Client resistance predicts outcomes in cognitive–behavioral therapy for panic disorder

Abstract

Objective: Little is known about how therapy processes relate to outcome in cognitive–behavioral therapy (CBT) for panic disorder (PD). This study examined whether client resistance predicts CBT for PD outcomes beyond the effects of established pre-treatment predictors. A secondary aim was to assess the consistency of resistance over treatment. Method: Data were from 71 adults participating in up to 24 biweekly sessions of CBT in a randomized controlled trial. Panic severity was assessed before, during (at Weeks 1, 5, and 9), and at termination of treatment (Week 12) using the Panic Disorder Severity Scale. Trained coders reliably rated resistance in videos of Sessions 2 and 10 using the Client Resistance Code. Results: Resistance was found to be moderately consistent (r?=?.64). Although overall resistance was unrelated to outcomes, hierarchical linear modeling revealed that openly hostile resistance at Session 10 predicted significantly diminished symptom change (r?=?.28, CI_95%?=?[.01, .51]), beyond the effects of pretreatment predictors. Hostile resistance at Session 2 predicted attrition (r_rb?=??.30, p?=?.001), even after established predictors were controlled. Conclusions: Although some forms of resistance may be benign, openly hostile resistance is an important therapy marker that warrants increased clinical and research attention.     

Moderators of the effects of transference interpretations in brief dynamic psychotherapy

Abstract

The primary aim of this study is to measure effects of transference interpretations in brief dynamic psychotherapy using an experimental design. One hundred patients were randomized to dynamic psychotherapy over 1 year either with a moderate level of transference interpretations or without transference interpretations. The outcome measures were the Psychodynamic Functioning Scales, Inventory of Interpersonal Problems, Global Assessment of Functioning, and Symptom Checklist-90-Revised. No main effect of treatment was found. Several pretreatment patient characteristics related to interpersonal functioning and symptom severity were selected for exploratory analyses of moderator effects. Contrary to our hypotheses and mainstream clinical thinking, we found that patients with more interpersonal problems, more severe symptoms, or poorer quality of life responded better to therapy with transference interpretations than to therapy without such interpretations. Conversely, we found that more resourceful and less disturbed patients tended to have a negative response to transference interpretations.     

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.     

Pre-treatment peripheral biomarkers associated with treatment response in panic symptoms in patients with major depressive disorder and panic disorder: A 12-week follow-up study

ObjectivePeripheral biomarkers have been studied to predict treatment response of panic symptoms. We hypothesized that depressive disorder (MDD) vs. panic disorder (PD) would exhibit different peripheral biomarkers, and their correlation with severity of panic attacks (PA) would also differ.MethodsForty-one MDD patients, 52 PD patients, and 59 healthy controls were followed for 12 weeks. We measured peripheral biomarkers along with the Panic Disorder Severity Scale (PDSS) at each visit—pre-treatment, 2, 4, 8, and 12 weeks on a regular schedule. Peripheral biomarkers including serum cytokines, plasma and serum brain-derived neurotrophic factor (BDNF), leptin, adiponectin, and C-reactive protein (CRP) were quantified using enzyme-linked immunosorbent assay (ELISA).ResultsPatients with MDD and PD demonstrated significantly higher levels of pre-treatment IL-6 compared to controls, but no differences were seen in plasma and serum BDNF, leptin, adiponectin, and CRP. Pre-treatment leptin showed a significant clinical correlation with reduction of panic symptoms in MDD patients at visit 5 (p = 0.011), whereas pre-treatment IL-6 showed a negative correlation with panic symptom reduction in PD patients (p = 0.022). An improvement in three panic-related items was observed to be positively correlated with pre-treatment leptin in MDD patients: distress during PA, anticipatory anxiety, and occupational interference.ConclusionHigher pre-treatment leptin was associated with better response to treatment regarding panic symptoms in patients with MDD, while higher IL-6 was associated with worse response regarding panic symptoms in PD patients. Different predictive peripheral biomarkers observed in MDD and PD suggest the need for establishing individualized predictive biomarkers, even in cases of similar symptoms observed in different disorders.     

