Group cognitive-behavior therapy for patients failing to respond to pharmacotherapy for panic disorder: a clinical case series.

The last decade has brought exciting advances to the treatment of panic disorder and agoraphobia, and a variety of cognitive-behavioral and pharmacologic treatment strategies offer clear benefit to patients. Nonetheless, treatment nonresponse continues to be a chronic problem, and additional strategies are needed to aid patients who do not respond fully to initial interventions. In the present study, we use 'services' research to document the clinical response of pharmacotherapy nonresponders to a standard program of brief, group cognitive-behavioral therapy. Patients responded well, regardless of whether they had received a full, adequate trial of pharmacotherapy. In addition to its application as an initial treatment for panic disorder, routine application of cognitive-behavioral therapy in pharmacologic treatment algorithms is encouraged, with attention to referral of pharmacotherapy nonresponders to cognitive-behavioral therapy.     

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.     

Impact of cognitive-behavioral therapy for panic disorder on comorbidity: a controlled investigation

This study examined the effects of cognitive-behavioral therapy (CBT) for principal panic disorder with or without agoraphobia, on comorbidity in 30 individuals (16 female). To test the hypothesis that improvements in co-existing conditions were not due to spontaneous fluctuations across time, patients receiving immediate CBT were compared to those assigned to wait list (n = 11). Results indicated clinician-rated severity of comorbid specific phobia declined significantly following immediate CBT compared to no change after wait list. The number of patients without comorbidity of any severity increased after immediate CBT, with no such increase following wait list. However, the groups did not differ in the frequency of additional diagnoses or overall severity of comorbidity. In the total sample, results indicated reductions in comorbidity by 9-month follow-up, with marked declines in the severity of comorbid generalized anxiety disorder (GAD), social and specific phobia. Our findings suggest that targeted CBT for panic disorder has beneficial effects on comorbidity over the longer term and that some of its immediate effects exceed those due to the passage of time alone.     

Treatment-resistant panic disorder

A substantial number of patients with panic disorder and agoraphobia may remain symptomatic after standard treatment (including selective serotonin reuptake inhibitors, tricyclic antidepressants, benzodiazepines, or irreversible monamine oxidase inhibitors). In this review, recommendations for the treatment of patients with panic disorder and agoraphobia who do not respond to these drugs are provided. Nonresponse to drug treatment could be defined as a failure to achieve a 50% reduction on a standard rating scale after a minimum of 6 weeks of treatment in adequate dose. When initial treatments have failed, the medication should be changed to other standard treatments. In further attempts at treatment, drugs should be used that have shown promising results in preliminary studies, such as venlafaxine. Combination treatments may be used, such as the combination of an selective serotonin reuptake inhibitor and a benzodiazepine. Psychological treatments such as cognitive-behavioral therapy have to be considered in all patients, regardless whether they are nonresponders or not. According to existing studies, a combination of pharmacologic treatment with cognitive-behavioral therapy can be recommended.     

Outcome Studies in the Treatment of Panic Disorder: A Review

The authors review outcome studies in the treatment of panic disorder without agoraphobia for an adult population. Empirical evidence is presented to support the efficacy of psychopharmacological and cognitive-behavioral interventions. In addition, this article can serve as the basis for the development of emerging standards of cure for the diagnosis and treatment of panic disorder.     

Sudden gains in group cognitive-behavioral therapy for panic disorder

The current study investigates sudden gains (rapid symptom reduction) in group cognitive-behavioral therapy for panic disorder. Sudden gains occurring after session 2 of treatment predicted overall symptom reduction at treatment termination and some changes in cognitive biases. Meanwhile, sudden gains occurring immediately following session 1 were not associated with symptom reduction or cognitive change. Together, this research points to the importance of examining sudden gains across the entire span of treatment, as well as the potential role of sudden gains in recovery from panic disorder.     

Cognitive Behavioral Treatment of Panic Disorder and Agoraphobia in a Multiethnic Urban Outpatient Clinic: Initial Presentation and Treatment Outcome

Few studies examine the effectiveness of panic control treatment across diverse ethnic groups. In this paper we present data on 40 patients (African American, n = 24; Caucasian, n = 16) with panic disorder and comorbid agoraphobia who presented at an anxiety disorder clinic in an inner-city area. On initial assessment both groups were similar on psychometric measures, and both groups moderately improved with treatment though significant residual symptoms remained. We illustrate, through case examples, a variety of clinical issues that need to be addressed when providing treatment to multiethnic African American clients with panic disorder and agoraphobia.     

