Cognitive-behavior therapy for Japanese patients with panic disorder: acute phase and one-year follow-up results

Aim:  The aim of this paper is to report the outcomes and follow-up data of our cognitive behavioral therapy program for Japanese patients with panic disorder and to examine the baseline predictors of their outcomes.
Methods:  Seventy outpatients with panic disorder with or without agoraphobia were treated with manualized group cognitive behavioral therapy.
Results:  Fourteen patients (20%) did not complete the program. Among the completers, the average Panic Disorder Severity Scale score fell from 12.8 at baseline to 7.1 post-therapy (44.7% reduction). This effectiveness was sustained for 1 year. While controlling for the baseline severity, the duration of illness and the baseline social dysfunction emerged as significant predictors of the outcome.
Conclusions:  Our data suggest that group cognitive behavioral therapy for panic disorder can bring about as much symptom reduction among Japanese patients with panic disorder as among Western patients.     

D-cycloserine does not improve but might slightly speed up the outcome of in-vivo exposure therapy in patients with severe agoraphobia and panic disorder in a randomized double blind clinical trial

d-cycloserine (DCS) - augmented exposure therapy has proven efficacy in the treatment of acrophobia, social phobia, panic disorder and OCD. Here we studied whether DCS can also improve the effect of cognitive behavioral therapy (CBT) in patients with agoraphobia and panic disorder. To this end, 39 patients with the diagnoses of agoraphobia and panic disorder were treated with 11 sessions of CBT including three individual in-vivo exposure sessions (flooding), augmented with either 50 mg of DCS (N = 20) or placebo (N = 19) in a randomized double blind design. Primary outcome was the total score of the panic and agoraphobia scale. Both groups profited considerably from therapy and DCS did not significantly improve this outcome (p = 0.475; η²_p = 0.01). However, there was a statistical trend (p = 0.075; η²_p = 0.17) in the more severely ill patients that DCS accelerated symptom reduction in the primary outcome at post-therapy. No serious adverse effects occurred during the trial. We conclude that in patients with agoraphobia and panic disorder, DCS seems to lack an additional benefit to efficient cbt, probably due to a floor effect. Nonetheless, the acceleration of symptom reduction in severely ill patients might represent a valuable treatment option deserving further investigation.     

Relationships between depressive symptoms and panic disorder symptoms during guided internet-delivered cognitive behavior therapy for panic disorder

Abstract

Aims: The current study explore the relationship between the trajectories of primary panic disorder symptoms and secondary depressive symptoms during guided internet-delivered cognitive behaviour therapy for panic disorder.

Materials and methods: The patients (N=143) were recruited from an ongoing effectiveness study in secondary mental health outpatient services in Norway. Weekly self-reported primary panic disorder symptoms and secondary depressive symptoms were analysed.

Results: primary panic disorder symptoms and secondary depressive symptoms improved significantly during the course of treatment, and at six months follow-up. Parallel process latent growth curve modelling showed that the trajectory of depressive symptoms and trajectory of panic disorder symptoms were significantly related. A supplementary analysis with cross-lagged panel modelling showed that (1) pre-treatment depressive symptoms predicted a positive effect of panic disorder symptoms early in treatment; (2) high early treatment panic disorder symptoms predicted low depressive symptoms at post-treatment.

Conclusions: Guided ICBT for panic disorder is effective for both primary panic disorder symptoms and secondary depressive symptoms. Patients with high pre-treatment secondary depressive symptoms may constitute a vulnerable subgroup. A high level of panic disorder symptoms early in treatment seems beneficiary for depressive symptoms outcome. A time-dependent model may be necessary to describe the relationship between PAD symptoms and depressive symptoms during the course of treatment.     

The effects of aggression on symptom severity and treatment response in a trial of cognitive behavioral therapy for panic disorder

BackgroundPrevious research suggests that patients with panic disorder exhibit higher levels of aggression than patients with other anxiety disorders. This aggression is associated with more severe symptomatology and interpersonal problems. However, few studies have examined whether higher levels of aggression are associated with a worse treatment response in this population.MethodsThe present study sought to examine the association of aggression with panic disorder symptom severity in a sample of 379 patients who participated in a trial examining long-term strategies for the treatment of panic disorder.ResultsWe found that aggression was significantly associated with higher baseline levels of panic disorder symptoms, anxiety, depression, and functional impairment. Further, we found that patients higher in aggression did not achieve the same level of improvement in general anxiety symptoms during treatment compared to patients lower in aggression, even when controlling for baseline anxiety symptom severity.ConclusionThese results suggest that more research is needed concerning patients with anxiety disorders with higher aggression, as they may be a group in need of additional treatment considerations.     

