Panic Disorder And Agoraphobia Research Articles

Balance Rehabilitation with Peripheral Visual Stimulation in Patients with Panic Disorder and Agoraphobia: An Open-Pilot Intervention Study.

Given the involvement of balance system abnormalities in the pathophysiology of panic disorder and agoraphobia (PD-AG), we evaluated initial evidence for feasibility, acceptability, and potential clinical usefulness of 10 sessions of balance rehabilitation with peripheral visual stimulation (BR-PVS) in an open-pilot 5-week intervention study including six outpatients with PD-AG who presented residual agoraphobia after selective serotonin reuptake inhibitor (SSRI) treatment and cognitive-behavioral therapy, dizziness in daily life, and peripheral visual hypersensitivity measured by posturography. Before and after BR-PVS, patients underwent posturography, otovestibular examination (no patients presented peripheral vestibular abnormalities), and panic-agoraphobic symptom and dizziness evaluation with psychometric tools. After BR-PVS, four patients achieved postural control normalization measured by posturography, and one patient exhibited a favorable trend of improvement. Overall, panic-agoraphobic symptoms and dizziness decreased, even though to a lesser extent in one patient who had not completed the rehabilitation sessions. The study presented reasonable levels of feasibility and acceptability. These findings suggest that balance evaluation should be considered in patients with PD-AGO presenting residual agoraphobia and that BR-PVS might be an adjunctive therapeutic option worth being tested in larger randomized controlled studies.

Videoconferencing Psychotherapy for Panic Disorder and Agoraphobia: Outcome and Treatment Processes From a Non-randomized Non-inferiority Trial.

BackgroundIn the context of the COVID-19 pandemic, legislations are being modified around the world to allow patients to receive mental health services through telehealth. Unfortunately, there are no large clinical trial available to reliably document the efficacy of delivering videoconferencing psychotherapy (VCP) for people with panic disorder and agoraphobia (PDA) and whether basic psychotherapeutic processes are altered.MethodsThis 2-arm intent-to-treat non-inferiority study reports on a clinical trial on VCP and documents how therapeutic working alliance and motivation toward psychotherapy are associated to treatment outcome. We hypothesized that VCP would not be inferior to standard face-to-face (FF) cognitive behavior therapy for PDA. No specific hypothesis was stated to address working alliance and treatment mechanisms. VCP was compared to a gold-standard psychotherapy treatment for PDA, which was delivered either in person or in videoconference, with a strict tolerance criterion of about 2 points on the primary outcome measure. Seventy one adult patients were recruited. Measures of working alliance were collected after the first, fifth, and last session. Motivation toward therapy at pre-treatment and working alliance after the fifth therapy session were used as predictors of treatment outcome and compared with change in dysfunctional beliefs toward bodily sensations.ResultsPanic disorder, agoraphobia, fear of sensations and depressed mood all showed significant improvements and large effect-sizes from pre to post-treatment. Gains were maintained at follow-up. No significant differences were found between VCP and FF, and effect sizes were trivial for three of the four outcome measures. Non-inferiority tests confirmed that VCP was no less effective than FF therapy on the primary outcome measure and two of the three secondary outcome measures. Working alliance was very strong in VCP and did not statistically differ from FF. Working alliance and motivation did not predict treatment outcome, which was significantly predicted by the reduction in dysfunctional beliefs. The strength of the therapeutic bond was correlated with change in dysfunctional beliefs.ConclusionMental health professionals can use VCP to provide services to patients with PDA. Building and maintaining a sound working alliance should not be a source concern. Practical recommendations are formulated.ISRCTN Trial Registration NumberISRCTN76456442.

Neural correlates of NOS1 ex1f-VNTR allelic variation in panic disorder and agoraphobia during fear conditioning and extinction in fMRI.