Virtual Reality Exposure in the Treatment of Panic Disorder With Agoraphobia: A Case Study

In this work we present a case example of the use of virtual reality exposure for the treatment of panic disorder with agoraphobia. The assessment protocol and procedure (including a baseline period) and the cognitive-behavioral treatment program are described. The clinical measures were categorized into target behaviors, panic and agoraphobia measures, global functioning, and general psychopathology measures. The patient’s expectations and satisfaction with regard to the virtual treatment were also assessed. The results showed an important reduction in all clinical measures after treatment with virtual exposure and the patient reached the therapeutic goals established during the pretreatment assessment. The patient also reported a good acceptance of virtual exposure. The goals achieved in the virtual environment generalized to real agoraphobic situations and to other real situations not treated. Three-, 6-, and 12-month follow-up assessments were conducted and long-term therapeutic gains were maintained.     

Affective Styles in Panic Disorder and Specific Phobia: Changes Through Cognitive Behavior Therapy and Prediction of Remission

Affective styles appear to be relevant to the development of psychopathology, especially anxiety disorders. The aim of the current study was to investigate changes in affective styles in patients with panic disorder and specific phobia, as a result of undergoing cognitive-behavioral therapy, and to identify a possible link between certain affective styles and remission. The sample consisted of outpatients (N = 101) suffering from panic disorder, specific phobia, or agoraphobia who completed the Affective Style Questionnaire (ASQ) before and after therapy, as well as at a 6-month follow-up assessment. Multivariate analyses of variance were conducted to test for changes due to therapy. Logistic regression analyses were calculated to test for the impact of affective styles on remission from anxiety disorders, and hierarchical regression analyses were calculated to examine the association between changes in affective styles and symptom reduction. Results indicated significant increases on the ASQ subscales adjusting and tolerating after therapy. Concealing did not decrease significantly after therapy. In addition, higher scores on adjusting significantly predicted remission from anxiety disorders. Finally, we found a significant association between increases on the adjusting scale and the reduction of anxiety symptoms.     

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.     

Randomized controlled trial of false safety behavior elimination therapy: a unified cognitive behavioral treatment for anxiety psychopathology

We tested the efficacy of a unified cognitive-behavioral therapy protocol for anxiety disorders. This group treatment protocol, termed false safety behavior elimination therapy (F-SET), is a cognitive-behavioral approach designed for use across various anxiety disorders such as panic disorder (PD), social anxiety disorder (SAD), and generalized anxiety disorder (GAD). F-SET simplifies, as well as broadens, key therapeutic elements of empirically validated treatments for anxiety disorders to allow for easier delivery to heterogeneous groups of patients with anxiety psychopathology. Patients with a primary anxiety disorder diagnosis (N=96) were randomly assigned to F-SET or a wait-list control. Data indicate that F-SET shows good efficacy and durability when delivered to mixed groups of patients with anxieties (i.e., PD, SAD, GAD) by relatively inexperienced clinicians. Findings are discussed in the context of balancing treatment efficacy and clinical utility.     

Role of cognitive appraisal in panic-related avoidance

The present study examined several dimensions of panic cognitions to test whether panic appraisals predict phobicity among panic sufferers. Thirty-five patients meeting DSM-III-R criteria for panic disorder with minimal or no phobic avoidance were compared to 40 patients meeting DSM-III-R criteria for panic disorder with agoraphobia (severe). The two groups looked strikingly similar on measures of panic symptoms, panic frequency and panic severity. As expected, patients diagnosed as having panic disorder with agoraphobia reported significantly more depression and phobic avoidance than patients with PD. Striking differences emerged on each of the following panic appraisal dimensions: (a) anticipated panic, (b) perceived consequences of panic, and (c) perceived self-efficacy in coping with panic. In each case, patients with panic disorder and agoraphobia reported significantly more dysfunctional panic appraisals than patients with panic disorder and no avoidance. Of those panic appraisal dimensions studied, anticipated panic emerged as the most potent correlate of agoraphobic avoidance. These findings support the hypothesis that cognitive appraisal factors may play an important role in the genesis or maintenance of phobic avoidance among panic patients.     

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).

     

Social anxiety and fear of bodily sensations in panic disorder and agoraphobia: A matched comparison

This study tests the hypothesis that social anxiety and fear of bodily sensations are associated with the development of agoraphobic avoidance behavior in panic disorder patients. Twenty patients with panic disorder were compared to 20 patients with panic disorder with agoraphobia, matched by sex and duration of disorder. The two groups did not differ on measures of fear and frequency of assertive social responses. However, the agoraphobics scored higher on measures of interpersonal sensitivity, depression, feelings of inadequacy, and hostility. They also reported higher fear of bodily sensations. Although definitive conclusions need to be postponed until prospective studies have been conducted, there is evidence suggesting that the development of agoraphobia in panic patients is associated with hypersensitivity to bodily sensations and interpersonal situations.This research was supported by Grant 560-268-009 of the Dutch Organization for Scientific Research.     

