Therapist contact in cognitive behaviour therapy for panic disorder and agoraphobia in primary care

Panic disorder with or without agoraphobia is a prevalent clinical disorder which places heavy demands on treatment resources in primary care. The efficiency of delivery of psychological treatments for this disorder is therefore important. Previous research has focused on psychological treatments delivered with reduced therapist contact but methodological problems preclude firm conclusions. The present study investigated the relevance of therapist contact in cognitive behaviour therapy for panic disorder and agoraphobia, taking account of previous methodological problems. One hundred and four patients suffering from DSM III‐R panic disorder with or without agoraphobia were randomly allocated to receive cognitive behaviour therapy with either, ‘standard’ therapist contact, ‘minimum’ therapist contact or as a bibliotherapy. All patients were seen by the same therapist and all received an identical treatment manual. Treatment response, as measured by patient and therapist report scales of anxiety, depression, and agoraphobic avoidance, was analysed in terms of both traditional statistical significance and clinical significance of outcome. At treatment end‐point the ‘standard’ therapist contact and ‘minimum’ therapist contact groups showed significant reductions pre‐ to post‐treatment on all measures. Pre‐ to post‐treatment reductions for the bibliotherapy group were significant on therapist‐ and patient‐rated measures of anxiety only. The ‘standard’ therapist contact group was consistently significantly improved in comparison to the bibliotherapy group. Significant differences between the ‘standard’ and ‘minimum’ therapist contact groups were found on therapist‐rated anxiety only. Assessment of clinical significance of treatment outcome showed further differences between treatment groups with the ‘standard’ therapist contact group showing the largest proportion of patients achieving clinically significant change on all measures both at treatment end‐point and at 6‐month follow‐up. Copyright © 2000 John Wiley & Sons, Ltd.     

Prognostic indices with brief and standard CBT for panic disorder: I. Predictors of outcome

BACKGROUND: Although the effectiveness of cognitive behavioural therapy (CBT) in the management of panic disorder (PD) is now well established, there have been few studies of predictors of outcome with this patient group using clinical effectiveness trial data, a hypothesis-testing model, and a dependent measure of clinically significant change.METHOD: The data for this study came from a randomized controlled trial of three forms of CBT delivery for PD with and without agoraphobia (two 6-week CBT programmes, one of which was computer assisted, and one therapist-directed 12-week CBT programme), comprising a total of 186 patients across two sites. Based on previous related research, five hypothesized predictors of post-treatment and follow-up outcome were identified and examined, using a series of bivariate and multivariate analyses. RESULTS: The results in general supported the hypotheses. Strength of blood/injury fears, age of initial onset of panic symptoms, co-morbid social anxieties and degree of agoraphobic avoidance were predictive of both measures of post-treatment outcome. Degree of residual social difficulties and the continued use of anxiolytics at post-treatment were also shown to predict poor outcome at the 6-month follow-up. However, strength of continuing dysfunctional agoraphobic cognitions by the end of active treatment did not predict outcome at follow-up for the sample as a whole. CONCLUSIONS: The identification of consistent predictors of outcome with CBT has many clinical and research benefits. As CBT, however, is being delivered increasingly in a variety of brief formats, further research is required to identify moderators of response to these 'non-standard' treatment formats.     

Treating medication-resistant panic disorder: predictors and outcome of cognitive-behavior therapy in a Brazilian public hospital