Can levels of a general anxiety-prone cognitive style distinguish between various anxiety disorders?

BackgroundThe question of whether certain anxiety disorders are especially related to a cognitive style characterized by an exaggerated perception of threat and appraisal of the future as excessively unpredictable (general anxiety-prone cognitive style) remains open.ObjectivesThis study aimed to compare patients with generalized social anxiety disorder (SAD), generalized anxiety disorder (GAD), panic disorder with agoraphobia (PDA), and panic disorder without agoraphobia (PD) in terms of the levels of general anxiety-prone cognitive style when the severity of general distress and psychopathology is controlled for and to ascertain whether a co-occurring depressive disorder contributes substantially to the levels of this cognitive style.MethodsThe Anxious Thoughts and Tendencies Scale, a measure of a general anxiety-prone cognitive style, and Symptom Checklist 90—Revised were administered to 204 patients with various anxiety disorders who attended an outpatient anxiety disorders clinic and were diagnosed based on a semistructured diagnostic interview.ResultsPatients with principal diagnoses of SAD and GAD had a more prominent general anxiety-prone cognitive style than patients with principal diagnoses of PD and PDA when the severity of general distress and psychopathology was controlled for. The presence or absence of a co-occurring depressive disorder had no bearing on this finding.ConclusionsThe general cognitive component characterizes SAD and GAD more than it does PD and PDA, and a co-occurring depressive disorder does not affect this finding. These results have implications for distinguishing between various anxiety disorders.     

Is internet-based CBT for panic disorder and agoraphobia as effective as face-to-face CBT?

This study compared Panic Online (PO), an internet-based CBT intervention, to best-practice face-to-face CBT for people with panic disorder with or without agoraphobia. Eighty-six people with a primary diagnosis of panic disorder were recruited from Victoria, Australia. Participants were randomly assigned to either PO (n=46) or best practice face-to-face CBT (n=40). Effects of the internet-based CBT program were found to be comparable to those of face-to-face CBT. Both interventions produced significant reductions in panic disorder and agoraphobia clinician severity ratings, self reported panic disorder severity and panic attack frequency, measures of depression, anxiety, stress and panic related cognitions, and displayed improvements in quality of life. Participants rated both treatment conditions as equally credible and satisfying. Participants in the face-to-face CBT treatment group cited higher enjoyment with communicating with their therapist. Consistent with this, therapists' ratings for compliance to treatment and understanding of the CBT material was higher in the face-to-face CBT treatment group. PO required significantly less therapist time than the face-to-face CBT condition.     

A discussion of various aspects of panic disorder depending on presence or absence of agoraphobia

ObjectiveThe quality of life of individuals with panic disorder and agoraphobia can be improved by the alleviation of agoraphobia. In other words, examining panic disorder in terms of whether agoraphobia is present is crucial. The current study examined panic disorder from this perspective.MethodsSubjects were 253 patients who met the diagnostic criteria for panic disorder (lifetime) according to the Mini International Neuropsychiatric Interview (MINI). Of those patients, 179 had agoraphobia and 74 did not. Statistical analysis was used to examine gender differences in the presence (or absence) of agoraphobia, comorbidities, and the effects of the presence of agoraphobia (severity, assessment of depression, assessment of anxiety, and personality) in these patients.ResultsResults indicated gender differences in the presence (or absence) of agoraphobia. Compared to patients without agoraphobia, significantly more patients with agoraphobia were female (p < .001), and had a higher prevalence of comorbidities. Patients with agoraphobia had a higher suicide risk (p < .05), more hypomanic episodes (current) (p < .05), and more frequent episodes of social phobia (p < .05). In addition, patients with agoraphobia had more severe panic disorder and a higher level of neuroticism, sensitivity to anxiety, and trait anxiety [PDSS-J, P&A, NEO-N: p < .01, ASI, STAI (Trait Anxiety): p < .05].ConclusionsThe current findings suggest that when treating a panic disorder, diagnosing the presence of agoraphobia is extremely important.     

