Correction to Gloster et al. (2011).

Reports an error in "Psychological treatment for panic disorder with agoraphobia: A randomized controlled trial to examine the role of therapist-guided exposure in situ in CBT" by Andrew T. Gloster, Hans-Ulrich Wittchen, Franziska Einsle, Thomas Lang, Sylvia Helbig-Lang, Thomas Fydrich, Lydia Fehm, Alfons O. Hamm, Jan Richter, George W. Alpers, Alexander L. Gerlach, Andreas Str?hle, Tilo Kircher, Jürgen Deckert, Peter Zwanzger, Michael H?fler and Volker Arolt (Journal of Consulting and Clinical Psychology, 2011[Jun], Vol 79[3], 406-420). In the article, the name of author Georg W. Alpers was misspelled as George W. Alpers. In Table 2, in the footnote, line two, the criteria should read “MI≤1.8”. The online versions of this article have been corrected. (The following abstract of the original article appeared in record 2011-08726-001.) Objective: Cognitive–behavioral therapy (CBT) is a first-line treatment for panic disorder with agoraphobia (PD/AG). Nevertheless, an understanding of its mechanisms and particularly the role of therapist-guided exposure is lacking. This study was aimed to evaluate whether therapist-guided exposure in situ is associated with more pervasive and long-lasting effects than therapist-prescribed exposure in situ. Method: A multicenter randomized controlled trial, in which 369 PD/AG patients were treated and followed up for 6 months. Patients were randomized to 2 manual-based variants of CBT (T+/T?) or a wait-list control group (WL; n = 68) and were treated twice weekly for 12 sessions. CBT variants were identical in content, structure, and length, except for implementation of exposure in situ: In the T+ variant (n = 163), therapists planned and supervised exposure in situ exercises outside the therapy room; in the T? group (n = 138), therapists planned and discussed patients' in situ exposure exercises but did not accompany them. Primary outcome measures were (a) Hamilton Anxiety Scale, (b) Clinical Global Impression, (c) number of panic attacks, and (d) agoraphobic avoidance (Mobility Inventory). Results: For T+ and T? compared with WL, all outcome measures improved significantly with large effect sizes from baseline to post (range = ?0.5 to ?2.5) and from post to follow-up (range = ?0.02 to ?1.0). T+ improved more than T? on the Clinical Global Impression and Mobility Inventory at post and follow-up and had greater reduction in panic attacks during the follow-up period. Reduction in agoraphobic avoidance accelerated after exposure was introduced. A dose–response relation was found for Time × Frequency of Exposure and reduction in agoraphobic avoidance. Conclusions: Therapist-guided exposure is more effective for agoraphobic avoidance, overall functioning, and panic attacks in the follow-up period than is CBT without therapist-guided exposure. Therapist-guided exposure promotes additional therapeutic improvement—possibly mediated by increased physical engagement in feared situations—beyond the effects of a CBT treatment in which exposure is simply instructed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

A comparison of bibliotherapy and group therapy in the treatment of panic disorder.

Investigated 2 methods of disseminating a cognitive-behavioral intervention for panic disorder (PD). 36 Ss who met diagnostic criteria for PD were randomly assigned to 1 of 3 conditions: bibliotherapy (BT), group therapy (GT), or a waiting-list control (WL) condition. Results show that both the BT and GT treatments were more effective than the WL condition in reducing frequency of panic attacks, severity of physical panic symptoms, catastrophic cognitions, agoraphobic avoidance, and depression and that the BT and GT treatments were more effective in increasing self-efficacy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment of panic disorder with agoraphobia: comparison of fluvoxamine, placebo, and psychological panic management combined with exposure and of exposure in vivo alone

OBJECTIVE: The purpose of this comparative outcome study was to investigate whether the effects of exposure in vivo treatment for panic disorder with agoraphobia could be enhanced by adding interventions specifically for panic attacks before the start of exposure treatment. The additional effect of two types of treatment for panic attacks--pharmacological (fluvoxamine) and psychological (repeated hyperventilation provocations and respiratory training)--was examined. Thus, the combined treatment of panic interventions with exposure in vivo could be compared to exposure in vivo alone. METHOD: Ninety-six patients were randomly assigned to four treatment conditions: double-blind, placebo-controlled fluvoxamine followed by exposure in vivo, psychological panic management followed by exposure, and exposure in vivo alone. Outcome was assessed by self-report measures, a standardized multitask behavioral avoidance test, and continuous monitoring of panic attacks. Seventy-six patients completed the study. RESULTS: All four treatments were effective and resulted in a significant decrease of agoraphobic avoidance. Moreover, the combination of fluvoxamine and exposure in vivo demonstrated efficacy superior to that of the other treatments and had twice as large an effect size (difference between pre- and posttreatment scores) on self-reported agoraphobic avoidance. The other treatments did not differ among each other in effectiveness. CONCLUSIONS: Results of the study indicate that the short-term outcome of exposure in vivo treatment can be enhanced by adding fluvoxamine treatment. Psychological panic management combined with exposure was not superior to exposure alone of equal duration.     