Neuronal nitric oxide synthase (NOS-I) impacts on fear/anxiety-like behavior in animals. In humans, the short (S) allele of a functional promotor polymorphism of NOS1 (NOS1 ex1f-VNTR) has been shown to be associated with higher anxiety and altered fear conditioning in healthy subjects in the amygdala and hippocampus (AMY/HIPP). Here, we explore the role of NOS1 ex1f-VNTR as a pathophysiological correlate of panic disorder and agoraphobia (PD/AG). In a sub-sample of a multicenter cognitive behavioral therapy (CBT) randomized controlled trial in patients with PD/AG (n=48: S/S-genotype n=15, S/L-genotype n=21, L/L-genotype n=12) and healthy control subjects, HS (n=34: S/S-genotype n=7, S/L-genotype n=17, L/L-genotype=10), a differential fear conditioning and extinction fMRI-paradigm was used to investigate how NOS1 ex1f-VNTR genotypes are associated with differential neural activation in AMY/HIPP. Prior to CBT, L/L-allele carriers showed higher activation than S/S-allele carriers in AMY/HIPP. A genotype × diagnosis interaction revealed that the S-allele in HS was associated with a pronounced deactivation in AMY/HIPP, while patients showed contrary effects. The interaction of genotype × stimulus type (CS+, conditioned stimulus associated with an aversive stimulus vs. CS-, unassociated) showed effects on differential learning in AMY/HIPP. All effects were predominately found during extinction. Genotype associated effects in patients were not altered after CBT. Low statistical power due to small sample size in each subgroup is a major limitation. However, our findings provide first preliminary evidence for dysfunctional neural fear conditioning/extinction associated with NOS1 ex1f-VNTR genotype in the context of PD/AG, shedding new light on the complex interaction between genetic risk, current psychopathology and treatment-related effects.

Association of rs7688285 allelic variation coding for GLRB with fear reactivity and exposure-based therapy in patients with panic disorder and agoraphobia

The gene coding for glycine receptor β subunits (GLRB) has been found to be related to panic disorder and agoraphobia (PD/AG) and to be associated with altered insular BOLD activation during fear conditioning, as an intermediate phenotype of defensive system reactivity in healthy subjects. In a multicenter clinical trial on PD/AG patients we investigated in three sub-samples whether GLRB allelic variation (A/G; A-allele identified as «risk») in the single nucleotide polymorphism rs7688285 was associated with autonomic (behavioral avoidance test BAT; n = 267 patients) and neural (differential fear conditioning; n = 49 patients, n = 38 controls) measures, and furthermore with responding towards exposure-based cognitive behavioral therapy (CBT, n = 184 patients). An interaction of genotype with current PD/AG diagnosis (PD/AG vs. controls; fMRI data only) and their modification after CBT was tested as well. Exploratory fMRI results prior to CBT, revealed A-allele carriers irrespective of diagnostic status to show overall higher BOLD activation in the hippocampus, motor cortex (MC) and insula. Differential activation in the MC, anterior cingulate cortex (ACC) and insula was found in the interaction genotype X diagnosis. Differential activation in ACC and hippocampus was present in differential fear learning. ACC activation was modified after treatment, while no overall rs7688285 dependent effect on clinical outcomes was found. On the behavioral level, A-allele carriers showed pronounced fear reactivity prior to CBT which partially normalized afterwards. In sum, rs7688285 variation interacts in a complex manner with PD/AG on a functional systems level and might be involved in the development of PD/AG but not in their treatment.

Patients’ characteristics and their influence on course of fear during agoraphobic symptom provocation: may SS(N)RI treatment compensate unfavorable individual preconditions?

Background: Patients’ characteristics and antidepressants are discussed to be relevant in the context of phobic exposure.Aims: To identify patients characteristics associated with a differential course of fear during disorder-specific symptom provocation as well as to elucidate the effect of selective serotonin-(noradrenalin-) reuptake inhibitors [SS(N)RI] on development of fear in the context of re-exposure to the phobic stimuli.Methods: Twenty-eight clinically well-characterized patients with panic disorder and agoraphobia (PD/AG) were classified into subjects who show a reduction of fear (‘Fear−’) during a symptom provocation via a picture-based paradigm (T1) and those who did not (‘Fear+’). Subsequently, SS(N)RI treatment was administered to all patients and subjects were re-exposed to the feared stimuli after 8 weeks of treatment (T2). Moreover, brain activity within the ‘fear network’ was measured via functional magnetic resonance imaging (fMRI) at T1 and T2.Results: Fear − were significantly younger and demonstrated increased exposure-related fear as well as stronger activity in several fear-related brain areas than Fear+. We found significant improvements in all clinical parameters after pharmacological intervention for the whole sample (T1–T2; all measures p < .02). However, reduction of fear as well as activation in (para)limbic structures during symptom provocation were now attenuated in Fear − but increased in Fear+.Conclusions: Advanced age may predict a therapeutically unfavorable course of fear during agoraphobic symptom provocation. Since we found no negative impact of medication on fear development at all, there was some evidence that SS(N)RI treatment might improve the individual ability to get involved with the agoraphobic stimuli while conducting disorder-specific exposure.

