Psychological treatment for panic disorder with agoraphobia: A randomized controlled trial to examine the role of therapist-guided exposure in situ in CBT.

[Correction Notice: An erratum for this article was reported in Vol 79(5) of Journal of Consulting and Clinical Psychology (see record 2011-21293-002). 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.] 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)     

Virtual reality exposure therapy for the treatment of fear of flying: A controlled investigation.

Forty-five participants who refused to fly during a screening test and who also met Diagnostic and Statistical Manual of Mental Disorders criteria for specific phobia, agoraphobia, or panic disorder with agoraphobia were randomly assigned to 5 sessions of either virtual reality exposure (VRE) or attention-placebo group treatment (GT). At posttreatment, 65% of VRE participants and 57% of GT participants flew during a test flight. Both groups showed significant improvement following treatment on standardized self-report measures of flight anxiety, with a better outcome for the VRE group on 4 of 5 of these measures. At 6-month follow-up, however, most group differences had disappeared; VRE resulted in a better outcome on only 1 of 5 standardized flight anxiety measures. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment of posttraumatic stress disorder with comorbid panic attacks: Combining cognitive processing therapy with panic control treatment techniques.

A large proportion of patients who present for treatment of posttraumatic stress disorder (PTSD) experience comorbid panic attacks, yet currently available PTSD treatment programs do not address this problem. This report provides an initial evaluation of a newly developed treatment, multiple channel exposure therapy (M-CET), for comorbid PTSD and panic attacks. The treatment uses elements of cognitive processing therapy treatment for PTSD and elements of panic control treatment to target physiological, cognitive, and behavioral symptoms. Results suggest that M-CET may be a promising treatment program for a subset of PTSD patients who experience panic attacks. Preliminary guidelines for conducting M-CET in a group format with participants exposed to diverse traumatic events are provided. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: An empirical examination of the status of empirically supported therapies.

The authors report a meta-analysis of high-quality studies published from 1990-1998 on the efficacy of manualized psychotherapies for depression, panic disorder, and generalized anxiety disorder (GAD) that bear on the clinical utility and external validity of empirically supported therapies. The results suggest that a substantial proportion of patients with panic improve and remain improved; that treatments for depression and GAD produce impressive short-term effects; that most patients in treatment for depression and GAD do not improve and remain improved at clinically meaningful follow-up intervals; and that screening procedures used in many studies raise questions about generalizability, particularly in light of a systematic relation across studies between exclusion rates and outcome. The data suggest the importance of reporting, in both clinical trials and meta-analyses, a range of outcome indices that provide a more comprehensive, multidimensional portrait of treatment effects and their generalizability. These include exclusion rates, percent improved, percent recovered, percent who remained improved or recovered at follow-up, percent seeking additional treatment at follow-up, and data on both completer and intent-to-treat samples. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effectiveness of cognitive-behavioral treatment for panic disorder versus treatment as usual in a managed care setting: 2-year follow-up.

Eighty clients meeting criteria for panic disorder and receiving either panic control therapy (PCT; M. G. Craske, E. Meadows, & D. H. Barlow, 1994) or treatment as usual (TAU) in a managed care setting were assessed 1 and 2 years following acute treatment. PCT was provided by therapists with little or no previous exposure to cognitive-behavioral therapies. Analyses of the full intent-to-treat sample revealed no significant differences between the treatments across the follow-up period. However, when treatment completer status was added as a moderator, those receiving PCT showed lower levels of panic severity and phobic avoidance and a greater likelihood of achieving and maintaining clinically significant change. Benzodiazepine use during follow-up was associated with greater panic severity for those clients who received PCT, but no such relationship was found for TAU clients. Results are discussed in relation to the dissemination and effectiveness of PCT as well as evidence-based psychotherapies more generally. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effectiveness of Cognitive-Behavioral Treatment for Panic Disorder Versus Treatment as Usual in a Managed Care Setting.