Internet versus face-to-face group cognitive-behavioral therapy for fibromyalgia: A randomized control trial

BackgroundThe aim of this study was to explore the effectiveness of Internet-delivered cognitive-behavioral therapy (iCBT) in treating fibromyalgia (FM) compared with an identical protocol using conventional group face-to-face CBT.MethodsSixty participants were assigned to either (a) the waiting list group, (b) the CBT group, or (c) the iCBT group. The groups were assessed at baseline, after 10 weeks of treatment, and at 3-, 6-, and 12-month follow-ups. The primary outcome measured was the impact of FM on daily functioning, as measured by the Fibromyalgia Impact Questionnaire (FIQ). The secondary outcomes were psychological distress, depression, and cognitive variables, including self-efficacy, catastrophizing, and coping strategies.ResultsIn post-treatment, only the CBT group showed improvement in the primary outcome. The CBT and iCBT groups both demonstrated improvement in psychological distress, depression, catastrophizing, and utilizing relaxation as a coping strategy. The iCBT group showed an improvement in self-efficacy that was not obtained in the CBT group. CBT and iCBT were dissimilar in efficacy at follow-up. The iCBT group members improved their post-treatment scores at their 6- and 12-month follow-ups. At the 12-month follow-up, the iCBT group showed improvement over their primary outcome and catastrophizing post-treatment scores. A similar effect of CBT was expected, but the positive results observed at the post-treatment assessment were not maintained at follow-up.ConclusionsThe results suggest that some factors, such as self-efficacy or catastrophizing, could be enhanced by iCBT. Specific characteristics of iCBT may potentiate the social support needed to improve treatment adherence.     

Behavioural and combined therapy in panic states

This review will focus only on those paradigms for treatment of panic states with agoraphobia. Until recently the behaviour therapy literature has completely ignored panic disorder and has focused exclusively on the agoraphobic aspect of this syndrome. To summarize the behavioural therapy of panic disorder and agoraphobia, it appears that exposure is in the short run the most effective behavioural paradigm in agoraphobia. However, when contrasted with cognitive approaches it does not appear to be as effective in the treatment of panic disorder. In conclusion, it is unclear whether we can speak of antiphobic medications. Certainly studies of imipramine, chlomipramine, monoamine oxidase inhibitors, and alprazolam have demonstrated an anti-panic affect of medications and a subsequent improvement in phobic avoidance. However, when exposure is not made a part of the treatment, there is a much poorer resolution and a tendancy for the patient to relapse.     

The relationships among separation anxiety disorder,adult attachment style and agoraphobia in patients with panic disorder

Epidemiological studies indicate that separation anxiety disorder occurs more frequently in adults than children. It is unclear whether the presence of adult separation anxiety disorder (ASAD) is a manifestation of anxious attachment, or a form of agoraphobia, or a specific condition with clinically significant consequences. We conducted a study to examine these questions. A sample of 141 adult outpatients with panic disorder participated in the study. Participants completed standardized measures of separation anxiety, attachment style, agoraphobia, panic disorder severity and quality of life. Patients with ASAD (49.5% of our sample) had greater panic symptom severity and more impairment in quality of life than those without separation anxiety. We found a greater rate of symptoms suggestive of anxious attachment among panic patients with ASAD compared to those without ASAD. However, the relationship between ASAD and attachment style is not strong, and adult ASAD occurs in some patients who report secure attachment style. Similarly, there is little evidence for the idea that separation anxiety disorder is a form of agoraphobia. Factor analysis shows clear differentiation of agoraphobic and separation anxiety symptoms. Our data corroborate the notion that ASAD is a distinct condition associated with impairment in quality of life and needs to be better recognized and treated in patients with panic disorder.     