Running for extinction? Aerobic exercise as an augmentation of exposure therapy in panic disorder with agoraphobia

Exposure-based Cognitive Behavioral Therapy (eb-CBT) represents the most evidence-based psychotherapeutic approach in anxiety disorders. However, its efficacy may be limited by a delay in onset of action and a substantial number of patients does not respond sufficiently to treatment. In this context, aerobic exercise was found to be effective in reducing clinical anxiety as well as to improve (elements of) disorder-specific CBT in some mental disorders. We therefore investigated the effect of aerobic exercise supplementary to an eb-CBT in panic disorder and agoraphobia (PD/AG). 77 patients with PD/AG performed a 30 min treadmill task with moderate or low intensity (70% or 30% of the maximal oxygen uptake [VO2max]) prior to five exposure sessions within a standardized seven-week CBT. At baseline, after completing the treatment period (post) and six month after post (follow-up), several measures of (un)specific psychopathology (Hamilton Anxiety Rating Scale [Ham-A], Mobility Inventory [MI], Panic and Agoraphobia Scale [PAS], Agoraphobic Cognitions Questionnaire [ACQ], Body Sensations Questionnaire [BSQ]) were established to assess for clinical changes. All patients experienced a significant improvement of symptoms from baseline to post (for all measures p < .001) but repeated-measures analyses of variance found a trend towards a significant time × group interaction in the Ham-A in favor for the moderate intense exercise group (f[1, 74] = 4.15, p = .045, α=.025). This trend, however, disappeared at follow-up since the low-intense exercise group further improved significantly in Ham-A after post. Our findings therefore might point to an accelerating effect of moderate-intense exercise within an exposure-based CBT for AG/PD.

Identifying Patterns in Complex Field Data

Abstract. Ambulatory assessment methods are well suited to examine how patients with panic disorder and agoraphobia (PD/A) undertake situational exposure. But under complex field conditions of a complex treatment protocol, the variability of data can be so high that conventional analytic approaches based on group averages inadequately describe individual variability. To understand how fear responses change throughout exposure, we aimed to demonstrate the incremental value of sorting HR responses (an index of fear) prior to applying averaging procedures. As part of their panic treatment, 85 patients with PD/A completed a total of 233 bus exposure exercises. Heart rate (HR), global positioning system (GPS) location, and self-report data were collected. Patients were randomized to one of two active treatment conditions (standard exposure or fear-augmented exposure) and completed multiple exposures in four consecutive exposure sessions. We used latent class cluster analysis (CA) to cluster heart rate (HR) responses collected at the start of bus exposure exercises (5 min long, centered on bus boarding). Intra-individual patterns of assignment across exposure repetitions were examined to explore the relative influence of individual and situational factors on HR responses. The association between response types and panic disorder symptoms was determined by examining how clusters were related to self-reported anxiety, concordance between HR and self-report measures, and bodily symptom tolerance. These analyses were contrasted with a conventional analysis based on averages across experimental conditions. HR responses were sorted according to form and level criteria and yielded nine clusters, seven of which were interpretable. Cluster assignment was not stable across sessions or treatment condition. Clusters characterized by a low absolute HR level that slowly decayed corresponded with low self-reported anxiety and greater self-rated tolerance of bodily symptoms. Inconsistent individual factors influenced HR responses less than situational factors. Applying clustering can help to extend the conventional analysis of highly variable data collected in the field. We discuss the merits of this approach and reasons for the non-stereotypical pattern of cluster assignment across exposures.

The role of treatment delivery factors in exposure-based cognitive behavioral therapy for panic disorder with agoraphobia

Treatment delivery factors (i.e., therapist adherence, therapist competence, and therapeutic alliance) are considered to be important for cognitive behavioral therapy (CBT) for panic disorder and agoraphobia (PD/AG). In the current study, four independent raters conducted process evaluations based on 168 two-hour videotapes of 84 patients with PD/AG treated with exposure-based CBT. Two raters evaluated patients’ interpersonal behavior in Session 1. Two raters evaluated treatment delivery factors in Session 6, in which therapists provided the rationale for conducting exposure exercises. At the 6-month follow-up, therapists’ adherence (r=0.54) and therapeutic alliance (r=0.31) were significant predictors of changes in agoraphobic avoidance behavior; therapist competence was not associated with treatment outcomes. Patients’ interpersonal behavior in Session 1 was a significant predictor of the therapeutic alliance in Session 6 (r=0.17). The findings demonstrate that treatment delivery factors, particularly therapist adherence, are relevant to the long-term success of CBT for PD/AG.

