Cognitive-behavioural group treatment of panic disorder and agoraphobia in a psychiatric setting: A naturalistic study of effectiveness

The purpose of the present study was to investigate the effectiveness of cognitive-behavioural group treatment of panic disorder and agoraphobia in a clinical setting. Fifty-three patients were offered treatment and assessed before, after and at follow-up 1 1/2-2 years after treatment. The study included an informal waiting-list control group of 40 patients. The investigation group achieved better outcome on most analyses with 47.2% found to be panic-free after treatment compared with 12.5% in the control group. Treatment gains were durable with 66.7% without panic attacks at follow-up. Most patients, however, still had major psychological problems after treatment. The outcomes of cognitive-behavioural group treatment of panic disorder in this study were modest compared with most controlled studies, possibly due to an unselected patient group with a high degree of agoraphobia.     

Predictors of willingness to consider medication and psychosocial treatment for panic disorder in primary care patients

The purpose of this investigation was to identify demographic and clinical patient characteristics related to willingness to consider panic disorder treatments in the primary care setting. Given the prevalence of anxiety disorders and the increased provision of mental health treatments in general medical settings, patients were selected from primary care settings. An unselected sample of 4,198 patients completed a brief questionnaire containing questions about demographic characteristics, physical health status, and symptoms of panic disorder, social phobia and PTSD. The 1,043 patients indicating a recent panic attack episode answered additional questions about their willingness to consider both medication and psychosocial forms of intervention for panic. Of these panic patients, 64% reported willingness to consider medication and 67% reported willingness to consider a psychosocial intervention for their panic. Logistic regression analyses for these panic patients revealed that willingness to consider medication treatment for panic was associated with older age, lower education, poorer health status and the presence of social phobia and/or PTSD symptoms. In addition, Asian and African American patients were less likely than Caucasian patients to indicate willingness to consider medication treatment for their panic. However, only the presence of comorbid social phobia and PTSD symptoms predicted willingness to consider a psychosocial intervention. Results suggest that acceptability of psychosocial treatment is unrelated to demographic and physical health factors, while primary care patients with certain demographic characteristics, good physical health, or who suffer from fewer comorbid mental health conditions may need additional encouragement to begin medication treatment for panic.     

Behavior therapy for vestibular rehabilitation

Patients with panic disorder and patients with vestibular disorders often share symptomatology, such as dizziness, spatial disorientation, and anxiety in particular environments. Because of the similar clinical presentations, it is not always apparent whether these symptoms are due primarily to a vestibular disorder or to panic disorder. Depending on where and how these patients enter the medical system, their symptoms may be remedied by treatment from behavioral therapists or physical therapists trained in vestibular rehabilitation. Although vestibular rehabilitation developed independently of behavioral treatment for anxiety disorders, there are remarkable similarities in treatment conceptualization and implementation. For example, both use exposure procedures designed to produce habituation of dizziness and disorientation, as well as enhancing functional compensation. Furthermore, there appears to be a subset of individuals with panic disorder who also have vestibular pathology and thus, may benefit from both interventions. In this paper, similarities and differences in the clinical presentation, treatment goals, and specific interventions for patients with panic disorder or vestibular pathology is examined, and future implications are discussed.     

Video-Delivered Relaxation Intervention Reduces Late-Life Anxiety: A Pilot Randomized Controlled Trial

Objective

The study's aim was to demonstrate the feasibility and preliminary efficacy of a 4-week video-delivered relaxation program called Breathing, Relaxation, and Education for Anxiety Treatment in the Home Environment (BREATHE) for reducing anxiety and increasing activity engagement in older adults with anxiety disorders.

Changing the psychiatric knowledge of primary care physicians. The effects of a brief intervention on clinical diagnosis and treatment

This research examined the malleability of physicians' knowledge about psychiatric disorders (and their recommended treatments) based on a brief educational intervention. Primary care physicians were randomly assigned to a single-session intervention dealing with selected DSM-IIIR affective and anxiety disorders or to a wait-list control group. Posttest (vs. pretest) measures indicated that experimental physicians showed greater increases than controls in diagnostic accuracy on relevant disorders, specifically, major depression, dysthymic disorder, and agoraphobia with panic attacks. Treatment recommendations were also influenced, specifically, for major depression and panic disorder. Interestingly, treatment recommendations were also influenced for certain somatic disorders not addressed in the intervention, suggesting "halo" effects for these disorders. Overall, the intervention was effective in increasing diagnostic knowledge and altering treatment recommendations. Implications for research on psychiatric interventions among physicians are discussed.     