The relationship between anxiety disorders in adults and recalled childhood teasing

This study investigated the relationship between retrospective accounts of childhood teasing and anxiety disorders as well as the relationship between experiences of teasing and more global psychological well-being. Participants (N = 377) with social anxiety disorder (SAD), obsessive compulsive disorder (OCD), or panic disorder with or without agoraphobia (PD) were compared on levels of self-reported teasing history using the Teasing Questionnaire-Revised (TQ-R; Storch et al., 2004). Teasing frequency scores were higher for the SAD group compared to both PD and OCD groups. Across all groups, teasing scores were significantly related to increased social anxiety, depression, stress, and greater impairment in functioning. Teasing frequency accounted for unique variance in severity of SAD symptoms even after controlling for concurrent mood, anxiety and stress. These results support and extend previous findings linking childhood teasing to anxiety disorders in adulthood.     

A patient post hoc perspective on advantages and disadvantages of blended cognitive behaviour therapy for depression: A qualitative content analysis

Abstract

Background: Blended cognitive behavioural therapy (bCBT), which combines face-to-face (FtF), and internet-based cognitive behavioural therapy (iCBT), may be a particularly promising approach, but little is known about the effectiveness and patients’ subjective evaluations of the bCBT format. The aim of this qualitative study is to explore perceived advantages and disadvantages of bCBT from the patients’ perspective in specialized mental health care. Methods: Semi-structured interviews were conducted with 15 patients suffering from major depression who underwent treatment in a bCBT format. The interview data were processed by means of a qualitative content analysis. Results: The content analysis generated 18 advantages and 15 disadvantages which were grouped into 6 main topics. In general, bCBT was perceived as purposive and effective for treating depression. The patients perceived the combined treatment as complementary and emphasized the advantage of the constant availability of the online programme. Furthermore, a segment analysis revealed that patients reported different advantages and disadvantages of bCBT as a function of the severity of their depressive episode. Conclusion: The findings of the present study reveal advantages and disadvantages of bCBT, which should be taken into account in the further implementation of this new treatment format.

Clinical or methodological significance of this article: Blended treatment seems to balance missing aspects of stand-alone internet-based and face-to-face treatment for depression. Patients suffering from major depression perceived the blended format as purposive and effective after 18 weeks. Patients with different levels of depression severity may perceive different advantages and disadvantages of blended treatment for depression.     

Trichotillomania and co-occurring anxiety

BackgroundTrichotillomania appears to be a fairly common disorder, with high rates of co-occurring anxiety disorders. Many individuals with trichotillomania also report that pulling worsens during periods of increased anxiety. Even with these clinical links to anxiety, little research has explored whether trichotillomania with co-occurring anxiety is a meaningful subtype.MethodsOne hundred sixty-five adults with trichotillomania were examined on a variety of clinical measures including symptom severity, functioning, and comorbidity. Participants also underwent cognitive testing assessing motor inhibition and cognitive flexibility. Clinical features and cognitive functioning were compared between those with current co-occurring anxiety disorders (i.e. social anxiety, generalized anxiety disorder, panic disorder, and anxiety disorder NOS) (n = 38) and those with no anxiety disorder (n = 127).ResultsParticipants with trichotillomania and co-occurring anxiety reported significantly worse hair pulling symptoms, were more likely to have co-occurring depression, and were more likely to have a first-degree relative with obsessive compulsive disorder. Those with anxiety disorders also exhibited significantly worse motor inhibitory performance on a task of motor inhibition (stop-signal task).ConclusionsThis study suggests that anxiety disorders affect the clinical presentation of hair pulling behavior. Further research is needed to validate our findings and to consider whether treatments should be specially tailored differently for adults with trichotillomania who have co-occurring anxiety disorders, or more pronounced cognitive impairment.     

Moderators and mediators among panic, agoraphobia symptoms, and suicidal ideation in patients with panic disorder

Objectives

The most important change of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) is the use of dimensional approach to assess the severity of symptoms across different diagnosis. There are 2 purposes in this study: the first purpose was to identify the proportion of outpatients with panic disorder who have suicidal ideation. The second aim was to examine the relationships among panic, agoraphobic symptoms, and suicidal ideation in patients with panic disorder, adjusting by age, social support, and alcohol use.