Threat expectancy bias and treatment outcome in patients with panic disorder and agoraphobia

Background and objectivesPrevious studies suggest that patients with panic disorder and agoraphobia (PD/A) tend to overestimate the associations between fear-relevant stimuli and threat. This so-called threat expectancy bias is thought to play a role in the development and treatment of anxiety disorders. The current study tested 1) whether patients with PD/A (N = 71) show increased threat expectancy ratings to fear-relevant and fear-irrelevant stimuli relative to a comparison group without an axis I disorder (N=65), and 2) whether threat expectancy bias before treatment predicts treatment outcome in a subset of these patients (n = 51). MethodsIn a computerized task, participants saw a series of panic-related and neutral words and rated for each word the likelihood that it would be followed by a loud, aversive sound. ResultsResults showed higher threat expectancy ratings to both panic-related and neutral words in patients with PD/A compared to the comparison group. Threat expectancy ratings did not predict treatment outcome. LimitationsThis study only used expectancy ratings and did not include physiological measures. Furthermore, no post-treatment expectancy bias task was added to shed further light on the possibility that expectancy bias might be attenuated by treatment. ConclusionsPatients show higher expectancies of aversive outcome following both fear-relevant and fear-irrelevant stimuli relative to the comparison group, but this does not predict treatment outcome.

Frontal cortex absolute beta power measurement in Panic Disorder with Agoraphobia patients

Panic disorder patients are hypervigilant to danger cues and highly sensitive to unpredictable aversive events, what leads to anticipatory anxiety, that is one key component of the disorder maintenance. Prefrontal cortex seems to be involved in these processes and beta band activity may be related to the involvement of top-down processing, whose function is supposed to be disrupted in pathological anxiety. The objective of this study was to measure frontal absolute beta-power (ABP) with qEEG in panic disorder and agoraphobia (PDA) patients compared to healthy controls. Methods: qEEG data were acquired while participants (24 PDA patients and 21 controls) watched a computer simulation (CS), consisting of moments classified as “high anxiety” (HAM) and “low anxiety” (LAM). qEEG data were also acquired during two rest conditions, before and after the computer simulation display. The statistical analysis was performed by means of a repeated measure analysis of variance (two-way ANOVA) and ABP was the dependent variable of interest. The main hypothesis was that a higher ABP in PDA patients would be found related to controls. Moreover, in HAM the ABP would be different than in LAM. Results: the main finding was an interaction between the moment and group for the electrodes F7, F8, Fp1 and Fp2. We observed a higher ABP in PDA patients when compared to controls while watching the CS. The higher beta-power in the frontal cortex for the PDA group may reflect a state of high excitability, together with anticipatory anxiety and maintenance of hypervigilant cognitive state. Conclusions: our results suggest a possible deficiency in top-down processing reflected by a higher ABP in the PDA group while watching the CS and they highlight the recruitment of prefrontal regions during the exposure to anxiogenic stimuli. Limitations: the small sample, the wide age range of participants and the use of psychotropic medications by most of the PDA patients.

Alpha absolute power measurement in panic disorder with agoraphobia patients

BackgroundPanic attacks are thought to be a result from a dysfunctional coordination of cortical and brainstem sensory information leading to heightened amygdala activity with subsequent neuroendocrine, autonomic and behavioral activation. Prefrontal areas may be responsible for inhibitory top-down control processes and alpha synchronization seems to reflect this modulation. The objective of this study was to measure frontal absolute alpha-power with qEEG in 24 subjects with panic disorder and agoraphobia (PDA) compared to 21 healthy controls. MethodsqEEG data were acquired while participants watched a computer simulation, consisting of moments classified as “high anxiety”(HAM) and “low anxiety” (LAM). qEEG data were also acquired during two rest conditions, before and after the computer simulation display. ResultsWe observed a higher absolute alpha-power in controls when compared to the PDA patients while watching the computer simulation. The main finding was an interaction between the moment and group factors on frontal cortex. Our findings suggest that the decreased alpha-power in the frontal cortex for the PDA group may reflect a state of high excitability. ConclusionsOur results suggest a possible deficiency in top-down control processes of anxiety reflected by a low absolute alpha-power in the PDA group while watching the computer simulation and they highlight that prefrontal regions and frontal region nearby the temporal area are recruited during the exposure to anxiogenic stimuli.