Transporting an empirically supported treatment for panic disorder to a service clinic setting: A benchmarking strategy.

This work examines the transportability of cognitive–behavioral therapy (CBT) for panic disorder to a community mental health center (CMHC) setting by comparing CMHC treatment outcome data with the results obtained in two controlled efficacy trials. Participants were 110 clients with a primary diagnosis of panic disorder with or without agoraphobia; clients were not excluded on the basis of medication use or changes, severity or frequency of panic attacks, age, or the presence of agoraphobia. Clients completed a 15-session CBT protocol. Despite differences in settings, clients, and treatment providers, the treatment outcomes for clients completing treatment in the CMHC and the efficacy studies were comparable: Of the CMHC clients who completed treatment, 87% were panic-free at the end of treatment, and clients showed significant reductions in anticipatory anxiety, agoraphobic avoidance, generalized anxiety, and symptoms of depression. The present study suggests that panic control treatment can be transported to a CMHC. Challenges facing the transportability of research-based treatment to CMHC clients, settings, and treatment providers are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Typology of prolonged anxious-phobic disorders with agoraphobia

There were studied 23 schizophrenic and cyclothymic patients with stable agoraphobia in the structure of anxiousphobic disorders (APD). No absolute correlation was found between stability of agoraphobia and severity of panic disorder (frequency and intensity of panic attacks). It was established that APD with manifestations of agoraphobia had been, perhaps, conditioned by the presence of comorbid disturbances in their structure which had determined peculiarities of the patients' behavior. Two types of prolonged APD with agoraphobic phenomena were recognized. Retention of agoraphobic disturbances in conditions of the first type was related to symptoms of generalized somatic disorder (generalized somatic anxiety) in clinical pattern of APD. Manifestations similar to panphobias prevailed, agoraphobic avoidance included all the situations in which the patient could find himself without help. In the states of the second type retention of agoraphobic disorders was conditioned by comorbidity of APD with asthenohypochondriac manifestations with somato-psychic fragility in their structure. Anxiety of expectation was formed in situations with emotional or physical tension. Agoraphobic avoidance in conditions of this type had displayed the character of preventive measures and one of manifestations of hypochondriac development of personality. The presence of pronounced anxiety (intensive panic attacks, generalized anxiety) in clinical pattern of prolonged agoraphobic conditions can serve a predictor of a favourable development of the disease.     

Predicted versus unpredicted panic attacks: Acute versus general distress.

Acute and longer term effects of unpredicted and predicted panic attacks were examined in a sample of patients with panic disorder who self-monitored their panic attacks over a 2-week interval. The study assessed the degree to which experimental observations of the effects of predictability over aversive events are paralleled in the clinical phenomenon of panic. For patients who experienced predicted and unpredicted panics, daily ratings of anxiety and worry about panic increased the day following unpredicted panic attacks and decreased or stabilized the day following predicted panic attacks. These patterns were not replicated in patients who experienced only 1 type of panic; nor were these patterns influenced by the frequency with which panic attacks occurred. Acute distress indexes did not differ during predicted and unpredicted panics, although patients who experienced predicted panic attacks exhibited more pervasive agoraphobic avoidance. The findings are discussed in relation to the safety-signal theory of prediction and alternative conceptualizations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: Outcome at academic and community clinics.