BACKGROUND: In Brazil, treatment of panic disorder is most frequently initiated with pharmacotherapy, but only half of the patients can be expected to be panic free after medication. Studies have suggested that individual or group cognitive-behavior therapy (CBT) is an effective treatment strategy for panic patients who have failed to respond to pharmacotherapy. METHODS: Thirty-two patients diagnosed with panic disorder with agoraphobia having residual symptoms despite being on an adequate dose of medication were treated with 12 weeks of group CBT. The outcome was evaluated for panic frequency and severity, generalized anxiety, and global severity. Comorbid conditions, a childhood history of anxiety, and defense mechanism styles were assessed as potential predictors of treatment response. RESULTS: Twenty-nine patients completed the 12-week protocol. Treatment was associated with significant reductions in symptom severity on all outcome measures (p < 0.001). Patients with depression had a poorer outcome of the treatment (p = 0.01) as did patients using more neurotic (p = 0.002) and immature defenses (p = 0.05). CONCLUSION: Consistent with previous reports, we found that CBT was effective for our sample of treatment-resistant patients. Among these patients, depression as well as neurotic defense style was associated with a poorer outcome. The use of CBT in Brazil for treatment-resistant and other panic patients is encouraged.     

EMDR for panic disorder with agoraphobia: comparison with waiting list and credible attention-placebo control conditions

In a randomized controlled trial, eye movement desensitization and reprocessing (EMDR) for panic disorder with agoraphobia (PDA) was compared with both waiting list and credible attention-placebo control groups. EMDR was significantly better than waiting list for some outcome measures (questionnaire, diary, and interview measures of severity of anxiety, panic disorder, and agoraphobia) but not for others (panic attack frequency and anxious cognitions). However, low power and, for panic frequency, floor effects may account for these negative results. Differences between EMDR and the attention-placebo control condition were not statistically significant on any measure, and, in this case, the effect sizes were generally small (eta2 = .00-.06), suggesting the poor results for EMDR were not due to lack of power. Because there are established effective treatments such as cognitive-behavior therapy for PDA, these data, unless contradicted by future research, indicate EMDR should not be the first-line treatment for this disorder.     

Effectiveness of an empirically based treatment for panic disorder delivered in a service clinic setting: 1-year follow-up

The transportability of cognitive-behavioral therapy (CBT) for panic disorder to a community mental health center (CMHC) setting at 1-year follow-up was examined by comparing CMHC treatment outcome data with results obtained in controlled efficacy studies. Participants were 81 CMHC clients with a primary diagnosis of panic disorder with or without agoraphobia who completed CBT for panic disorder. Despite differences in settings, clients, and treatment providers, both the magnitude of change from pretreatment to follow-up and the maintenance of change from posttreatment to follow-up in the CMHC sample were comparable with the parallel findings in the efficacy studies. At follow-up, 89% of the CMHC clients were panic free and a substantial proportion of the sample successfully discontinued benzodiazepine use.     

Physical, mental, and social catastrophic cognitions as prognostic factors in cognitive-behavioral and pharmacological treatments for panic disorder

The authors explored the prognostic value of 3 different types of catastrophic cognitions in the treatment of panic disorder with and without mild-to-moderate agoraphobia using a sample of 143 participants who received either cognitive-behavioral therapy (CBT) or imipramine in a randomized controlled trial. Stronger fears of social catastrophes both prior to and following treatment with CBT or imipramine were associated with a poorer outcome. In contrast, cognitions involving physical or mental catastrophes were unrelated to outcome, regardless of whether these thoughts were measured prior to or following treatment. These findings are consistent with the notion that although the intensity of physical catastrophe cognitions may best discriminate between panic disorder and other anxiety disorders, it is the intensity of social catastrophe cognitions that is most closely tied to success in treating this disorder.     

Virtual reality exposure in the treatment of panic disorder and agoraphobia: A controlled study

The main goal of this study was to offer data about the efficacy of virtual reality exposure (VRE) in the treatment of panic disorder with or without agoraphobia (PDA). The study was a between‐subject design with three experimental conditions (VRE group, in vivo exposure [IVE] group and waiting‐list [WL] group) and repeated measures (pre‐treatment, post treatment and 12 month follow‐up). The treatment programmes lasted 9 weekly sessions. Thirty‐seven patients meeting DSM‐IV criteria for PDA participated in this study. The improvement achieved using virtual exposure was superior to a WL condition and similar to that achieved using IVE. Our results support the efficacy of VRE in the treatment of PDA at short and long term. The advantages of VRE for the treatment of PDA regarding cost‐benefit issues are described. Copyright © 2007 John Wiley & Sons, Ltd.     