Changing character: A narrative review of personality change in psychotherapies for personality disorder

Objective: Personality disorder (PD) is a negative prognostic indicator for treatment, and absolute improvements in functioning among these patients are often modest. This may be because personality features that give rise to dysfunction in PD are not targeted optimally during most treatments. Method: Attachment, mentalization, core beliefs, and personality organization/defense use were identified as personality constructs that have been pursued in treatment studies and that are proposed to underlie PD. Results: All constructs correlate with psychiatric symptoms, PD diagnosis, and functioning. Defense mechanisms and core beliefs further distinguish specific PDs, whereas personality organization separates more versus less severe PDs. Evidence from treatment and naturalistic studies indicate that maturation of defense mechanisms temporally precedes improvements in symptoms and functioning. Changes in attachment and mentalization correlate with some outcomes, but mediation of improvement has not been established. In psychodynamic therapy, transference interpretations may promote amelioration of personality dysfunction. With the exception of attachment, the experimental literature is lacking that could explicate the mechanisms by which these personality constructs maintain psychosocial dysfunction. Conclusions: Future research should aim to identify changes in these mechanisms that mediate positive outcomes in PD, as well as the specific therapeutic procedures that best promote positive change in PD.     

Group interpersonal psychotherapy for low-income women with posttraumatic stress disorder

Abstract

The aim of this study was to assess the efficacy of group interpersonal psychotherapy (IPT) for low-income women with chronic posttraumatic stress disorder (PTSD) subsequent to interpersonal trauma. Non-treatment-seeking predominantly minority women were recruited in family planning and gynecology clinics. Individuals with interpersonal trauma histories (e.g., assault, abuse, and molestation) who met criteria for current PTSD (N=48) were randomly assigned to treatment or a wait list. Assessments were conducted at baseline, treatment termination, and 4-month follow-up; data analysis used a mixed-effects regression approach with an intent-to-treat sample. The results showed that IPT was significantly more effective than the wait list in reducing PTSD and depression symptom severity. IPT participants also had significantly lower scores than waitlist individuals on four interpersonal functioning subscales: Interpersonal Sensitivity, Need for Social Approval, Lack of Sociability, and Interpersonal Ambivalence.     

A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder

OBJECTIVE: The purpose of this study was to determine the efficacy of panic-focused psychodynamic psychotherapy relative to applied relaxation training, a credible psychotherapy comparison condition. Despite the widespread clinical use of psychodynamic psychotherapies, randomized controlled clinical trials evaluating such psychotherapies for axis I disorders have lagged. To the authors' knowledge, this is the first efficacy randomized controlled clinical trial of panic-focused psychodynamic psychotherapy, a manualized psychoanalytical psychotherapy for patients with DSM-IV panic disorder. METHOD: This was a randomized controlled clinical trial of subjects with primary DSM-IV panic disorder. Participants were recruited over 5 years in the New York City metropolitan area. Subjects were 49 adults ages 18-55 with primary DSM-IV panic disorder. All subjects received assigned treatment, panic-focused psychodynamic psychotherapy or applied relaxation training in twice-weekly sessions for 12 weeks. The Panic Disorder Severity Scale, rated by blinded independent evaluators, was the primary outcome measure. RESULTS: Subjects in panic-focused psychodynamic psychotherapy had significantly greater reduction in severity of panic symptoms. Furthermore, those receiving panic-focused psychodynamic psychotherapy were significantly more likely to respond at treatment termination (73% versus 39%), using the Multicenter Panic Disorder Study response criteria. The secondary outcome, change in psychosocial functioning, mirrored these results. CONCLUSIONS: Despite the small cohort size of this trial, it has demonstrated preliminary efficacy of panic-focused psychodynamic psychotherapy for panic disorder.     