Female assault survivors (N = 171) with chronic posttraumatic stress disorder (PTSD) were randomly assigned to prolonged exposure (PE) alone, PE plus cognitive restructuring (PE/CR), or wait-list (WL). Treatment, which consisted of 9-12 sessions, was conducted at an academic treatment center or at a community clinic for rape survivors. Evaluations were conducted before and after therapy and at 3-, 6-, and 12-month follow-ups. Both treatments reduced PTSD and depression in intent-to-treat and completer samples compared with the WL condition; social functioning improved in the completer sample. The addition of CR did not enhance treatment outcome. No site differences were found: Treatment in the hands of counselors with minimal cognitive- behavioral therapy (CBT) experience was as efficacious as that of CBT experts. Treatment gains were maintained at follow-up, although a minority of patients received additional treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Extinction of panicogenic effects of a 35% CO? challenge in patients with panic disorder.

Inhalations of high concentrations of carbon dioxide (CO?) reliably produce panic attacks in patients with panic disorder. The present study evaluated whether cognitive–behavioral treatment (CBT) for panic disorder would extinguish CO?-induced panic and whether changes in panic and arousal-related cognitions were associated with the induction of panic. Patients with panic disorder (N?=?54) were assigned to 1 of 3 experimental conditions: CBT with respiratory training (CBT-R), CBT without respiratory training (CBT), or delayed treatment. Participants received 5 repeated vital-capacity inhalations of 35% CO?/65% O? prior to and following either 12 treatment sessions or a 12-week waiting period. During pretreatment assessments, 74% of patients experienced a panic attack during at least 1 inhalation. At posttreatments only 20% of treated participants (CBT-R?=?19%, CBT?=?22%), compared with 64% of untreated participants, panicked. Forty-four percent of treated participants, compared with 0% of untreated participants, reported no anxiety during all posttreatment inhalations. Anxiety sensitivity as well as panic appraisals regarding the likelihood of panic and self-efficacy with coping with panic were significantly related to fearful responding to the CO? challenge. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Panic disorder: effective treatment options

Panic disorder is a distressing and debilitating condition with a familial tendency; it may be associated with situational (agoraphobic) avoidance. The diagnosis of panic disorder requires recurrent, unexpected panic attacks and at least one of the following characteristics: persistent concern about having an additional attack (anticipatory anxiety); worry about the implications of an attack or its consequences (e.g., a catastrophic medical or mental consequence) and making a significant change in behavior as a consequence of the attacks. A variety of pharmacologic interventions is available, as are non-pharmacologic cognitive or cognitive-behavioral therapies that have demonstrated safety and efficacy in the treatment of panic disorder. Early detection and thoughtful selection of appropriate first-line interventions can help these patients, who often have been impaired for years, regain their confidence and ability to function in society.     

Panic disorder and agoraphobia with panic attacks: Covariation along the dimensions of panic and agoraphobic fear.

Tested the validity of the distinction made in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) between the diagnoses of "panic disorder" and "agoraphobia with panic attacks" by examining the pattern of covariation between panic symptoms and agoraphobic fear in a group of individuals presenting with panic attacks as a prominent symptom. Ss were 17 patients (mean age 34.4 yrs) who had been diagnosed as having panic disorder and 56 patients (mean age 36.4 yrs) diagnosed as having agoraphobia with panic attacks, and who had completed at the time of diagnosis both the Fear Survey Schedule and the SCL-90-R. Analyses of the panic-related items and the agoraphobia-related items of these 2 inventories revealed that irrespective of diagnosis, the degree of panic was highly correlated with the degree of agoraphobic fear. Although panic patients tended to experience more severe panic and milder agoraphobic fear than agoraphobics, the groups overlapped with respect to both kinds of symptoms. Findings are discussed in terms of whether panic disorder and agoraphobia should be classified as qualitatively distinct conditions. (10 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Impact of cognitive-behavioral treatment on quality of life in panic disorder patients.

Panic disorder (PD) is associated with significant social and health consequences. The present study examined the impact of treatment on PD patients' quality of life. Patients (N?=?156) meeting DSM-III—R (Diagnostic and Statistical Manual of Mental Disorders [3rd ed., rev.]; American Psychiatric Association, 1987) criteria for PD with agoraphobia were randomly assigned to group cognitive behavioral treatment (CBT) or a delayed-treatment control. An assessment battery measuring the major clinical features of PD as well as quality of life was administered at baseline (Week 0), post treatment (Week 9) and 6-month follow-up (Week 35). Consistent with previous studies, PD patients displayed significant impairment in quality of life at intake. Compared with delayed-treatment control participants, CBT-treated participants showed significant reductions in impairment that were maintained at follow-up. Consistent with prediction, anxiety and phobic avoidance were significantly associated with quality of life, whereas frequency of panic attacks was not. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A meta-analysis of treatments for panic disorder.