Comorbidity and Internet-Delivered Transdiagnostic Cognitive Behavioural Therapy for Anxiety Disorders

Internet-delivered transdiagnostic anxiety interventions aim to reduce symptoms across several anxiety disorders using one treatment protocol. However, it is unclear whether comorbidity affects outcomes of such treatment. This study re-examined data from a recent randomised controlled trial (N = 129) that evaluated the efficacy of an Internet-delivered transdiagnostic cognitive behavioural therapy (iCBT) intervention for participants with principal diagnoses of generalised anxiety disorder (GAD), social phobia (SP) panic disorder and agoraphobia (PDA), of whom 72% met criteria for a comorbid anxiety disorder or depression. Participants were divided into two groups based on whether or not they had a comorbid disorder before treatment. Participants with comorbid conditions reported higher symptom levels at pre-treatment, post-treatment, and follow-up across a range of measures. Both groups showed significant reductions in symptoms over treatment; however, participants with comorbid disorders showed greater reductions in measures of GAD, PDA, SP, depression, and neuroticism. In addition, treatment significantly reduced the number of comorbid diagnoses at follow-up. These results indicate transdiagnostic iCBT protocols have the potential to reduce comorbidity.

Dynamics of Defensive Reactivity in Patients with Panic Disorder and Agoraphobia: Implications for the Etiology of Panic Disorder

The learning perspective of panic disorder distinguishes between acute panic and anxious apprehension as distinct emotional states. Following animal models, these clinical entities reflect different stages of defensive reactivity depending upon the imminence of interoceptive or exteroceptive threat cues. The current study tested this model by investigating the dynamics of defensive reactivity in a large group of patients with panic disorder and agoraphobia (PD/AG). Three hundred forty-five PD/AG patients participated in a standardized behavioral avoidance test (being entrapped in a small, dark chamber for 10 minutes). Defense reactivity was assessed measuring avoidance and escape behavior, self-reports of anxiety and panic symptoms, autonomic arousal (heart rate and skin conductance), and potentiation of the startle reflex before and during exposure of the behavioral avoidance test. Panic disorder and agoraphobia patients differed substantially in their defensive reactivity. While 31.6% of the patients showed strong anxious apprehension during this task (as indexed by increased reports of anxiety, elevated physiological arousal, and startle potentiation), 20.9% of the patients escaped from the test chamber. Active escape was initiated at the peak of the autonomic surge accompanied by an inhibition of the startle response as predicted by the animal model. These physiological responses resembled the pattern observed during the 34 reported panic attacks. We found evidence that defensive reactivity in PD/AG patients is dynamically organized ranging from anxious apprehension to panic with increasing proximity of interoceptive threat. These data support the learning perspective of panic disorder.

Depression Does Not Affect the Treatment Outcome of CBT for Panic and Agoraphobia: Results from a Multicenter Randomized Trial

Background: Controversy surrounds the questions whether co-occurring depression has negative effects on cognitivebehavioral therapy (CBT) outcomes in patients with panic disorder (PD) and agoraphobia (AG) and whether treatment for PD and AG (PD/AG) also reduces depressive symptomatology. Methods: Post-hoc analyses of randomized clinical trial data of 369 outpatients with primary PD/AG (DSM-IV-TR criteria) treated with a 12-session manualized CBT (n = 301) and a waitlist control group (n = 68). Patients with comorbid depression (DSM-IV-TR major depression, dysthymia, or both: 43.2% CBT, 42.7% controls) were compared to patients without depression regarding anxiety and depression outcomes (Clinical Global Impression Scale [CGI], Hamilton Anxiety Rating Scale [HAM-A], number of panic attacks, Mobility Inventory [MI], Panic and Agoraphobia Scale, Beck Depression Inventory) at post-treatment and follow-up (categorical). Further, the role of severity of depressive symptoms on anxiety/depression outcome measures was examined (dimensional). Results: Comorbid depression did not have a significant overall effect on anxiety outcomes at post-treatment and follow-up, except for slightly diminished post-treatment effect sizes for clinician-rated CGI (p = 0.03) and HAM-A (p = 0.008) when adjusting for baseline anxiety severity. In the dimensional model, higher baseline depression scores were associated with lower effect sizes at post-treatment (except for MI), but not at follow-up (except for HAM-A). Depressive symptoms improved irrespective of the presence of depression. Conclusions: Exposure-based CBT for primary PD/AG effectively reduces anxiety and depressive symptoms, irrespective of comorbid depression or depressive symptomatology.