Methods

Sixty patients with panic disorder were recruited from outpatient psychiatric clinics in southern Taiwan. Suicidal ideation in the preceding 2 weeks was measured. The Panic and Agoraphobic Symptoms Checklist, Social Support Scale, Questionnaire for Adverse Effects of Medication for Panic Disorder, and Social Status Rating Scale were used to understand the severity of panic and agoraphobia, social support, drug adverse effects, and social status. Significant variables from the univariate analysis were included in a forward regression model. Then, we used structural equation modeling to fit the model.

Results

We found that 31.7% of outpatients with panic disorder had had suicidal ideation in the preceding 2 weeks. Multiple regression analysis showed that younger age, current alcohol use, more severe panic symptoms, and less social support were associated with suicidal ideation. In addition, the structural equation model illustrated the recursive model from panic to agoraphobia and suicidal ideation. Agoraphobia had no association with suicidal ideation. Panic symptom was a mediator to suicidal ideation but not agoraphobic symptoms.

Conclusions

A high proportion of patients with panic disorder had suicidal ideation. We found that panic symptoms, social support, age, and alcohol use affected suicide and could be identified. The 3-level model from panic to agoraphobia revealed that panic was a predictor of agoraphobia and agoraphobia was not a predictor of panic. This verified the evolution of the diagnostic view of the DSM. Panic symptom was a mediator to suicidal ideation. With the dimensional model in DSM-V, panic symptoms can be used as a marker for greater morbidity and severity.     

Overcoming resistance to exposure in panic disorder with agoraphobia

The issue of panic disorder resistant to treatment (whether pharmacological or psychological) has attracted little research attention, despite its clinical frequency and importance. The aim of this study was to compare three treatment modalities, namely exposure alone (E), exposure associated with imipramine (EI) and cognitive therapy supplementing exposure (EC), in a sample of 21 patients with DSM-IV panic disorder and agoraphobia, who failed to respond to a first standard course of individual behavioural treatment based on exposure in vivo. Treatments were administered according to a cross-over, controlled design (E-EI-EC, EI-EC-E, EC-E-EI). Twelve of the 21 patients achieved remission (panic-free status) during the trial. In 8 cases this occurred after exposure alone (E) and in two cases each after the other treatments (EI and EC). The results revealed a significant effect of the factor time on a number of variables, and the superiority of exposure alone compared to other treatment modalities with regard to some variables. These findings suggest that long-term behavioural treatment based on exposure may be necessary in some patients, and may induce clinical remission. However, patients who do not respond to exposure show poor tolerance of and compliance with pharmacological treatment, and are unlikely to achieve remission with imipramine or cognitive therapy, even though this may occur in individual cases.     

The Burden of Agoraphobia in Worsening Quality of Life in a Community Survey in Italy

ObjectiveCurrent nosology redefined agoraphobia as an autonomous diagnosis distinct from panic disorder. We investigated the lifetime prevalence of agoraphobia, its association with other mental disorders, and its impact on the health-related quality of life (HR-QoL). MethodsCommunity survey in 2,338 randomly selected adult subjects. Participants were interviewed with the Advanced Neuropsychiatric Tools and Assessment Schedule (ANTAS), administered by clinicians. The diagnoses were based on the ICD-10 criteria. The Short-Form Health Survey (SF-12) was used to quantify HR-QoL. ResultsIn the sample, 35 subjects met the criteria for agoraphobia (1.5%), with greater prevalence among women (2.0%) than men (0.9%): odds ratio (OR) 2.23; 95% CI: 1.0-5–2. Agoraphobia was more often seen among those with (n=26; 1.1%) than without (n=9; 0.4%) panic disorder: OR=8.3; 2.9–24.4. Co-morbidity with other mental disorders was substantial. The mean score of SF-12 in people with agoraphobia was 35.2±7.8, with similar levels of HR-QoL in people with (35.3±7.9) or without (34.8±7.3) panic disorder: ANOVA: F(1;33)=0.0; p=1.00. ConclusionOne out of seventy people may suffer from agoraphobia in their lifetime. The attributable burden in terms of HR-QoL is substantial and comparable to the one observed for chronic mental disorders such as major depression, post-traumatic stress disorder, or obsessive-compulsive disorder.     