Psychoticism in patients with panic disorder with or without comorbid agoraphobia

Objective: A few case-reports have previously described transient psychotic-like symptoms in non-psychotic patients with panic disorder (PD). We aimed to systematically explore whether PD patients without any current or past psychosis can be differentiated according to the severity of ‘psychoticism’ as a dimension, comprising clinical features such as psychotic-like experiences, increased social alienation, hostility and suspiciousness.

Methods: Sample included 35 (female?=?26) medication-free, non-psychotic patients consecutively referred from our Department’s Outpatient Clinic for acute symptoms of DSM-5 PD with (PDA; N?=?29) or without concurrent agoraphobia. Psychometric measures included the Symptom Checklist–90–Revised (SCL-90-R), Agoraphobic Cognitions Questionnaire (ACQ), Body Sensations Questionnaire (BSQ), and panic attacks during last 21 days PA-21d.

Results: Multiple regression analysis (forward stepwise) revealed that, among all SCL-90-R subscales, the psychoticism-subscale was most significantly associated with panic-related beliefs included in the ACQ, while significant associations emerged between the paranoid ideation-subscale and the ACQ and BSQ measures. Moreover, significant correlations emerged between the SCL-90-R psychoticism-subscale and all three measures of PD symptoms (ACQ, BSQ, PA-21d) and between the SCL-90-R paranoid ideation-subscale and both the ACQ and BSQ.

Conclusions: This significant association between levels of psychoticism and severity of panic symptoms may reflect a more severe subtype of PD.     

The role of treatment delivery factors in exposure-based cognitive behavioral therapy for panic disorder with agoraphobia

Treatment delivery factors (i.e., therapist adherence, therapist competence, and therapeutic alliance) are considered to be important for cognitive behavioral therapy (CBT) for panic disorder and agoraphobia (PD/AG). In the current study, four independent raters conducted process evaluations based on 168 two-hour videotapes of 84 patients with PD/AG treated with exposure-based CBT. Two raters evaluated patients’ interpersonal behavior in Session 1. Two raters evaluated treatment delivery factors in Session 6, in which therapists provided the rationale for conducting exposure exercises. At the 6-month follow-up, therapists’ adherence (r = 0.54) and therapeutic alliance (r = 0.31) were significant predictors of changes in agoraphobic avoidance behavior; therapist competence was not associated with treatment outcomes. Patients’ interpersonal behavior in Session 1 was a significant predictor of the therapeutic alliance in Session 6 (r = 0.17). The findings demonstrate that treatment delivery factors, particularly therapist adherence, are relevant to the long-term success of CBT for PD/AG.     

Favourable outcome of long-term combined psychotherapy for patients with borderline personality disorder: Six-year follow-up of a randomized study

Objective: This study reports the six-year follow-up data of patients with borderline personality disorder (BPD) who participated in the Ullevål Personality Project (UPP), a randomized clinical study comparing outpatient individual psychotherapy (OIP) with a long-term combination programme (CP) comprising short-term day-hospital treatment followed by outpatient combined group and individual psychotherapy. Methods: For 52 patients, outcomes were evaluated after 8 months, 18 months, 3 years, and 6 years based on a wide range of clinical measures, such as symptom severity, psychosocial functioning, personality functioning, and Axis-I and II diagnoses. Results: At the six-year follow-up, patients in the CP condition reported significantly greater reduction of symptom distress and improvements in the personality functioning domains Identity Integration and Self-control compared with patients allocated to OIP. Patients in the CP also had a more favourable long-term course of psychosocial functioning. There were no differences between treatment conditions in outcomes of interpersonal functioning and self-esteem. Conclusions: Long-term psychotherapy in a combination programme seems favourable for BPD patients. In this study, patients who received combined treatment fared better on crucial parameters than patients who received individual therapy. Of particular importance are the positive effects on fundamental borderline problem areas like Identity Integration and Self-control.     