A pilot study of two-day cognitive-behavioral therapy for panic disorder

The present study investigated the short-term efficacy of brief, intensive cognitive-behavioral therapy (CBT) for panic disorder (PD). The treatment involved 9h of therapist contact over two consecutive days and was developed for the purpose of delivering CBT for PD to a largely rural patient population that must travel long distances to find a treatment provider. Ten patients who elected to participate in brief, intensive CBT instead of weekly CBT were recruited from routine clinical practice in a hospital-based anxiety disorders clinic. Patients were not excluded based on the presence of agoraphobia, diagnostic comorbidity, concurrent use of PRN benzodiazepine medications, or previous nonresponse to psychotherapy for PD. Assessments conducted at pre-treatment and 1-month follow-up revealed large, clinically significant reductions in PD symptoms, anxiety sensitivity, body vigilance, and anxiety and depressive symptoms. Most patients (60%) were panic-free after treatment and evidenced normative levels of symptomatology at follow-up. The present study suggests that brief, intensive treatment may be an effective means of delivering CBT for PD.     

Expectations and attributions in social anxiety disorder: diagnostic distinctions and relationship to general anxiety and depression

Contemporary cognitive models suggest that social anxiety disorder arises from a number of cognitive factors, including tendencies to form pessimistic (rather than optimistic) attributions and expectations for socially-related events. These models also assume that the strengths of such attributions and expectations are more closely linked with social anxiety than with general anxiety or depression. To test these assumptions, a battery of self-report measures was completed by participants with a primary diagnosis of generalized social anxiety disorder (n = 75), panic disorder with agoraphobia (n = 44), or post-traumatic stress disorder (n = 59). To examine differences on these cognitive variables, group comparisons were performed controlling for general anxiety, depression and medication status. Social anxiety disorder, compared with panic disorder with agoraphobia and post-traumatic stress disorder, was characterized by lower expectations for positive social events and higher expectations for negative social events. There was no difference among the groups on expectations for non-social positive or negative events. Stable and global attributions for social negative events were more closely associated with social anxiety disorder than with panic disorder with agoraphobia and post-traumatic stress disorder. Correlational analyses also revealed specific relationships among social-cognitive measures and social anxiety, even after controlling for general anxiety and depression. The results are consistent with cognitive models of social anxiety disorder.     

Expectations and Attributions in Social Anxiety Disorder: Diagnostic Distinctions and Relationship to General Anxiety and Depression

Contemporary cognitive models suggest that social anxiety disorder arises from a number of cognitive factors, including tendencies to form pessimistic (rather than optimistic) attributions and expectations for socially-related events. These models also assume that the strengths of such attributions and expectations are more closely linked with social anxiety than with general anxiety or depression. To test these assumptions, a battery of self-report measures was completed by participants with a primary diagnosis of generalized social anxiety disorder (n?=?75), panic disorder with agoraphobia (n?=?44), or post-traumatic stress disorder (n?=?59). To examine differences on these cognitive variables, group comparisons were performed controlling for general anxiety, depression and medication status. Social anxiety disorder, compared with panic disorder with agoraphobia and post-traumatic stress disorder, was characterized by lower expectations for positive social events and higher expectations for negative social events. There was no difference among the groups on expectations for non-social positive or negative events. Stable and global attributions for social negative events were more closely associated with social anxiety disorder than with panic disorder with agoraphobia and post-traumatic stress disorder. Correlational analyses also revealed specific relationships among social-cognitive measures and social anxiety, even after controlling for general anxiety and depression. The results are consistent with cognitive models of social anxiety disorder.     

Treatment of Adolescent Panic Disorder: A Nonrandomized Comparison of Intensive Versus Weekly CBT

This study compared the relative efficacy of intensive versus weekly panic control treatment (PCT) for adolescent panic disorder with agoraphobia (PDA). Twenty-six adolescents participated in weekly sessions and 25 received intensive treatment involving daily sessions. Both groups demonstrated significant and comparable reductions in panic disorder severity and general anxiety symptoms, which maintained over time. Participants receiving weekly treatment showed significant decreases in depressive symptoms, whereas those in the intensive program reported no change. Findings support the efficacy of the intensive approach for adolescent PDA, but suggest that adolescents receiving intensive treatment may benefit from a brief course of additional weekly sessions.     

Cognitive factors in panic disorder, agoraphobic avoidance and agoraphobia

There remains a lack of consensus regarding the possibility that especially high levels of panic-related cognitions characterise panic disorder with agoraphobia. We administered the Anxiety Sensitivity Index, the Agoraphobic Cognitions Questionnaire and the Anxious Thoughts and Tendencies Scale as well as measures of agoraphobic avoidance to patients diagnosed with panic disorder with agoraphobia (n=75) and without agoraphobia (n=26). Patients with panic disorder with agoraphobia did not score significantly higher on any of the cognitive variables than did panic disorder patients without agoraphobia. However, most of the cognitive variables showed small to moderate-strength correlations with self-report measures of agoraphobic avoidance. Our findings suggest that anxiety sensitivity, catastrophising of the consequences of panic and a general anxiety-prone cognitive style, although to some extent associated with agoraphobic avoidance, do not discriminate panic disorder with agoraphobia from panic disorder without agoraphobia.