognitive behaviour therapy for panic disorder in a psychiatric setting: a randomised trial

BackgroundInternet administered cognitive behaviour therapy (CBT) is a promising new way to deliver psychological treatment, but its effectiveness in regular care settings and in relation to more traditional CBT group treatment has not yet been determined. The primary aim of this study was to compare the effectiveness of Internet-and group administered CBT for panic disorder (with or without agoraphobia) in a randomised trial within a regular psychiatric care setting. The second aim of the study was to establish the cost-effectiveness of these interventions.MethodsPatients referred for treatment by their physician, or self-referred, were telephone-screened by a psychiatric nurse. Patients fulfilling screening criteria underwent an in-person structured clinical interview carried out by a psychiatrist. A total of 113 consecutive patients were then randomly assigned to 10 weeks of either guided Internet delivered CBT (n = 53) or group CBT (n = 60). After treatment, and at a 6-month follow-up, patients were again assessed by the psychiatrist, blind to treatment condition.ResultsImmediately after randomization 9 patients dropped out, leaving 104 patients who started treatment. Patients in both treatment conditions showed significant improvement on the main outcome measure, the Panic Disorder Severity Scale (PDSS) after treatment. For the Internet treatment the within-group effect size (pre-post) on the PDSS was Cohen's d = 1.73, and for the group treatment it was d = 1.63. Between group effect sizes were low and treatment effects were maintained at 6-months follow-up. We found no statistically significant differences between the two treatment conditions using a mixed models approach to account for missing data. Group CBT utilised considerably more therapist time than did Internet CBT. Defining effect as proportion of PDSS responders, the cost-effectiveness analysis concerning therapist time showed that Internet treatment had superior cost-effectiveness ratios in relation to group treatment both at post-treatment and follow-up.ConclusionsThis study provides support for the effectiveness of Internet CBT in a psychiatric setting for patients with panic disorder, and suggests that it is equally effective as the more widely used group administered CBT in reducing panic-and agoraphobic symptoms, as well as being more cost effective with respect to therapist time.Trial registrationClinicalTrials.gov NCT00845260

A pilot study of cognitive behaviour therapy for panic disorder augmented by panic surfing

This pilot study reports the outcome of cognitive behaviour therapy for panic disorder augmented by panic surfing. This treatment approach encourages acceptance of feelings rather than control of symptoms and anxiety, at the same time also targeting catastrophic misinterpretations, bodily vigilance and safety-seeking behaviours. Eighteen participants completed a brief group treatment for panic disorder incorporating psychoeducation, panic surfing, interoceptive exposure, graded exposure and cognitive restructuring. Significant improvements occurred over the course of this treatment and were maintained at a 1-month follow-up. Results suggest that cognitive behaviour therapy augmented by panic surfing may be effective in the treatment of panic disorder, but there is a need for controlled studies and investigation of the relative contribution of its various components.

Cognitive Behaviour Therapy for Panic Disorder in Chronic Obstructive Pulmonary Disease: Two Case Studies

Anxiety symptoms and panic disorder are common sequelae of chronic obstructive pulmonary disease, an illness that primarily affects older adults. The aim of this paper is to describe the application of cognitive behavioural treatment for two patients with chronic obstructive pulmonary disease and co-morbid panic disorder. The patients attended for eight to twelve sessions of cognitive behaviour therapy. Both improved on a range of indices of anxiety and quality of life. Neither patient met criteria for panic disorder at the end of treatment or over the following year. These two cases provide evidence that interventions of proven efficacy for treating panic disorder in healthy individuals can be adapted to treat patients with chronic obstructive pulmonary disease.

Outcome Prediction of Cognitive Behaviour Therapy for Panic Disorder: Initial Symptom Severity is Predictive for Treatment Outcome, Comorbid Anxiety or Depressive Disorder, Cluster C Personality Disorders and Initial Motivation Are Not

AbstractFive variables were investigated with regard to their possible predictive value for cognitive behavioural treatment (CBT) outcome in a large sample of panic disorder (PD) patients. The variables were initial symptom severity, comorbid anxiety or depressive disorders, comorbid cluster C personality disorders, and initial motivation for treatment. A total number of 161 PD patients received a standardized CBT of 15 sessions. Assessments of predictive variables took place prior to treatment. Outcome measures were assessed at pre- and posttreatment. The patients had significantly improved after the treatment. None of the variables, separately or together, affected CBT outcome, save initial severity of panic disorder symptoms, which was positively associated with posttreatment symptom severity. Since research efforts failed to produce consistent predictors for CBT treatment outcome in panic disorder thus far, the usefulness of future outcome prediction research in panic disorder by pre-treatment demographic, disorder-related, psychological, or socio-psychological variables is put into question.