In a meta-analysis, the authors compared the effectiveness of psychological and pharmacological treatments for panic disorder. Percentage of agoraphobic Ss in the sample and duration of the illness were unrelated to effect size (ES). Type of dependent variable was generally unrelated to treatment outcome, although behavioral measures yielded significantly smaller ESs. Dependent measures of general anxiety, avoidance, and panic attacks yielded larger ESs than did depression measures. Choice of control was related to ES, with comparisons with placebo controls greater than comparisons with exposure-only or "other treatment" controls. Psychological coping strategies involving relaxation training, cognitive restructuring, and exposure yielded the most consistent ESs; flooding and combination treatments (psychological and pharmacological) yielded the next most consistent ESs. Antidepressants were the most effective pharmacological intervention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Short- and long-term effectiveness of an empirically supported treatment for agoraphobia.

This study examined the effectiveness of individual high-density exposure (2–3 weeks, all day) for panic disorder with agoraphobia (PDAG). Participants were 416 unselected patients with a primary diagnosis of PDAG who were treated by 52 therapists in 3 outpatient clinics of the Christoph-Dornier Foundation of Clinical Psychology in Germany. Results 6 weeks after the end of therapy and at the 1-year follow-up showed highly significant reductions in anxiety symptoms, anxious cognition, agoraphobic avoidance, general symptomatology, and depressive symptoms. Results did not differ significantly between the 3 outpatient clinics and are comparable with the average effect sizes reported by meta-analytic studies of controlled efficacy research, using selected patients and specifically trained therapists. Effectiveness was not dependent on duration of disorder, number of treatment sessions, and therapist experience. The study suggests that high-density exposure can be transported from research settings to the mental health field. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Randomized Trial of Cognitive-Behavioral Therapy for Chronic Posttraumatic Stress Disorder in Adult Female Survivors of Childhood Sexual Abuse.

The authors conducted a randomized clinical trial of individual psychotherapy for women with posttraumatic stress disorder (PTSD) related to childhood sexual abuse (n = 74), comparing cognitive-behavioral therapy (CBT) with a problem-solving therapy (present-centered therapy; PCT) and to a wait-list (WL). The authors hypothesized that CBT would be more effective than PCT and WL in decreasing PTSD and related symptoms. CBT participants were significantly more likely than PCT participants to no longer meet criteria for a PTSD diagnosis at follow-up assessments. CBT and PCT were superior to WL in decreasing PTSD symptoms and secondary measures. CBT had a significantly greater dropout rate than PCT and WL. Both CBT and PCT were associated with sustained symptom reduction in this sample. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Two cases of panic disorder treated with autogenic training and in vivo exposure without medication

The aim of this study was to use autogenic training in combination with in vivo exposure in the behavioral treatment of panic disorder without medication. Two cases of panic disorder with agoraphobic avoidance were presented. Case 1 was a 33 year old married female who exhibited mild panic symptoms, and case 2 was a 23 year old single male who had severe panic symptoms. Both subjects were successfully treated with the combination of these two techniques. Treatment effects were maintained for 9 years as a follow up in case 1, and for 4 years in case 2.     

Cognitive-behavioral group therapy for panic disorder in the general clinical setting: a naturalistic study with 1-year follow-up

BACKGROUND: Cognitive-behavioral therapy (CBT) is well documented in the treatment of panic disorder. As most investigators have studied selected patients without comorbid disorders, it is less clear how well the treatment will perform in the usual clinical setting for patients with comorbid disorders and with physicians who do not have training in CBT. During the last 6 years, we have offered CBT in outpatient groups for patients with panic disorder and agoraphobia. The purpose of this prospective study was to assess the outcome of group treatment and compare the results with those of studies that used individual treatment. We wanted to identify variables that might predict outcome at follow-up and to assess the number and characteristics of dropouts. METHOD: Eighty-three consecutive patients with DSM-III-R panic disorder (56 women and 27 men; mean age = 34.5 years) were studied. Mean duration of panic disorder was 7.5 years. There was a high degree of comorbid major depression, social phobia, and psychoactive substance abuse/dependence. Treatment consisted of 4-hour group sessions conducted once a week for 11 weeks. More than half of the patients used antidepressant drugs. Degree of phobic avoidance, bodily sensations, anxiety cognitions, and depression were assessed at pretreatment, baseline, and end of treatment and at follow-up after 3 and 12 months. RESULTS: There was a large decrease in scores from start to end on all assessments. Sixty-three (89%) of 73 completers responded (> or = 50% reduction in Phobic Avoidance Rating Scale scores). Gains were maintained and even improved upon at follow-up. The results are comparable with studies that used individual therapy. A high depression score at the end of treatment predicted poor outcome at 1-year follow-up. Twelve (14%) of 83 did not complete the program. The presence of severe personality disorders and ongoing alcohol or substance abuse or dependence was associated with poor outcome and high dropout rate. CONCLUSION: CBT appears to be effective in the usual clinical setting, even in the hands of therapists without formal competence. Group therapy is a feasible arrangement, and the results from group treatment are comparable to those of individual approaches. Precise diagnosis and treatment of comorbid depression are of utmost importance. Patients with additional substance abuse or dependence, as well as severe personality disorders, may find this treatment modality less helpful.     