Eighty clients enrolled in a managed care health plan who identified panic disorder as their primary presenting problem were randomly assigned to treatment by a therapist recently trained in a manual-based empirically supported psychotherapy (M. G. Craske, E. Meadows, & D. H. Barlow, 1994) or a therapist conducting treatment as usual (TAU). Participants in both conditions showed significant change from pre- to posttreatment on a number of measures. Those receiving panic control therapy (PCT) showed greater levels of change than those receiving TAU. Among treatment completers, an average of 42.9% of those in PCT and 18.8% in TAU achieved clinically significant change across measures. The results are discussed with reference to the dissemination of PCT and other evidence-based psychotherapies to clinical practice settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Specificity of treatment effects: Cognitive therapy and relaxation for generalized anxiety and panic disorders.

[Correction Notice: An erratum for this article was reported in Vol 76(5) of Journal of Consulting and Clinical Psychology (see record 2008-13625-021). In the article, "Specificity of Treatment Effects: Cognitive Therapy and Relaxation for Generalized Anxiety and Panic Disorders," by Jedidiah Siev and Dianne L. Chambless (Journal of Consulting and Clinical Psychology, 2007, Vol. 75, No. 4, pp. 513-522), the individual measures were not listed in the domains labeled "Panic" and "Cognitive" for the ?st and Westling (1995) citation in Table 3. The corrected table is included, with the added text appearing in bold font.] The aim of this study was to address claims that among bona fide treatments no one is more efficacious than another by comparing the relative efficacy of cognitive therapy (CT) and relaxation therapy (RT) in the treatment of generalized anxiety disorder (GAD) and panic disorder without agoraphobia (PD). Two fixed-effects meta-analyses were conducted, for GAD and PD separately, to review the treatment outcome literature directly comparing CT with RT in the treatment of those disorders. For GAD, CT and RT were equivalent. For PD, CT, which included interoceptive exposure, outperformed RT on all panic-related measures, as well as on indices of clinically significant change. There is ample evidence that both CT and RT qualify as bona fide treatments for GAD and PD, for which they are efficacious and intended to be so. Therefore, the finding that CT and RT do not differ in the treatment of GAD, but do for PD, is evidence for the specificity of treatment to disorder, even for 2 treatments within a CBT class, and 2 disorders within an anxiety class. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Catastrophic misinterpretations as a predictor of symptom change during treatment for panic disorder.

Objective: Cognitive models of panic disorder suggest that change in catastrophic misinterpretations of bodily sensations will predict symptom reduction. To examine change processes, we used a repeated measures design to evaluate whether the trajectory of change in misinterpretations over the course of 12-week cognitive behavior therapy is related to the trajectory of change in a variety of panic-relevant outcomes. Method: Participants had a primary diagnosis of panic disorder (N = 43; 70% female; mean age = 40.14 years). Race or ethnicity was reported as 91% Caucasian, 5% African American, 2.3% biracial, and 2.3% “other.” Change in catastrophic misinterpretations (assessed with the Brief Body Sensations Interpretation Questionnaire; Clark et al., 1997) was used to predict a variety of treatment outcomes, including overall panic symptom severity (assessed with the Panic Disorder Severity Scale [PDSS]; Shear et al., 1997), panic attack frequency (assessed with the relevant PDSS item), panic-related distress/apprehension (assessed by a latent factor, including peak anxiety in response to a panic-relevant stressor—a straw breathing task), and avoidance (assessed by a latent factor, which included the Fear Questionnaire–Agoraphobic Avoidance subscale; Marks & Mathews, 1979). Results: Bivariate latent difference score modeling indicated that, as expected, change in catastrophic misinterpretations predicted subsequent reductions in overall symptom severity, panic attack frequency, distress/apprehension, and avoidance behavior. However, change in the various symptom domains was not typically a significant predictor of later interpretation change (except for the distress/apprehension factor). Conclusions: These results provide considerable support for the cognitive model of panic and speak to the temporal sequence of change processes during therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"Specificity of treatment effects: Cognitive therapy and relaxation for generalized anxiety and panic disorders": Correction.