Do Medications Matter in the Context of Cognitive Behavior Therapy for Panic Disorder?

Patients with panic disorder are frequently medicated when they participate in psychotherapy such as cognitive behavioral therapy (CBT). The present study examined the effects of overall medication status, medication type (benzodiazepine versus antidepressant), and medication dose in a large sample of patients with panic disorder (N=178) participating in CBT. Overall, medications exhibited very little effect on outcome. After controlling for the effects of CBT, however, taking higher doses of antidepressants was associated with poorer end-state functioning. Results are discussed in relation to better understanding the role of combining psychopharmacological and psychosocial treatments for panic disorder. Keywords: panic disorder; medication; cognitive behavioral therapy, treatment Epidemological evidence suggests that panic disorder (PD) afflicts millions (Kessler et al., 1994). Individuals with PD experience marked impairment (Simon et al., 2002) and are at an increased risk for alcohol use disorders (Otto, Pollack, Sachs, O'Neil, & Rosenbaum, 1992), smoking (see Zvolensky, Schmidt, & Stewart, 2003, for review), and suicide attempts (Schmidt, Woolaway-Bickel, & Bates, 2001). Fortunately, efficacious treatments for PD are available including several types of pharmacotherapies as well as cognitive behavioral therapy (CBT) (Schmidt, Koselka, & Woolaway-Bickel, 2001). Antidepressants such as monoamine oxidase inhibitors (MAOIs), tricydic antidepressants (TCAs), and serotonin selective reuptake inhibitors (SSRIs) are among the psychotropics that have demonstrated the highest levels of efficacy in the treatment of PD (see Schmidt, 1999, for review). Antidepressants have become the medication of choice in the pharmacological treatment of PD, reducing panic-related symptoms without causing the withdrawal and dependency that can occur with benzodiazepines. Yet, benzodiazepines are appealing hi that they provide more rapid anxiolytic effects and therefore continue to also serve as a common treatment for PD. In terms of psychotherapy, research has consistently demonstrated that CBT is one of the most efficacious treatments for PD (see Barlow, Raffa, & Cohen, 2002, for a review). CBT for PD is a highly structured, skill-based treatment in which the therapist works with patients to modify thinking and behaviors that maintain PD. Techniques utilized in CBT include education, cognitive reappraisal, interoceptive exposure (i.e., repeated exposure to bodily sensations associated with the fear response), in vivo exposure (i.e., repeated exposure to external situations connected to the fear response), and breathing control techniques. The efficacy of both psychopharmacology and psychosocial treatments for mental disorders has led some to assume that combined treatments, in which psychotherapy is coupled with pharmacotherapy, may be superior to singular ones. In fact, over half of patients receiving mental health services have been found to receive a combination of psychotherapy and medication (Pincus et al., 1999). In the case of PD, the majority of patients presenting for psychosocial treatments are medicated. It is therefore critical to determine the effects of medication use on psychosocial treatment for PD. Overall, there is little work on the combined effects of medication and CBT for PD. Among the antidepressants, there is some support for the short-term superiority of the combination of CBT plus fluvoxamine (de Beurs, van Balkom, Lange, Koele, & van Dyck, 1995) and CBT plus paroxetine (Stein, Norton, Walker, Chartier, & Graham, 2000) relative to CBT alone or CBT plus placebo. However, evidence suggests that the preliminary benefits of combining antidepressants with psychosocial treatments are often lost during follow-up and that combined treatment may actually result in poorer long-term outcome. In the case of CBT plus imipramine, Barlow, German, Shear, and Woods (2000) found that the combined treatment resulted in better initial outcome, but CBT alone predicted the best outcome at 6-month follow-up. …

Do Medications Matter in the Context of Cognitive Behavior Therapy for Panic Disorder?