Discrepancies in therapist and client ratings of global improvement following cognitive behavioral therapy for social phobia and their differential relations with symptom improvement at post-treatment and 12-month follow-up

Abstract

Objective: This study aimed to examine discrepancies in client and therapist ratings of global improvement and their relations to symptom improvement at post-treatment and 12-month follow-up. Method: Participants (N = 59) with social phobia received eight sessions of cognitive behavioral therapy (CBT). Participants and therapists rated improvement following each session. Participants also rated improvement at follow-up. Participants completed symptom severity self-reports at post-treatment and follow-up. Results: Clients consistently rated themselves as more improved than therapists. Relative to client ratings, therapist post-treatment ratings of improvement were related to more indices of symptom change at both timepoints. Conclusions: Results suggest that therapist ratings have good predictive utility of client-reported change in symptoms.     

DSM-III-R Axis I and II disorders in agoraphobic patients with and without panic disorder

Patients attending an inpatient phobia treatment program were diagnosed for DSM-III-R Axis I and II disorders, using the Structured Clinical Interview for DSM-III-R Disorders, and completed a set of self-report instruments. They were divided into 3 groups: (a) those who met the criteria for panic disorder with agoraphobia (n= 57), (b) those who met the criteria for agoraphobia without a history of panic disorder (n= 21), and (c) those who met criteria for other anxiety disorders, but not for panic/agoraphobia (n= 14). On Axis I, more of the panic with agoraphobia than of the agoraphobia without panic patients had obsessive-compulsive disorder. On Axis II, no significant differences between the agoraphobic patients with and without panic occurred. However, the number of hysterical traits was related to the presence of panic disorder among the agoraphobic patients. Avoidant and dependent traits were related to symptom severity.     

Changes in risk-taking over the course of an internet-delivered cognitive behavioral therapy treatment for generalized anxiety disorder

It has been proposed that a persistent and pervasive tendency to avoid risks is involved in the development and maintenance of clinically significant anxiety. Few studies, however, have examined the clinical implications of risk-aversion, and particularly the association between risk-aversion and treatment outcome. The current study investigated how risk-aversion in specific domains (Social and Recreational) related to treatment outcome in a clinical sample of patients with generalized anxiety disorder (GAD) undergoing internet-delivered cognitive-behavioral therapy (CBT). We hypothesized that: (i) risk-taking would increase as a result of treatment and (ii) risk-taking would mediate changes in symptom severity and impairment as a result of treatment. Individuals recruited online (N=44) meeting diagnostic criteria for GAD were randomized to the treatment (n=24) or control group (n=20). Participants completed measures of symptom severity, impairment and risk-taking before and after treatment. Results partially confirmed our hypotheses, demonstrating that participants in the treatment group significantly increased social and recreational risk-taking scores relative to the control group and risk-taking mediated treatment outcome for depression, but not for anxiety symptoms. The results of this study suggest that social and recreational risk-avoidance decreases following CBT treatment, and this change may mediate treatment outcome for depression. Clinical implications of these findings are discussed.     

The impact of internet-delivered cognitive behavioural therapy for health anxiety on cyberchondria

Cyberchondria refers to an emotional-behavioural pattern whereby excessive online searches lead to increased anxiety about one’s own health status. It has been shown to be associated with health anxiety, however it is unknown whether existing cognitive behavioural therapy (CBT) interventions targeting health anxiety also improve cyberchondria. This study aimed to determine whether internet-delivered cognitive behavioural therapy (iCBT) for severe health anxiety led to improvements in self-reported cyberchondria and whether improvements in cyberchondria were associated with improvements in health anxiety observed during treatment. Methods: We analysed secondary data from a randomised controlled trial (RCT) comparing an iCBT group (n = 41) to an active control group who underwent psychoeducation, monitoring and clinical support (n = 41) in health anxious patients with a DSM-5 diagnosis of Illness Anxiety Disorder and/or Somatic Symptom Disorder. The iCBT group showed a significantly greater reduction in cyberchondria compared to the control group, with large differences at post-treatment on the Cyberchondria Severity Scale Total scale (CSS; Hedges g = 1.09), and the Compulsion, Distress, Excessiveness subscales of the CSS (g’s: 0.8–1.13). Mediation analyses showed improvements in health anxiety in the iCBT group were mediated by improvements in all of the CSS subscales, except for the Mistrust subscale. Conclusions: Internet CBT for health anxiety improves cyberchondria.