(Don't) panic in the scanner! How panic patients with agoraphobia experience a functional magnetic resonance imaging session

Although functional magnetic resonance imaging (fMRI) has gained increasing importance in investigating neural substrates of anxiety disorders, less is known about the stress eliciting properties of the scanner environment itself. The aim of the study was to investigate feasibility, self-reported distress and anxiety management strategies during an fMRI experiment in a comprehensive sample of patients with panic disorder and agoraphobia (PD/AG). Within the national research network PANIC-NET, n = 89 patients and n = 90 controls participated in a multicenter fMRI study. Subjects completed a retrospective questionnaire on self-reported distress, including a habituation profile and exploratory questions about helpful strategies. Drop-out rates and fMRI quality parameters were employed as markers of study feasibility. Different anxiety measures were used to identify patients particularly vulnerable to increased scanner anxiety and impaired data quality. Three (3.5%) patients terminated the session prematurely. While drop-out rates were comparable for patients and controls, data quality was moderately impaired in patients. Distress was significantly elevated in patients compared to controls; claustrophobic anxiety was furthermore associated with pronounced distress and lower fMRI data quality in patients. Patients reported helpful strategies, including motivational factors and cognitive coping strategies. The feasibility of large-scale fMRI studies on PD/AG patients could be proved. Study designs should nevertheless acknowledge that the MRI setting may enhance stress reactions. Future studies are needed to investigate the relationship between self-reported distress and fMRI data in patient groups that are subject to neuroimaging research.

Gender differences in Axis I and Axis II disorders comorbidity in patients with panic disorder and agoraphobia

Objective:To explore the gender differences in Axis I and Axis II disorders comorbidity in patients with panic disorder and agoraphobia (PDA).Method:The sample consisted of 157 consecutive patients (71.3% females) with principal diagnosis of PDA. The assessment included administration of SCID-I and SCID-II. Women and men were then compared with regards to the type and frequency of the comorbid Axis I and Axis II disorders.Results:Axis I disorders. Men (2.02±1.82) and women (2.05±1.27) did not differ significantly the mean number of comorbid Axis I diagnoses per patient but women had a significantly higher rate of at least one comorbid Axis I diagnosis (87.5% vs. 73.3%) and a significantly higher rate of at least one comorbid anxiety disorder (79.5% vs. 53.3%). Women had a significantly higher frequency of specific phobia (58.9% vs 33.3%) and major depressive disorder (51.8% vs. 35.6%) than men. Men had a significantly higher rate of hypochondriasis (26.7% vs. 7.1%) and past alcohol abuse/dependence (33.3% vs. 0.9%). Axis II disorders. Men and women did not differ on the mean number of personality disorder (PD) diagnoses (1.02 vs. 0.96) and the distribution of at least one PD diagnosis (51.1% vs. 53.6%). Women had significantly higher rate of dependent PD (27.7% vs. 11.1%) and men had higher rate of narcissistic PD (15.6% vs. 6.3%).

Psychometric properties of the social phobia inventory: Further evaluation

This study investigated the psychometric properties of the Social Phobia Inventory [SPIN; Connor, K. M., Davidson, J. R. T., Churchill, L. E., Sherwood, A., Foa, E., Wesler, R.H., 2000. Psychometric properties of the Social Phobia Inventory (SPIN). British Journal of Psychiatry, 176, 379–386], a measure of severity in social phobia (social anxiety disorder). Participants included 132 participants with social phobia, 57 participants with panic disorder and agoraphobia (PDA), and 62 participants with obsessive-compulsive disorder (OCD). Confirming findings from an initial validation study, the SPIN was found to have excellent internal consistency and good test–retest reliability. It also distinguished well between those with social phobia and those with either PDA or OCD. Good convergent and discriminant validity were established by examining correlations with other conceptually related and unrelated scales. Finally, the SPIN was sensitive to changes in social phobia severity following cognitive behavioral group treatment. In conclusion, the SPIN is both reliable and valid for the measurement of social phobia severity and outcome following psychological treatment.