Reports an error in "Specificity of treatment effects: Cognitive therapy and relaxation for generalized anxiety and panic disorders" by Jedidiah Siev and Dianne L. Chambless (Journal of Consulting and Clinical Psychology, 2007[Aug], Vol 75[4], 513-522). The individual measures were not listed in the domains labeled "Panic" and "Cognitive" for the ?st and Westling (1995) citation in Table 3. The corrected table is included, with the added text appearing in bold font. (The following abstract of the original article appeared in record 2007-11558-001.) The aim of this study was to address claims that among bona fide treatments no one is more efficacious than another by comparing the relative efficacy of cognitive therapy (CT) and relaxation therapy (RT) in the treatment of generalized anxiety disorder (GAD) and panic disorder without agoraphobia (PD). Two fixed-effects meta-analyses were conducted, for GAD and PD separately, to review the treatment outcome literature directly comparing CT with RT in the treatment of those disorders. For GAD, CT and RT were equivalent. For PD, CT, which included interoceptive exposure, outperformed RT on all panic-related measures, as well as on indices of clinically significant change. There is ample evidence that both CT and RT qualify as bona fide treatments for GAD and PD, for which they are efficacious and intended to be so. Therefore, the finding that CT and RT do not differ in the treatment of GAD, but do for PD, is evidence for the specificity of treatment to disorder, even for 2 treatments within a CBT class, and 2 disorders within an anxiety class. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Development and Validation of an Observational Coding System for Emotional Overinvolvement.

The present study investigated the reliability and construct validity of a behavioral observation coding system of emotional overinvolvement (EOI), an index of intrusive, excessively self-sacrificing, or exaggeratedly emotional behavior displayed by the relative of a psychiatric patient. Separate behavioral ratings of relatives' intrusiveness, excessive self-sacrifice, and exaggerated emotional response were generated from 10-min problem-solving interactions between adult outpatients with obsessive-compulsive disorder or panic disorder with agoraphobia and their relatives. The interrater reliability for the 3 scales was adequate to excellent, and the scales appeared to tap related, but distinct, aspects of the EOI construct. Results from a multitrait-multimethod matrix and a confirmatory factor analysis supported the measure's convergent validity but were equivocal with respect to its discriminant validity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Trauma-focused imaginal exposure for individuals with comorbid posttraumatic stress disorder and alcohol dependence: Revealing mechanisms of alcohol craving in a cue reactivity paradigm.

With a sample (N = 43) of participants meeting current diagnostic criteria for both alcohol dependence and posttraumatic stress disorder (PTSD), the authors tested the hypothesis that alcohol craving elicited by a trauma cue might be attenuated if trauma-elicited negative emotion were reduced following trauma-focused imaginal exposure. In a laboratory-based experiment, participants were randomly assigned to either trauma-focused imaginal exposure or imagery-based relaxation. A cue reactivity paradigm was used to assess alcohol craving prior to, and after completion of, the 6 clinical sessions. Attrition was high but did not differ between experimental conditions. For study completers, PTSD symptoms decreased in the exposure condition but not in the relaxation condition. Alcohol craving and distress elicited by trauma images decreased in the exposure condition but did not change in the relaxation condition. Results support the hypothesis that negative emotion is a mechanism of alcohol craving. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Bridging the Gap Between Posttraumatic Stress Disorder Research and Clinical Practice: The Example of Exposure Therapy.

There are notable challenges in translating empirically supported psychosocial treatments (ESTs) into general routine clinical practice. However, there may be additional unique dissemination and implementation obstacles for ESTs for trauma-related disorders. For example, despite considerable evidence from randomized clinical trials that attests to the efficacy of exposure therapy for posttraumatic stress disorder, front-line clinicians in real-world settings rarely use this treatment. Perceived and actual barriers that interfere with adoption include clinician misconceptions about what exposure entails and complex cases to which ESTs may not be readily applicable. Specific suggestions for bridging the science-into-service gap in trauma ESTs (in general) and in exposure therapy (in particular) are proposed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Testing the effectiveness of cognitive-behavioral treatment for substance abuse in a community setting: Within treatment and posttreatment findings.

This study evaluated the short-term effectiveness of cognitive- behavioral treatment (CBT) for substance abuse delivered in a community setting. At entry into outpatient community substance abuse treatment, participants (N=252) were randomly assigned to 3 conditions: high-standardization CBT, low-standardization CBT, and treatment as usual. Treatment consisted of 12 weekly individual therapy sessions. There was a significant decrease in substance use from baseline, with participants reporting being abstinent on 90% of within-treatment days and 85% of days during the 6 months posttreatment. However, there were no significant differences in outcomes across conditions. Findings do not support the hypothesis that disseminating CBT to community settings will improve outcomes and suggest that standard substance abuse counseling may be more effective than previously thought. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Trauma- and grief-focused intervention for adolescents exposed to community violence: Results of a school-based screening and group treatment protocol.

