Cognitive behavioral therapy for panic disorder and comorbidity: more of the same or less of more?

This study compared the effects of a higher dose of cognitive behavioral therapy (CBT) for panic disorder versus CBT for panic disorder combined with "straying" to CBT for comorbid disorders in individuals with a principal diagnosis of panic disorder with or without agoraphobia. Sixty-five participants were randomly assigned to one of two treatment conditions, either CBT focused solely upon panic disorder and agoraphobia or CBT that simultaneously addressed panic disorder and agoraphobia and, to a lesser degree, the most severe comorbid condition. Results indicated a significant reduction in panic disorder severity and a decline in severity of comorbid diagnoses across both treatment conditions. However, individuals receiving CBT focused only on panic disorder were more likely to meet high end-state functioning at post-treatment, even in intent-to-treat analyses, and report zero panic attacks at the 1-year follow-up, although this effect was not retained in intent-to-treat analyses. At follow-up, CBT focused only on panic disorder yielded more substantial improvement in the most severe baseline comorbid condition, although not in intent-to-treat analyses, and a greater proportion of individuals in this treatment condition were rated as having no comorbid diagnoses, even in intent-to-treat analyses. These findings raise the possibility that remaining focused on CBT for panic disorder may be more beneficial for both principal and comorbid diagnoses than combining CBT for panic disorder with 'straying' to CBT for comorbid disorders.     

Cognitive-Behavior Therapy (CBT) for Panic Disorder: Relationship of Anxiety and Depression Comorbidity with Treatment Outcome

Research evaluating the relationship of comorbidity to treatment outcome for panic disorder has produced mixed results. The current study examined the relationship of comorbid depression and anxiety to treatment outcome in a large-scale, multi-site clinical trial for cognitive-behavior therapy (CBT) for panic disorder. Comorbidity was associated with more severe panic disorder symptoms, although comorbid diagnoses were not associated with treatment response. Comorbid generalized anxiety disorder (GAD) and major depressive disorder (MDD) were not associated with differential improvement on a measure of panic disorder severity, although only rates of comorbid GAD were significantly lower at posttreatment. Treatment responders showed greater reductions on measures of anxiety and depressive symptoms. These data suggest that comorbid anxiety and depression are not an impediment to treatment response, and successful treatment of panic disorder is associated with reductions of comorbid anxiety and depressive symptoms. Implications for treatment specificity and conceptual understandings of comorbidity are discussed.     

The impact of an 8-day intensive treatment for adolescent panic disorder and agoraphobia on comorbid diagnoses

Previous research findings have shown positive effects of cognitive-behavioral therapy for primary anxiety disorders as well as for nonprimary, co-occurring anxiety disorders. In this study, we analyzed data from an existing randomized controlled trial of intensive treatment for panic disorder with or without agoraphobia (PDA) to examine the effects of the treatment on comorbid psychiatric diagnoses. The overall frequency and severity of aggregated comorbid diagnoses decreased in a group of adolescents who received an 8-day treatment for PDA. Results suggest that an 8-day treatment for PDA can alleviate the symptoms of some specific comorbid clinical diagnoses; in particular specific phobias, generalized anxiety disorder, and social phobia. These findings suggest that an intensive treatment for PDA is associated with reductions in comorbid symptoms even though disorders other than PDA are not specific treatment targets.     

Comorbidity and the Treatment of Principal Anxiety Disorders in a Naturalistic Sample

This study examined the impact of comorbidity on treatment outcome and the effects of cognitive behavioral therapy (CBT) for anxiety and depressive disorders on comorbid disorders in a naturalistic sample of 150 patients presenting to an anxiety disorders clinic. The following results were observed across principal (i.e., most severe) diagnoses. Patients with comorbid anxiety and depressive disorders presented for treatment with higher severity of their principal disorder than patients without comorbidity. However, the presence of comorbidity did not predict dropout or poor treatment response, and patients demonstrated significant improvement in their principal disorders regardless of comorbidity. The frequency of clinically severe and subclinical (i.e., not severe enough to meet diagnostic criteria) comorbid conditions decreased significantly over the course of treatment. The implication of these findings for the classification and treatment of emotional disorders is discussed.     