Effektivität stationärer Verhaltenstherapie bei schwerer Panikstörung und Agoraphobie

The efficacy of cognitive-behavioral therapy(CBT), of selective serotonin reuptake inhibitors (SSRI) andother antidepressants in panic disorder and agoraphobia(PDA) has been proven in many controlled trials. However,efficacy does not guarantee good effectiveness in certain subgroupsof patients. Only few studies have investigated the effectivenessof CBT with or without concomitant medication ininpatients with severe PDA. Methods: 80 inpatients weretreated with CBT comprising intense exposure in vivo. 41 ofthem received additional medication, mostly SSRI and otherantidepressants. Drug treatment was not randomized orblinded. Progress in therapy was measured weekly with Bandelow’sPanic and Agoraphobia Scale. Psychopathology, demographicand clinical features were assessed as well. Thetemporal course was analyzed using cox regression. Results:71 patients (89%) improved by at least 30%. At posttest12 patients (15%) were free of panic and avoidance, another49 patients (61,2%) experienced only mild residual anxietysymptoms. The main outcome measure yielded an effect sizeof 2,50. A reliable improvement by 30% took 7 weeks in median.Female sex and secondary school education, but not universitydegree, predicted better outcome. Depression andmultiple comorbidity influenced results adversely. Additionalpharmacotherapy did not enhance or accelerate treatmentoutcome in general, but the medication group had more severepsychopathology at pretest. Conclusions: CBT bringsabout a good reduction of anxiety and avoidance in inpatientswith serious PDA. Residual symptoms remain in manyof these patients. Combining SSRI or other antidepressantdrugs with CBT is not generally beneficial. Future studiesshould investigate the differential effectiveness of CBT/drugcombination.

11-1 - Panic disorder and agoraphobia: What is effective?

The present survey of controlled studies on the treatment of panic disorder and agoraphobia (PDA) reveals that treatment with tricyclic antidepressants (e.g., imipramine and clomipramine), benzodiazepines (e.g., alprazolam), serotonin reuptake inhibitors (e.g., fluvoxamine) and the monoamine oxidase inhibitor phenelzine has been proven effective. Among psychological therapies, cognitive therapy and exposure therapy in agoraphobia have been shown to be effective. There is an insufficient number of comparisons between pharmacological and psychological treatments. From the existing studies it can be assumed that none of these treatment modalities is superior to the other. The few existing follow-up studies do not suffice to prove a longer lasting effect for the psychological therapies, compared with drug therapies. Because of the low number of investigations, it cannot be clearly stated whether it is useful or harmful do treat patients with psychopharmacological drugs during psychological therapy. It is more likely that this combination is advantageous.

Panic disorder — acceptance of the diagnostic entity and treatment modalities preferred by German health professionals

A survey of the pharmacological and psychological treatment of panic disorder and agoraphobia (PDA) was conducted among 103 physicians, psychologists and psychotherapists. It revealed that the treatments for PDA preferred by the majority of the respondents are inconsistent with the recommendations given in the international literature. Non-psychiatric physicians most frequently proposed herbal preparations as a possible treatment (46% of non-psychiatric physicians), followed by homoeopathic formulations (32%). Tricyclic antidepressants which are recommended as first-line treatment in panic disorder by the literature are preferred by 74% of the psychiatrists, but only by 24% of the non-psychiatric physicians. Benzodiazepines are prescribed by twice as many psychiatrists (45%) as non-psychiatric physicians (22%). Beta blockers and neuroleptics which are not recommended as first-line treatment in panic disorder are used quite often (psychiatrists: 15%; non-psychiatric physicians: 26%). Selective serotonin reuptake inhibitors are prescribed by 24% of the psychiatrists, but by only 3% of the non-psychiatric physicians. Among psychological therapies, psychoanalysis was proposed as first-line treatment by 44% of all professionals applying psychological therapies, while cognitive/behaviour therapy was preferred by only 28%, though proof of efficacy exists only for cognitive/behaviour therapy. In general, psychologists prefer behaviourally-orientated therapy, while physicians mostly propose psychodynamic therapy. One reason for the fact that the results of controlled studies have little influence on professionals treating PDA patients might be that 40% of the respondents do not accept the new classification of the anxiety disorders as introduced in 1980 by the DSM-III.