Vasoactive substances and long-term control of blood pressure and hypertension]

The relationship between panic expectancy, social demand and agoraphobic avoidance was investigated in a group of 48 panic disorder subjects. Subjects were observed surreptitiously while completing a naturalistic behavioral avoidance task (BAT) involving either a high or low social challenge task. Subjects in the high social challenge task avoided more compared to subjects in the low social challenge task. Prediction of panic made before entering the situation and type of social challenge condition (high/low) were the only variables that accounted for significant amounts of unique variance in prediction of BAT score. The results confirm previous findings regarding the relationship between panic expectancy and avoidance and suggest that social interaction and scrutiny is a factor in avoidance.     

A clinical study of autogenic training-based behavioral treatment for panic disorder

The present study investigated the effect of autogenic training-based behavioral treatment for panic disorder and identified the predictors of treatment outcome. Thirty-four patients meeting DSM-III-R criteria for panic disorder received autogenic training-based behavioral treatment from October 1981 to December 1994. They were treated individually by the author. The medical records of the patients were investigated for the purpose of this study. The results showed that this autogenic training-based behavioral treatment had successful results. Fifteen patients were cured, nine much improved, five improved, and five unchanged at the end of the treatment. Improvement trends were found as for the severity of panic attack and the severity of agoraphobic avoidance. No consistent findings about predictors emerged when such pretreatment variables as demographics and severity of symptoms were used to predict the outcome. Also, three treatment variables showed useful predictive power. First, practicing the second standard autogenic training exercise satisfactorily predicted better outcomes. Second, application of in vivo exposure was found to be positively associated with the treatment outcome in patients with agoraphobic avoidance. Third, longer treatment periods were associated with better outcomes. These findings suggested that the autogenic training-based behavioral treatment could provide relief to the majority of panic disorder patients.     

A 1-year prospective study of panic attacks: Clinical course and factors associated with maintenance.

A prospective naturalistic l-year follow-up study of 39 patients with current panic disorder, 17 remitted panic patients, 46 infrequent panickers, 22 patients with simple phobias, and 45 controls assessed clinical course and variables related to the maintenance of panic attacks. Nearly all panic disorder patients (92%) continued to experience panic attacks, and 41% of the initially remitted patients relapsed. No significant effects of treatments delivered in the community were found. Infrequent panickers tended to be more likely to develop panic disorder (15%) than controls (2%). Maintenance/relapse was most consistently linked with good heartbeat perception, anxiety sensitivity, and avoidance in the different subsamples. Patients with simple phobias or normal controls who experienced their first panic attack during follow-up had shown higher anxiety sensitivity at initial assessment than nonpanickers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical features in panic disorder with agoraphobia: a comparison of men and women

This study compared 96 women and 58 men suffering from panic disorder with agoraphobia. Participants completed questionnaires assessing various clinical features associated with panic disorder with agoraphobia (PDA), general adjustment, and drug/alcohol use. Results showed that PDA is a more severe condition in women. Women reported more severe agoraphobic avoidance when facing situations or places alone, more catastrophic thoughts, more body sensations, and higher scores on the Fear Survey Schedule. Also, women more often had a comorbid social phobia or posttraumatic stress disorder. The lower agoraphobic avoidance of men was associated with their alcohol use. However, there were no differences between genders in other dimensions, including depression, situational and trait anxiety, stressful life events, social self-esteem, marital adjustment, and drug use.