Treatment of major depression in the context of panic disorder.

BACKGROUND: Individuals with major depression frequently have panic attacks, and often panic disorder, but rarely have researchers studied the impact of comorbidity of panic on the outcome of psychological treatment of depression. METHODS: In this study, patients with comorbid panic and depression were first treated with cognitive-behavioral therapy (CBT) for panic. Depression symptoms in this treated group were compared to a group of patients with major depression who were on a minimal therapist contact waitlist. In the second phase of the study, patients in both groups (comorbid and depression-only) were treated with CBT for depression. RESULTS: CBT for panic had little effect on co-existing depression, suggesting a specificity of action for CBT directed at different disorders. In addition, the presence of current or recently remitted panic attacks or agoraphobic avoidance did not interfere with the outcome of CBT for depression. CONCLUSION: These findings stand in contrast to previous studies showing greater linkage between depression and panic in treatment outcome. LIMITATIONS: While there are implications for treatment planning, these conclusions may be limited by the exclusion criteria and the highly structured treatment approach of separating treatment for panic from treatment for depression.     

Mechanism of change in cognitive-behavioral treatment of panic disorder: evidence for the fear of fear mediational hypothesis

Numerous clinical trials have demonstrated the efficacy of cognitive-behavioral treatment (CBT) for panic disorder. However, studies investigating the mechanisms responsible for improvement with CBT are lacking. The authors used regression analyses outlined by R. M. Baron and D. A. Kenny (1986) to test whether a reduction in fear of fear (FOF) underlies improvement resulting from CBT. Pre- and posttreatment measures were collected from 90 CBT-treated patients and 40 wait-list control participants. Overall, treatment accounted for 31% of the variance in symptom reduction. The potency of FOF as a mediator varied as a function of symptom facet, as full mediation was observed for the change in global disability, whereas the effects of CBT on agoraphobia, anxiety, and panic frequency were partially accounted for by reductions in FOF. Clinical implications and future research directions are discussed.     

Predicting treatment outcome for panic disorder and agoraphobia in primary care

The ability to predict post‐treatment response on indices of pre‐treatment condition is likely to have considerable clinical utility. Previous attempts to identify prognostic indicators are reviewed and methodological problems in such research discussed. The present study attempts improvements in study methodology including the use of standardized measures of outcome and predictor variables, and the controlled definition of the clinical significance of treatment outcome. In a sample of n=149 patients with DSM III‐R panic disorder with and without agoraphobia, logistic regression analyses were used to predict clinically significant versus non‐significant outcome following treatment with fluvoxamine, placebo and cognitive behaviour therapy used alone and in combination. Findings indicated good prediction of post‐treatment response with predictor variables measuring anxiety level, frequency of panic attacks and extroversion all showing some predictive value over and above that found for treatment received. Prediction of outcome at 6 month follow‐up was less impressive. Possible reasons for this are discussed. Copyright © 1999 John Wiley & Sons, Ltd.     

Reducing therapist contact in cognitive behaviour therapy for panic disorder and agoraphobia in primary care: global measures of outcome in a randomised controlled trial.