Should art be integrated into cognitive behavioral therapy for anxiety disorders?

Although cognitive behavioral therapy (CBT) is the preferred treatment method for anxiety disorders, it is underutilized and has been critiqued for being too verbal or abstract. Due to the role of imagery in maintaining anxiety disorders, art may be a useful addition to CBT for anxiety disorders. Art was incorporated into a brief CBT model in two quantitative case studies: Case 1 for panic disorder with agoraphobia (PDA) and Case 2 for generalized anxiety disorder (GAD). The A-B, single-subject experimental design included a two-week baseline period and a seven-week intervention period in both cases. The participant with PDA recorded her symptoms of PDA and her level of general anxiety throughout the baseline and intervention periods using a panic diary, whereas the participant with GAD recorded her level of general anxiety. In Case 1 for PDA, the intervention resulted in statistically significant reductions in panic frequency and some features of panic anxiety and agoraphobia. In Case 2 for GAD, the decrease in general anxiety was marginally significant.     

A crossover study of focused cognitive therapy for panic disorder.

OBJECTIVE: This study sought to determine the short- and long-term effects of focused cognitive therapy for panic disorder. METHOD: Thirty-three psychiatric outpatients with the DSM-III diagnosis of panic disorder were randomly assigned to either 12 weeks of individual, focused cognitive therapy or 8 weeks of brief supportive psychotherapy based on principles of client-centered therapy. The patients who received supportive psychotherapy were subsequently given the opportunity to cross over to cognitive therapy for 12 weeks. Patients were rated for panic and depression before therapy, after 4 and 8 weeks of therapy, and at 6-month and 1-year follow-up. RESULTS: Clinician ratings and self-ratings of panic frequency and intensity indicated that the focused cognitive therapy group achieved significantly greater reductions in panic symptoms and general anxiety after 8 weeks of treatment than did the group that received brief supportive psychotherapy. At 8 weeks, 71% of the cognitive therapy group were panic free, compared to 25% of the psychotherapy group. Moreover, 94% of the psychotherapy patients elected to cross over to 12 weeks of cognitive therapy. At 1-year follow-up, 87% of the group that received cognitive therapy only and 79% of the group that crossed over into cognitive therapy remained free of panic attacks. CONCLUSIONS: Focused cognitive therapy offers a promising nonpharmacological alternative for the treatment of panic disorder.     

Use of selective serotonin reuptake inhibitors for the treatment of childhood panic disorder: a pilot study.

This preliminary study examines the effectiveness and safety of selective serotonin reuptake inhibitors (SSRIs) for the treatment of panic disorder in children and adolescents. In a prospective open label study, 12 children and adolescents with panic disorder were treated with SSRIs, and if necessary, with benzodiazepines, for a period of 6-8 weeks and were followed for approximately 6 months. During the trial, clinician-based and self-report rating scales for anxiety and depression, functioning, and side effects, were administered. Using the Clinical Global Impression Scale (CGIS) 75% of patients showed much to very much improvement with SSRIs without experiencing significant side effects. After controlling for changes in depressive symptoms, self-report and clinician-based anxiety scales also showed significant improvement. At the end of the trial, 67% of patients no longer fulfilled criteria for panic disorder and 4 patients remained with significant residual symptoms. In conclusion, SSRIs appear to be a safe and promising for the treatment of children and adolescents with panic disorder, however, randomized controlled trials evaluating the effects of SSRIs and other interventions (e.g., cognitive therapy) for treating panic disorder in children and adolescents are warranted. It appears that until the SSRIs begin to exert their effects, a benzodiazepine adjunct treatment might be helpful for patients with severe panic disorder.     