This study assessed the prevalence of trauma exposure among middle school students and evaluated the effectiveness of a school-based, trauma- and grief-focused group psychotherapy protocol in treating a subset of students with severe exposure, posttraumatic stress disorder (PTSD), and functional impairment. Using a stratified screening procedure, 812 students completed a screening survey; 58 students (7.1% of those surveyed) met criteria for group treatment, and 26 students participated in the group. Group participation was associated with improvements in posttraumatic stress and complicated grief symptoms and in academic performance. Results suggest that students who are exposed to severe levels of community violence often may not be identified or treated. The findings also suggest that severe PTSD in adolescence may be associated with impaired school functioning, and that a reduction in PTSD symptoms may be related to academic remediation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Role of perfectionism and personality disorder features in response to brief treatment for depression.

Using data from the Treatment of Depression Collaborative Research Program (TDCRP), the authors compared the role of patients' perfectionism and features of personality disorder (PD) in the outcome of brief treatment for depression. Data were extracted as to patients' intake levels of symptoms; perfectionism; and PD features, measured as continuous variables, as well as their symptoms at termination; their contribution to the therapeutic alliance; and their satisfaction with social relations. Poorer therapeutic outcome was demonstrated for patients with elevated levels of perfectionism and odd-eccentric and depressive PD features. Patients' contribution to therapeutic alliance and satisfaction with social relations were predicted by perfectionism but not by PD features. Results highlight the central role played by patients' personality in the course of brief treatment for depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A Comparison of Narrative Exposure Therapy, Supportive Counseling, and Psychoeducation for Treating Posttraumatic Stress Disorder in an African Refugee Settlement.

Little is known about the usefulness of psychotherapeutic approaches for traumatized refugees who continue to live in dangerous conditions. Narrative exposure therapy (NET) is a short-term approach based on cognitive-behavioral therapy and testimony therapy. The efficacy of narrative exposure therapy was evaluated in a randomized controlled trial. Sudanese refugees living in a Ugandan refugee settlement (N = 43) who were diagnosed as suffering from posttraumatic stress disorder (PTSD) either received 4 sessions of NET, 4 sessions of supportive counseling (SC), or psychoeducation (PE) completed in 1 session. One year after treatment, only 29% of the NET participants but 79% of the SC group and 80% of the PE group still fulfilled PTSD criteria. These results indicate that NET is a promising approach for the treatment of PTSD for refugees living in unsafe conditions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The results of a 6-month treatment for depression on symptoms, life satisfaction, and community activities among individuals aging with a disability.

Objective: To evaluate the results of treating major depression in individuals aging with a disability. Design: Pre-post quasi-experimental design with a treatment and comparison group over 6 months. Participants: Participants were people with a disability living in a community in Southern California. Fifty-four participants who accepted treatment were compared with 22 individuals who declined treatment. Interventions: Combination of psychotherapy and antidepressant medication. Measures: Depressive symptoms, life satisfaction, and community activities. Results: Treated individuals improved significantly on all 3 measures. Average depression scores declined 50% (p = .001). There was a nonsignificant 12% decline in the comparison group. Conclusion: These results suggest that depression is treatable in this population. Studies that overcome obstacles to randomized clinical trials are needed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims.

The purpose of this study was to compare cognitive-processing therapy (CPT) with prolonged exposure and a minimal attention condition (MA) for the treatment of posttraumatic stress disorder (PTSD) and depression. One hundred seventy-one female rape victims were randomized into 1 of the 3 conditions, and 121 completed treatment. Participants were assessed with the Clinician-Administered PTSD Scale, the PTSD Symptom Scale, the Structured Clinical Interview for DSM-IV, the Beck Depression Inventory, and the Trauma-Related Guilt Inventory. Independent assessments were made at pretreatment, posttreatment, and 3 and 9 months posttreatment. Analyses indicated that both treatments were highly efficacious and superior to MA. The 2 therapies had similar results except that CPT produced better scores on 2 of 4 guilt subscales. (PsycINFO Database Record (c) 2010 APA, all rights reserved)