The phenomenology of the first panic attack in clinical and community-based samples

The purpose of the study was to contrast first panic attacks (PAs) of patients with panic disorder (PD) with vs. without agoraphobia and to explore differences between first PAs leading to the development of PD and those that remain isolated. Data were drawn from a community survey (N = 2259 including 88 isolated PAs and 75 PD cases). An additional sample of 234 PD patients was recruited in a clinical setting. A standardized interview assessed the symptoms of the first PA, context of its occurrence and subsequent coping attempts. Persons who developed PD reported more severe first PAs, more medical service utilization and exposure-limiting coping attempts than those with isolated PAs. The context of the first PA did not differ between PD and isolated PAs. PD with agoraphobia was specifically associated with greater symptom severity and occurrence of first attacks in public. Future research should validate these findings using a longitudinal approach.     

The relationship between obsessive-compulsive disorder and anxiety disorders: A question of diagnostic boundaries or simply severity of symptoms?

BackgroundA growing number of studies are questioning the validity of current DSM diagnoses, either as “discrete” or distinct mental disorders and/or as phenotypically homogeneous syndromes. In this study, we investigated how symptom domains in patients with a main diagnosis of obsessive-compulsive disorder (OCD), panic disorder (PD) and social anxiety disorder (SAD) coaggregate. We predicted that symptom domains would be unrelated to DSM diagnostic categories and less likely to cluster with each other as severity increases.MethodsOne-hundred eight treatment seeking patients with a main diagnosis of OCD, SAD or PD were assessed with the Dimensional Obsessive-Compulsive Scale (DOCS), the Social Phobia Inventory (SPIN), the Panic and Agoraphobia Scale (PAS), the Anxiety Sensitivity Index-Revised (ASI-R), and the Beck Depression and Anxiety Inventories (BDI and BAI, respectively). Subscores generated by each scale (herein termed “symptom domains”) were used to categorize individuals into mild, moderate and severe subgroups through K-means clusterization and subsequently analysed by means of multiple correspondence analysis.ResultsBroadly, we observed that symptom domains of OCD, SAD or PD tend to cluster on the basis of their severities rather than their DSM diagnostic labels. In particular, symptom domains and disorders were grouped into (1) a single mild “neurotic” syndrome characterized by multiple, closely related and co-occurring mild symptom domains; (2) two moderate (complicated and uncomplicated) “neurotic” syndromes (the former associated with panic disorder); and (3) severe but dispersed “neurotic” symptom domains.ConclusionOur findings suggest that symptoms domains of treatment seeking patients with OCD and anxiety disorders tend to be better conceptualized in terms of severity rather than rigid diagnostic boundaries.     

Aging and panic disorder: phenomenology, comorbidity, and risk factors.

OBJECTIVE: The authors compared young and older adults with panic disorder (PD) to investigate differences in panic-associated phenomenology, psychiatric comorbidity, and risk factors. METHOD: Patients in the older group (age 60 and above) were further subdivided into early- and late-onset groups and compared. Phenomenology (number of panic symptoms, severity of anxiety, physiological symptoms, panic-associated cognitions, and overall severity of PD); comorbidity (depressive and anxiety disorders); and risk factors (family history of anxiety and life stressors) were assessed in 167 outpatients with PD. RESULTS: Older patients reported fewer panic symptoms, less anxiety and arousal, less severe PD, lower levels of depression, and higher levels of functioning. Furthermore, within the older-patient group, late-onset patients were found to report less distress during panic attacks in relation to body sensations and panic-related cognitions and emotions. Multiple-regression analysis of the entire sample showed that chronological age and age at onset of PD distinctly predicted different domains of panic phenomenology. CONCLUSION: PD was consistently less severe in older patients across multiple domains, and a later age at onset was associated with less distress due to body sensations, cognitions, and emotions during panic attacks.     