Patterns of axis II comorbidity in early-onset versus late-onset panic disorder in Japan

Early onset of psychiatric disorders has been reported to be associated with increased familial risk or more severe clinical symptoms. In this study, we specifically examine the association between clinical severity and early versus late onset in panic disorder. We hypothesize the existence of differences in rates of axis II disorders in these two groups that will relate to clinical severity. Subjects were a consecutive clinical case series of 105 panic disorder patients (age, 18.3 to 70.9 years). Thirty-one panic disorder patients were classified as early onset (age of onset < or = 25 years) and 74 as late onset (age of onset >25). We compared symptomatology and rates of comorbid axis II disorders (diagnosed by structured clinical interview) between the early- and the late-onset groups. We found a statistically significant increase in the number of suicide attempts and likelihood of comorbid axis II disorders in the early-onset group compared to the late-onset group. In logistic regression analyses, cluster B personality disorders (PDs), especially borderline and histrionic, were statistically significantly associated with the presence of suicide attempts. The following limitations are present: first, we have not taken into consideration comorbidity of other axis I disorders, especially major depression. Second, there is imprecision associated with efforts to date the onset of panic disorder retrospectively. We conclude that comorbid axis II disorders are more likely to occur in early-onset panic disorder patients. Cluster B PDs, especially borderline or histrionic, may be associated with a high frequency of suicide attempts in this group. In clinical practice, efforts to aggressively detect and treat axis II disorders in early-onset panic disorder patients are warranted.     

Changes in anxiety sensitivity with pharmacotherapy for panic disorder

Fear of anxiety symptoms (anxiety sensitivity) has been implicated in the etiology and maintenance of panic disorder, and has been shown to improve with cognitive-behavioral treatment. The impact of pharmacotherapy on anxiety sensitivity is less clear. We administered the Anxiety Sensitivity Index (ASI) during a 12-week randomized controlled trial investigating the relative efficacy of paroxetine, paroxetine plus sustained clonazepam, and paroxetine plus brief clonazepam for patients with panic disorder. We found a mean reduction in ASI scores of 9.6 points, which correlated with symptomatic improvement, and did not differ significantly between groups. Our data provides further evidence that pharmacotherapy leads to significant acute reductions in fears of anxiety symptoms in patients with panic disorder, albeit at levels that may be somewhat less than the changes associated with CBT. Implications of these findings are discussed relative to optimizing pharmacologic treatment of panic disorder.     

Intensive weekend group treatment for panic disorder and its impact on co-occurring PTSD: A pilot study

This pilot study examines the feasibility, acceptability, and potential effectiveness of delivering an intensive weekend group treatment for panic disorder (PD) to Veterans returning from deployments to Iraq and Afghanistan with co-occurring posttraumatic stress disorder (PTSD). The treatment program lasted 6 h each day and was delivered by two experienced therapists. Patients received core components of panic treatment, including psychoeducation, cognitive restructuring, and interoceptive exposure. The interoceptive exposure exercises directly targeted anxiety sensitivity, a psychological construct also implicated in the maintenance of PTSD. Eighty-nine percent of patients who expressed interest in the treatment attended a baseline evaluation, and 63% of those who were study eligible initiated treatment. Treatment retention was high, with all 10 patients who initiated treatment completing the program. Veterans reported finding the treatment and delivery format highly acceptable and reported high levels of satisfaction. Panic symptoms improved significantly following the treatment and were maintained at a 7-month follow-up, with 71.4% of the sample reporting being panic free. Co-occurring PTSD symptoms also improved along with symptoms of anxiety and depression. Preliminary findings suggest that brief and intensive group treatments for PD/PTSD are a promising method of delivering cognitive behavioral therapy that may rapidly improve symptoms. This innovative treatment delivery format also may be a cost-effective way of increasing treatment engagement through increased access to quality care.     

Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders.

OBJECTIVE: This study was designed to determine the effectiveness of a group stress reduction program based on mindfulness meditation for patients with anxiety disorders. METHOD: The 22 study participants were screened with a structured clinical interview and found to meet the DSM-III-R criteria for generalized anxiety disorder or panic disorder with or without agoraphobia. Assessments, including self-ratings and therapists' ratings, were obtained weekly before and during the meditation-based stress reduction and relaxation program and monthly during the 3-month follow-up period. RESULTS: Repeated measures analyses of variance documented significant reductions in anxiety and depression scores after treatment for 20 of the subjects--changes that were maintained at follow-up. The number of subjects experiencing panic symptoms was also substantially reduced. A comparison of the study subjects with a group of nonstudy participants in the program who met the initial screening criteria for entry into the study showed that both groups achieved similar reductions in anxiety scores on the SCL-90-R and on the Medical Symptom Checklist, suggesting generalizability of the study findings. CONCLUSIONS: A group mindfulness meditation training program can effectively reduce symptoms of anxiety and panic and can help maintain these reductions in patients with generalized anxiety disorder, panic disorder, or panic disorder with agoraphobia.     