Patients with panic disorder are frequently medicated when they participate in psychotherapy such as cognitive behavioral therapy (CBT). The present study examined the effects of overall medication status, medication type (benzodiazepine versus antidepressant), and medication dose in a large sample of patients with panic disorder (N = 178) participating in CBT. Overall, medications exhibited very little effect on outcome. After controlling for the effects of CBT, however, taking higher doses of antidepressants was associated with poorer end-state functioning. Results are discussed in relation to better understanding the role of combining psychopharmacological and psychosocial treatments for panic disorder.

Healthcare Utilization Following Cognitive‐Behavioral Treatment for Panic Disorder with Agoraphobia

The aim of this study was to examine the overall changes in healthcare services utilization after providing an empirically supported cognitive‐behavioral treatment for panic disorder with agoraphobia. Data on healthcare utilization were collected for a total of 84 adults meeting DSM‐IV criteria. Participants were completers of a cognitive‐behavioral treatment for panic disorder with agoraphobia. Data on utilization of healthcare services and medication were obtained from semi‐structured interviews from baseline to 1‐year after treatment. Results of the Friedman non‐parametric analysis reveal a significant decrease in overall and mental health‐related costs following treatment. This study shows a significant reduction in healthcare costs following cognitive behavior therapy for panic disorder with agoraphobia. More studies are needed to examine the potential long‐term cost‐offset effect of empirically supported treatments for panic disorder.

Looking beyond the negatives: A time period analysis of positive cognitions, negative cognitions, and working alliance in cognitive–behavior therapy for panic disorder

Time period analysis was used in an international sample of clients (N=106) to demonstrate that cognitive–behavioral therapy (CBT) for panic disorder is associated with specific changes in both negative and positive cognitions during the treatment period. In the first 6 weeks of the treatment phase, working alliance failed to predict changes in panic severity, whereas changes in panic self-efficacy and catastrophic misinterpretation of bodily sensations predicted rapid symptom relief. In the last 6 weeks of treatment, higher doses of CBT were associated with further changes in positive and negative cognitions. The findings can be interpreted as suggesting that the role of the working alliance in CBT for panic disorder is to facilitate cognitive change. Ein Blick uber negative Indikatoren hinaus: Eine zeitbezogene Analyse positiver und negativer Kognitionen und der therapeutischen Arbeitsbeziehung bei kognitiv-verhaltensorientierter Therapie bei Panikstorungen Um zu zeigen, dass kognitiv-verhaltensorientie...

Treatment of panic disorder: live therapy vs. self-help via the Internet

A randomized trial was conducted comparing 10 individual weekly sessions of cognitive behaviour therapy for panic disorder (PD) with or without agoraphobia with a 10-module self-help program on the Internet. After confirming the PD diagnosis with an in-person structured clinical interview (SCID) 49 participants were randomized. Overall, the results suggest that Internet-administered self-help plus minimal therapist contact via e-mail can be equally effective as traditional individual cognitive behaviour therapy. Composite within-group effect sizes were high in both groups, while the between-group effect size was small (Cohen's d = 16 ). One-year follow-up confirmed the results, with a within-group effect size of Cohen's d = 0.80 for the Internet group and d = 0.93 for the live group. The results from this study generally provide evidence to support the continued use and development of Internet-distributed self-help programs.

Cognitive behavioural therapy was more effective for panic disorder when given with 6 hours of total therapist contact than with 2 or 0 hours

Sharp DM, Power KG, Swanson V. Reducing therapist contact in cognitive behaviour therapy for panic disorder and agoraphobia in primary care: global measures of outcome in a randomised controlled trial....

Dropout prediction in cognitive behavior therapy for panic disorder

The aim of this study was to attempt to identify reliable factors associated with dropout risk in a sample of 161 panic disorder patients treated with manualized cognitive behavior therapy. Four possible predictors of dropout were selected from the literature: level of education, treatment motivation, personality psychopathology, and initial symptom severity. Thirty-two patients (19.9%) were dropouts. Level of education and motivation were significantly associated with dropout, but the associations were small. Personality psychopathology and initial symptom severity were not associated with dropout. It is concluded that, at present, we are unable to make precise dropout risk predictions, even in a homogeneous group of patients treated using standardized treatment.