Effects of nasal continuous positive airway pressure on panic disorder comorbid with obstructive sleep apnea syndrome

BackgroundsBoth obstructive sleep apnea syndrome (OSAS) and panic disorder (PD) are common disorders that often coexist. Continuous positive airway pressure (CPAP) has been established as the first-line treatment for OSAS. In this study, we examined the efficacy of CPAP on PD comorbid with OSAS by conducting a randomized crossover study using sham CPAP as control.MethodsPD patients (n = 12) with an apnea hypopnea index (AHI) of 20/h or higher completed the study. At baseline, the subjects were asked to write their own records pertaining to the frequency of attacks and their score on the panic disorder severity scale (PDSS), and then they participated in the randomized crossover trial period, which measured optimal CPAP and sham CPAP set at 4 cmH₂O during nighttime sleep for each 4-week assignment.ResultsThe frequency of panic attacks, total PDSS score, and the frequency of alprazolam use for alleviating the attack symptoms were significantly decreased during the optimal CPAP period than during the baseline period and the sham CPAP period. Among the PDSS subitems, the frequency of attacks, panic distress, work impairment, and social impairment showed significant improvements during the optimal pressure period.ConclusionOur results suggest that OSAS contributes to PD aggravation, and a combination of pharmaceutical treatment for PD and OSAS-specific treatments such as CPAP could be recommended for patients with PD comorbid with OSAS.     

Main and interactive effects of a nonclinical panic attack history and distress tolerance in relation to PTSD symptom severity

The current study investigated the main and interactive effects of a nonclinical panic attack history and distress tolerance in relation to PTSD symptoms. The sample consisted of 91 adults (62.6% women; M_age = 23.45, SD = 9.56) who met DSM-IV criteria for trauma exposure, 53.8% of whom met criteria for a recent (past 2 years) history of nonclinical panic attacks. Results indicated that distress tolerance, as measured by the Distress Tolerance Scale (Simons & Gaher, 2005), was significantly related to all PTSD symptom clusters, and a nonclinical panic attack history was significantly related to PTSD re-experiencing and hyperarousal symptoms. The interaction of a nonclinical panic attack history and distress tolerance significantly predicted unique variance in only PTSD hyperarousal symptoms. Implications and future directions are discussed for the role of nonclinical panic attacks and distress tolerance in PTSD symptom expression.     

Changes in quality of life following cognitive-behavioral group therapy for panic disorder

BackgroundData about quality of life (QoL) are important to estimate the impact of diseases on functioning and well-being. The present study was designed to assess the association of different aspects of panic disorder (PD) with QoL and to examine the relationship between QoL and symptomatic outcome following brief cognitive-behavioral group therapy (CBGT).MethodThe sample consisted of 55 consecutively recruited outpatients suffering from PD who underwent CBGT. QoL was assessed by the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) at baseline, post-treatment and six months follow-up. SF-36 baseline scores were compared with normative data obtained from a large German population sample.ResultsAgoraphobia, disability, and worries about health were significantly associated with decreased QoL, whereas frequency, severity and duration of panic attacks were not. Treatment responders showed significantly better QoL than non-responders. PD symptom reduction following CBGT was associated with considerable improvement in emotional and physical aspects of QoL. However, the vitality subscale of the SF-36 remained largely unchanged over time.ConclusionsOur results are encouraging for cognitive-behavior therapists who treat patients suffering from PD in groups, since decrease of PD symptoms appears to be associated with considerable improvements in QoL. Nevertheless, additional interventions designed to target specific aspects of QoL, in particular vitality, may be useful to enhance patients’ well-being.     