Cost-effectiveness of psychological and pharmacological interventions for generalized anxiety disorder and panic disorder

OBJECTIVE: To assess from a health sector perspective the incremental cost-effectiveness of interventions for generalized anxiety disorder (cognitive behavioural therapy [CBT] and serotonin and noradrenaline reuptake inhibitors [SNRIs]) and panic disorder (CBT, selective serotonin reuptake inhibitors [SSRIs] and tricyclic antidepressants [TCAs]). METHOD: The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analyses of randomised controlled trials. An assessment on second stage filter criteria ("equity", "strength of evidence", "feasibility" and "acceptability to stakeholders") is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are calculated for a period of one year for the eligible population (prevalent cases of generalized anxiety disorder/panic disorder identified in the National Survey of Mental Health and Wellbeing, extrapolated to the Australian population in the year 2000 for those aged 18 years and older). Simulation modelling techniques are used to present 95% uncertainty intervals (UI) around the incremental cost-effectiveness ratios (ICERs). RESULTS: Compared to current practice, CBT by a psychologist on a public salary is the most cost-effective intervention for both generalized anxiety disorder (A$6900/DALY saved; 95% UI A$4000 to A$12 000) and panic disorder (A$6800/DALY saved; 95% UI A$2900 to A$15 000). Cognitive behavioural therapy results in a greater total health benefit than the drug interventions for both anxiety disorders, although equity and feasibility concerns for CBT interventions are also greater. CONCLUSIONS: Cognitive behavioural therapy is the most effective and cost-effective intervention for generalized anxiety disorder and panic disorder. However, its implementation would require policy change to enable more widespread access to a sufficient number of trained therapists for the treatment of anxiety disorders.     

Lack of efficacy of carbamazepine in the treatment of panic disorder

The authors conducted a controlled study of carbamazepine in the treatment of 14 patients with panic disorder. Although there was a statistically significant reduction in symptoms of anxiety on several measures, only one of the patients was judged to have a marked and sustained clinical improvement while taking carbamazepine. Forty percent of the patients had a decrease in frequency of panic attacks during carbamazepine treatment, 50% had an increase, and 10% showed no change. The presence of either EEG abnormalities or prominent psychosensory symptoms did not predict response to carbamazepine. These findings are discussed within the context of an epileptiform model for panic disorder.     

Open trial of psychodynamic psychotherapy for panic disorder: a pilot study

OBJECTIVE: This report contains preliminary data from an open trial of brief psychodynamic psychotherapy for panic disorder. METHOD: Fourteen patients with primary DSM-IV panic disorder completed a 24-session, twice-weekly course of psychodynamic psychotherapy. Other psychiatric treatment was not permitted throughout the 12-week treatment period and the 6-month follow-up. Symptoms were assessed at baseline, treatment termination, and 6-month posttermination follow-up (40 weeks). RESULTS: Statistically significant, clinically meaningful improvements appeared in panic, depression, anxiety, and functional impairment both at treatment termination and at 6-month follow-up. CONCLUSIONS: Psychodynamic monotherapy can be used successfully to retain and treat patients with panic disorder. Psychodynamic interventions warrant further study for patients with panic disorder.     

Panic attack-associated placental abruption: a case report

A case of placental abruption is described in a nonmedicated pregnant woman with panic disorder who experienced panic symptoms and resultant hypertension. The authors suggest that sympathetic arousal associated with panic symptoms may have an adverse effect on the fetoplacental unit. The potential impact of untreated anxiety symptoms on fetal well-being must be considered when deciding whether pharmacotherapeutic intervention is appropriate for certain patients with anxiety disorders.     