Diagnostic Comorbidity in Adults With Generalized Anxiety Disorder: Impact of Comorbidity on Psychotherapy Outcome and Impact of Psychotherapy on Comorbid Diagnoses

The current study examined the impact of comorbidity on cognitive and behavioral therapies for generalized anxiety disorder (GAD) as well as the impact of these therapies on diagnoses comorbid to GAD. Seventy-six treatment-seeking adults with principal diagnoses of GAD received 14 sessions of therapy. Most (n = 46; 60.5%) of the sample had at least one comorbid diagnosis. Although the presence of comorbid diagnoses was associated with greater severity of GAD symptoms at pretreatment, greater severity of comorbid major depression, simple phobia, and social phobia was associated with greater change in symptoms of GAD in response to treatment, with no effect on maintenance of gains during a 2-year follow-up. Further, psychotherapy for principal GAD led to a reduction in number of comorbid diagnoses and in severity of social phobia, simple phobia, and major depression at posttreatment. At 2-year follow-up severity of social and simple phobia remained below pretreatment levels, whereas severity of depression was no longer significantly below pretreatment levels. These results suggest that although people with comorbid disorders enter treatment with more severe GAD symptomatology, they demonstrate greater change, and therefore such comorbidity does not diminish the efficacy of cognitive and behavioral therapies for GAD. In addition, the impact of these treatments for GAD may generalize to reduced severity of simple phobia, social phobia, and major depression; however, gains in severity of major depression are not maintained.     

Changes in Anxiety Control Beliefs Following a Brief CBT Treatment and Their Association With Anxiety Symptom Reduction

Anxiety control beliefs (i.e., beliefs regarding one’s ability to cope with external, fear-inducing threats and internal reactions to those perceived threats) have been found to negatively predict anxiety symptoms in children and adults and to be modifiable by cognitive-behavioral therapy for anxiety disorders. The current study examines whether changes in anxiety control beliefs were seen following a brief, intensive treatment for specific phobias, and whether those changes were associated with improvements in the targeted phobia and comorbid anxiety disorder symptoms. Participants were 135 children and adolescents (M age = 9.01 years, 49% male) who received one-session treatment (OST) with or without parental involvement for their primary specific phobia. Results indicated that self-reported anxiety control beliefs significantly increased following treatment and that these increases significantly predicted reductions in specific phobia severity and symptoms of comorbid anxiety disorders 6 months and 1 year following treatment. Findings illustrate that involvement in a single 3-hour OST was associated with changes in anxiety control beliefs and demonstrate the potential importance of targeting control beliefs in pediatric anxiety treatment.     

Antidepressant discontinuation in the context of cognitive behavioral treatment for panic disorder.

Cognitive behavioral treatment (CBT) has been shown to reduce risk for adverse reactions (e.g., rebound panic) following benzodiazepine taper for patients with panic disorder (PD). This study evaluated the effects of antidepressant discontinuation for patients with PD in the context of CBT. Patients with PD (n=21) on a stable dose of antidepressants completed a 12-week group CBT treatment and were randomly assigned to discontinue antidepressants during week 8 of the treatment. There were no statistically significant differences between groups at posttreatment or 6-month follow-up. Data indicate no apparent immediate or long-term adverse effects for antidepressant discontinuation for patients with PD receiving CBT.     

Comorbid anxiety and mood disorders among persons with social anxiety disorder.

Axis I comorbidity is associated with greater severity of social anxiety disorder. However, the differential effects of comorbid mood and anxiety disorders on symptom severity or treatment outcome have not been investigated. We evaluated 69 persons with uncomplicated social anxiety disorder, 39 persons with an additional anxiety disorder, and 33 persons with an additional mood disorder (with or without additional anxiety disorders). Those with comorbid mood disorders reported greater duration of social anxiety than those with uncomplicated social anxiety disorder. They were also judged, before and after 12 weeks of cognitive-behavioral group treatment and at follow-up, to be more severely impaired than those with no comorbid diagnosis. In contrast, persons with comorbid anxiety disorders were rated as more impaired than those with no comorbid diagnosis on only a single measure. Type of comorbid diagnosis did not result in differential rates of improvement of social anxiety disorder.     

The role of comorbid disruptive behavior in the clinical expression of pediatric obsessive-compulsive disorder

This study explored the impact of disruptive behavior disorder (DBD) comorbidity on a number of theoretically relevant outcomes among 192 children and adolescents with obsessive-compulsive disorder (OCD). Youth were divided into three groups: OCD Only, OCD+DBD comorbidity and OCD+Other comorbidity. Relative to those without a comorbid condition and those with any non-DBD comorbidity, comorbid DBD was associated with greater family accommodation and less symptom resistance. Youth with comorbid DBD exhibited greater OCD symptom severity, OCD-related impairment, anxiety, and internalizing problems than those with no comorbidity. Those with comorbid DBD were over 3.6 times as likely to be taking an atypical antipsychotic medication relative to children without comorbidity. The present results suggest that comorbid DBD contributes to more severe illness presentation above and beyond an OCD diagnosis alone, and may be associated with differing pharmacotherapy prescribing practices.     