Goldilocks on the couch: Moderate levels of psychodynamic and process-experiential technique predict outcome in psychodynamic therapy

Objectives: Greater symptom change is often assumed to follow greater technique use, a “more is better” approach. We tested whether psychodynamic techniques, as well as common factors and techniques from other orientations, had a curvilinear relation to outcome (i.e., whether moderate or “just right” intervention levels predict better outcome than lower or higher levels). Methods: For 33 patients receiving supportive-expressive psychodynamic psychotherapy for depression, interventions were assessed at Week 4 using the multitheoretical list of therapeutic interventions and symptoms were rated with the Hamilton Rating Scale for Depression. Results: Moderate psychodynamic and experiential techniques predicted greater symptom change compared to lower or higher levels. Conclusion: This “Goldilocks effect” suggests a more complex relation of intervention use to outcome might exist.     

The evaluation of metacognitive beliefs and emotion recognition in panic disorder and generalized anxiety disorder: effects on symptoms and comparison with healthy control

Abstract

Background: The impairments in metacognitive functions and emotion recognition are considered as liable factors in anxiety disorders.

Aims: The better understanding of these cognitive abilities might lead to develop more accurate treatment methods for patients who suffer from anxiety.

Methods: Forty-four patients with panic disorder (PD), 37 individuals with generalized anxiety disorder (GAD) and 44 healthy control (HC) were participated in our study. Metacognition questionnaire-30 (MCQ-30), Reading The Mind From The Eyes Test and symptom severity tests were administered.

Results: Statistical analyses estimated the dysfunctional metacognitive beliefs and disrupted emotion recognition in patients relative to HC. The ‘need to control thoughts’ aspect of metacognitive beliefs was accounted for symptom severity in GAD. Improper metacognitive beliefs were significantly predicted the PD and GAD. In addition, impoverished emotion recognition predicted the GAD.

Conclusions: Our study revealed the role of inconvenient metacognitive beliefs and distorted emotion recognition in PD and GAD. These findings might facilitate the treatment management in cognitive therapies of anxiety disorders via pointing out more reasonable targets across improper cognitive fields.     

Baseline predictors of worsening apathy in Parkinson's disease: A prospective longitudinal study

IntroductionApathy is one of the most common behavioural disorders in Parkinson's disease (PD) and contributes significantly to a reduced quality of life in PD patients.MethodsWe conducted a prospective longitudinal study of 89 mild PD patients over 18 months, measuring apathy symptoms at 6-monthly intervals using the Starkstein Apathy Scale, as well as measures of motor and non-motor symptoms, cognitive function, and functional disability at baseline. Mixed-effects models were used to characterise the individual trajectories of apathy symptom severity, and linear regression with stepwise elimination procedure was used to select significant baseline predictors.ResultsClinically significant levels of apathy were present in 42.7% of our sample at baseline, with symptom severity remaining relatively stable on average over the course of 18 months. Male gender, lower educational attainment, higher depression symptom severity, more severe functional disability, and the presence of dyskinesias at study entry predicted increasing apathy over the subsequent 18 months.ConclusionsPatients with these factors are at risk for progression of apathy, which may be prevented by treating depression and functional disability. Further studies are needed to address both the specific neurobiological pathways and psychosocial factors underpinning apathy in PD.     

Cultural adaptation in measuring common client characteristics with an urban Mainland Chinese sample

Abstract

Objectives: This study aimed to develop a culturally adapted version of the Systematic Treatment Selection-Innerlife (STS) in China. Methods: A total of 300 nonclinical participants collected from Mainland China and 240 nonclinical US participants were drawn from archival data. A Chinese version of the STS was developed, using translation and back-translation procedures. After confirmatory factor analysis (CFA) of the original STS sub scales failed on both samples, exploratory factor analysis (EFA) was then used to access whether a simple structure would emerge on these STS treatment items. Parallel analysis and minimum average partial were used to determine the number of factor to retain. Results: Three cross-cultural factors were found in this study, Internalized Distress, Externalized Distress and interpersonal relations. Conclusions: This supported that regardless of whether one is in presumably different cultural contexts of the USA or China, psychological distress is expressed in a few basic channels of internalized distress, externalized distress, and interpersonal relations, from which different manifestations in different culture were also discussed.