The use of the Internet in the treatment of anxiety disorders

PURPOSE OF REVIEW: The aim of this article is to review the emerging literature on the use of the Internet in the treatment of anxiety disorders. The questions asked are: (1) are Internet-delivered treatments for anxiety disorders supported by the research literature? (2) what is the quality of the evidence as it stands? (3) is there any evidence to suggest that Internet interventions can be harmful? RECENT FINDINGS: Recent and ongoing trials on panic disorder show that Internet-based self-help with minimal therapist contact is a promising approach in the treatment of panic disorder. However, trials have been small and there is a need for large-scale trials and studies conducted in psychiatric settings as most studies have recruited patients via advertisement. There is no evidence in the literature that Internet intervention is harmful, but most likely a stepped-care approach would be feasible to handle cases who fail to respond. SUMMARY: Internet-delivered interventions for anxiety disorders, and in particular panic disorder, are promising. There is however a need for further research and evaluation and there is also a need to find a proper place for such interventions in the clinical management of anxiety disorders, preferably using a stepped-care approach.     

Potential effectiveness and safety of olanzapine in refractory panic disorder

Panic disorder is a common and disabling psychiatric disorder. Despite treatment advances, refractory panic disorder requires novel interventions. One such pharmacologic intervention with theoretical and case study support includes olanzapine, a thienobenzodiazepine medication currently approved for schizophrenia in the United States. Ten people with refractory DSM-IV diagnosed panic disorder completed an 8-week, open-label, flexible-dose clinical trial. Baseline, in-treatment, and end-of-treatment data for panic attacks, anticipatory anxiety, phobic avoidance, and impairment were collected. Data were analyzed using SPSS software. Refractory panic disorder patients required a wide dose range averaging 12.3 mg/day of olanzapine to significantly improve or ablate panic attacks. On the average, number of attacks decreased from 6.1/week at baseline to 1.1/week at the end of treatment, and anticipatory anxiety from 32% of the day to 8% of the day. At treatment end, 5 of 10 participants (50%) were panic free, 4 (40%) had one attack in the previous week, 1 (10%) had seven attacks in the previous week, and 6 of 10 participants (60%) were anticipatory anxiety free. There were also statistically and clinically significant improvements in impairment over the course of the trial. There were no significant changes in vital signs, emergent side effects, or average weight, although 6 of 10 people did gain weight. Olanzapine is potentially effective and safe in panic disorder. Due to study limitations, further clinical trials are needed to demonstrate effectiveness.     

Functional adaptation skills training (FAST): a randomized trial of a psychosocial intervention for middle-aged and older patients with chronic psychotic disorders

OBJECTIVE: Behavioral interventions designed to improve functioning of older patients with schizophrenia and other chronic psychotic disorders have the potential to significantly increase patients' independence and quality of life. This study evaluated a psychosocial intervention designed to improve everyday living skills of middle-aged and older outpatients with chronic psychotic disorders. METHODS: A total of 240 patients with a DSM-IV-based chart diagnosis of schizophrenia or schizoaffective disorder participated in a 24-week, randomized controlled trial comparing a behavioral group intervention called "Functional Adaptations and Skills Training" (FAST; n=124) to a time-equivalent attention-control (AC; n=116) group focused on improving functional skills. RESULTS: Compared to participants randomized to AC, those in the FAST intervention demonstrated significant improvement in everyday living skills (p=.046) and social skills (p=.003), but not medication management skills (p=.268). CONCLUSIONS: Results suggest that middle-aged and older patients with psychotic disorders may benefit from participation in interventions designed specifically to improve functional skills.     

Obsessive-compulsive disorder in children and adolescents

With a prevalence of about 2% obsessive-compulsive disorder is ranking among the most frequent psychiatric disorders in childhood and adolescence. The symptoms often lead to severe impairments in academic and social life, as well as to family conflicts. Despite the high efficacy of cognitive-behavioural and psychopharmacological interventions, the long-term course of the disorder is less favourable in a significant number of patients. A profound knowledge of the disorder is crucial to implement effective treatment strategies shortly after the onset of symptoms. This paper gives a review on juvenile obsessive-compulsive disorder and addresses issues of classification, epidemiology, symptoms, co-morbidity, diagnostics, aetiology, treatment strategies and the course of the disorder.