The Treatment of Social Phobia in a Young Boy With Asperger's Disorder

Anxiety disorders, including social phobia, occur often in children with autism spectrum disorders (ASD; Gillott, Furniss, & Walter, 2001; Leyfer et al., 2006; Simonoff et al., 2008); however, little is known about the conceptualization and treatment of social phobia in this population. The current study presents the case of “James,” a 6-year-old male with comorbid Asperger's disorder and social phobia. A cognitive-behavioral treatment (CBT) package, including parent training, psychoeducation, graduated exposure, and reinforced practice, was implemented to decrease avoidance behaviors in social settings. Results showed that James's avoidance behaviors were reduced significantly following intervention, suggesting that a CBT approach may be effective in treating social phobia in children with ASD. The significant influence of CBT on decreasing avoidance behavior in comorbid social phobia and ASD highlights the need for continued investigation of adapting CBT for use with children with ASD.     

One-year follow-up of pharmacotherapy-resistant patients with panic disorder treated with cognitive-behavior therapy: Outcome and predictors of remission

Non-response to pharmacotherapy for panic disorder (PD) is a well-documented problem. However, little information exists to guide next-step strategies for these non-responders. In addition to pharmacologic augmentation strategies, several studies support the efficacy of cognitive-behavior therapy (CBT) for these patients, although data on long-term outcomes has been lacking. In this study, we provide one-year outcomes on a sample of 63 patients who completed group CBT for PD after failing to respond adequately to previous pharmacotherapy. Sustained significant benefit was found for all dimensional outcome scores, and nearly two-thirds of the sample met remission criteria. This occurred with reductions in medication use over the follow-up period. Negative predictors of remission status included comorbid dysthymia, social phobia, and generalized anxiety disorder. These results provide additional evidence for the efficacy of CBT for medication non-responders with PD.     

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.     

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.     

Treatment of Anxiety Disorders With Comorbid Depression: A Survey of Expert CBT Clinicians

Cognitive-behavioral therapy (CBT) is an empirically supported psychological treatment for anxiety disorders. These treatments have primarily been developed to target primary anxiety disorders, despite the fact that these disorders frequently co-occur with a diagnosis of depression. Empirical evidence provides guidance regarding how to treat an individual with a primary anxiety disorder with comorbid depression; however, there is limited data regarding how to translate these findings into clinical practice. Improving our understanding of how CBT is currently being used in practice among experts is integral to learning whether modifications to protocols lead to more or less effective treatments. Accordingly, we surveyed expert CBT clinicians about their assessment and treatment approaches and what challenges they face in formulating and treating mood and anxiety comorbidity. Most experts reported that their assessment includes a semistructured interview and self-report measures to determine breadth and hierarchical ordering of comorbidity severity. Symptom severity, client's goals, temporal onset of disorders, presence of suicide risk, and potential for early treatment success were reported as factors to consider when deciding where to begin treatment. Almost three quarters of experts surveyed indicated that they usually take some type of sequential treatment approach when treating primary anxiety disorders with comorbid depression. The top three reported challenges associated with treating comorbid presentations were client's motivation/energy, hopelessness/pessimism, and ongoing need for risk assessment. Implications for the nature and timing of CBT interventions in “real-world” clinical practice are discussed.     

A Review of Cognitive Behavioral Therapy for Panic Disorder in Patients with Chronic Obstructive Pulmonary Disease: The Rationale for Interoceptive Exposure

Panic disorder commonly co-occurs in patients with chronic obstructive pulmonary disease (COPD), and translational interventions are needed to address the fear of physiological arousal in this population. This paper examines the utility of interoceptive exposures (IE), a key component of cognitive behavioral therapy (CBT) for panic disorder, in patients with comorbid panic and COPD. Our translational review of the literature suggests that IE is supported by both cognitive- and learning-theory perspectives of panic, and that the breathing exercises associated with IE are safe and highly compatible with existing pulmonary rehabilitation exercises for COPD. Unfortunately, few research studies have examined the use of CBT to treat anxiety in COPD patients, and none have included IE. Given the strong theoretical and empirical support for the use of IE, we suggest that mental health providers should consider incorporating IE into CBT interventions for patients with comorbid panic and COPD.     

Evidenzbasierte Psychotherapie der Panikst?rung mit und ohne Agoraphobie

From the evidence reported in the recent guidelines [Heinrichs et al. (2009) Evidenzbasierte Leitlinie zur Psychotherapie der Panikst?rung mit und ohne Agoraphobie. Hogrefe, G?ttingen] the following conclusions can be drawn with respect to the treatment of panic disorder with or without agoraphobia, as well as for agoraphobia without panic disorder:

1. Every psychotherapy should be preceded by suitable diagnostics and a case formulation.
2. The effectiveness of every psychotherapy should be evaluated with well established measures.
3. For the treatment of panic disorder without agoraphobia, cognitive behavioral treatment (CBT) and applied relaxation have been shown to be effective (evidence grade 1).
4. For panic disorder with agoraphobia, CBT, combination treatment (CBT plus medication), as well as panic-focused psychodynamic psychotherapy in the outpatient setting have shown short-term effectiveness (evidence grade 1). Longer lasting effects have been documented for CBT (evidence grade 1).
5. For agoraphobia without panic disorder, CBT with a focus on situational exposure can be recommended (evidence grade 1).

     

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.     

Comorbid ADHD: Implications for the Treatment of Anxiety Disorders in Children and Adolescents

Despite high comorbidity rates and potential clinical implications, the influence of co-occurring attention-deficit/hyperactivity disorder (ADHD) on outcomes of cognitive-behavioral treatment (CBT) for anxious youth remains poorly understood. In this qualitative review, the current literature on the influence of comorbid ADHD on CBT of youth with diverse anxiety disorders is explored. Peer-reviewed studies examining ADHD, at the diagnostic and symptom level, received highest priority. In addition, inasmuch as some studies did not isolate the effects of ADHD from other disruptive behavior disorders (DBDs: oppositional defiant disorder, conduct disorders), studies with the three DBDs were explored as well. Ten studies met our specified methodological criteria. Findings are discussed in relation to the following two factors: type of anxiety disorder and measurement of ADHD (diagnostic or symptom level) in these studies. There was evidence that youth with a variety of anxiety disorders and with co-occurring ADHD fared worse than their counterparts without ADHD. Additionally, grouping ADHD with other DBDs tended to obscure the negative impact of ADHD on treatment outcomes. Additional research is needed to delineate the influence of comorbid ADHD specifically on treatment outcomes for the various anxiety disorders. Clinical implications of treating anxious youth with comorbid ADHD are explored.     

Panic Disorder: Cognitive Behavioral and Pharmacological Treatment Strategies

The past decade has seen significant advances in both psychosocial, notably cognitive behavioral (CBT), and pharmacological treatments for panic disorder. Given the widely acknowledged efficacy of both forms of treatment, it is reasonable to consider that the combination of approaches should yield an extremely potent strategy to treating panic disorder. The present report summarizes scientific evidence for the singular and combined treatment approaches to panic disorder. Data across studies indicate that combined treatments yield immediate and short-term benefits above those provided by either pharmacologic treatment or CBT alone. In the long-term, however, these benefits disappear. In fact, the combination of benzodiazepines and CBT appears to produce poorer end-state functioning than CBT alone. Other data indicate that the sequencing of pharmacotherapy and CBT may be useful for benzodiazepine fading. Although these data are preliminary, combined treatments do not appear to be the treatment of choice for patients with panic disorder. Treatment algorithms are suggested based on existing data.     

Differences in reported symptom profile between panic disorder and other DSM-III-R anxiety disorders.

Previous research has indicated that reports of panic attacks are associated with a different set of symptoms to reports of generalized anxiety. The present two studies attempted to extend these findings to specific (situational) fears. In Study 1, 55 subjects with panic disorder were compared on their symptom profile during their panic attacks to 65 subjects with other anxiety disorders [simple phobia, social phobia and obsessive-compulsive disorder (OCD)] during response to their feared cue. The results indicated that, compared to subjects with other anxiety disorders, subjects with panic disorder were more likely to report parasthesias, dizziness, faintness, unreality, dyspnea, fear of dying and fear of going crazy/losing control. In Study 2, 90 subjects meeting diagnostic criteria for both panic disorder and another anxiety disorder (simple phobia, social phobia or OCD) were compared on the symptoms experienced during their unexpected panic attacks and their situationally-triggered fears respectively. Combining the symptoms found in Study 1 to differ between the groups into a linear combination, there was a significant interaction found between the type of fear reaction (panic attack vs cued fear response) and symptom group. Taken together, these findings suggest that reports of unexpected panic attacks associated with panic disorder are characterized by a different symptom profile to reports of specific fear reactions that are part of a phobic disorder or OCD.