BACKGROUND: Panic disorder, with and without agoraphobia, is a prevalent condition presenting in general practice. Psychological treatments are effective but are limited by restricted availability. Interest has grown in methods by which the efficiency and thus availability of psychological treatments can be improved, with particular emphasis on reduced therapist contact formats. AIM: To evaluate the relative efficacy in a primary care setting of a cognitive behaviour therapy (CBT) delivered at three levels of therapist contact: standard contact, minimum contact, and bibliotherapy. METHOD: A total of 104 patients were randomly allocated to receive standard therapist contact, minimum therapist contact or bibliotherapy, with 91 patients completing treatment. All patients received an identical treatment manual and were seen by the same psychologist therapist. Outcome was reported in terms of brief global ratings of severity of illness, change in symptoms, and levels of social disruption. These brief measures were chosen to be suitable for use in general practice and were used at treatment entry and endpoint. RESULTS: The standard therapist contact group had the strongest and most comprehensive treatment response, showing significant differences from the bibliotherapy group on all, and the minimum therapist contact group on some, endpoint measures. Some reduction in efficacy was therefore found for the reduced therapist contact groups. CONCLUSION: The standard therapist contact group showed the greatest treatment efficacy in the present study. As it was of notably shorter duration than many other current formulations of CBT, it represents a useful and efficient treatment for panic disorder and agoraphobia in primary care.     

Follow-up study of patients with panic disorder and agoraphobia with panic attacks treated with tricyclic antidepressants

One hundred and seven patients with panic disorder or agoraphobia with panic attacks were studied 1-4 years after treatment with a tricyclic antidepressant. At follow-up more than 80% of the patients remained symptomatic but fewer than half were experiencing panic attacks and only 40% were avoiding phobic situations. Although patients with agoraphobia were more severely ill and had been ill longer than those with panic disorder, their response to tricyclics and eventual outcome was similar to that for patients with panic disorder. Panic and agoraphobic patients who had the most severe symptoms initially showed the least improvement. The results suggest that panic disorder and agoraphobia with panic attacks are variants of a single illness and that, despite its chronicity, this illness has a favorable outcome.     

Cognitive-behavioral group treatment for panic disorder with agoraphobia

Cognitive-behavioral therapy (CBT) is well documented in the treatment of panic disorder with or without agoraphobia; however, little is known about the efficacy of group treatment. The purpose of this open study is to investigate the benefits of a combination of the major cognitive and behavioral techniques used in the several specific versions of CBT thus far developed, in a psychotherapeutic group approach for panic and agoraphobia. Seventy-six outpatients meeting the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R; American Psychiatric Association, 1987) criteria for panic disorder with or without agoraphobia were included in the study. The treatment consisted of 14 weekly 2-hr group sessions and included: (a) an educational component, (b) interoceptive exposure, (c) cognitive restructuring, (d) problem solving, and (e) in vivo exposure. Patients achieved significant treatment gains on all dimensions assessed with a high rate of panic remission and significant improvement in the associated symptoms. Furthermore, these gains were maintained at 6-months' follow-up. Our results suggest the feasibility of this combination of cognitive and behavioral techniques. The findings raise questions about the specificity and the impact of each technique.     

Manual‐guided cognitive–behavioural therapy for insomnia delivered by ordinary primary care personnel in general medical practice: a randomized controlled effectiveness trial

Chronic insomnia is a prevalent problem in primary health care and tends to be more serious than insomnia in the general population. These patients often obtain little benefit from hypnotics, and are frequently open to exploring various options for medical treatment. However, most general practitioners (GPs) are unable to provide such options. Several meta‐analyses have shown that cognitive–behavioural therapy (CBT) for insomnia results in solid improvements on sleep parameters, and a few studies have demonstrated promising results for nurse‐administered CBT in primary care. The aim of this randomized controlled study was to investigate the clinical effectiveness of manual‐guided CBT for insomnia delivered by ordinary primary care personnel in general medical practice with unselected patients. Sixty‐six primary care patients with insomnia were randomized to CBT or a waiting‐list control group. The CBT group improved significantly more than the control group using the Insomnia Severity Index as the outcome. The effect size was high. Sleep diaries showed a significant, medium‐sized treatment effect for sleep onset latency and wake time after sleep onset. However, for all measures there is a marked deterioration at follow‐up assessments. Almost half of the treated subjects (47%) reported a clinically relevant treatment effect directly after treatment. It is concluded that this way of delivering treatment may be cost‐effective.     

A meta-analysis of the influence of comorbidity on treatment outcome in the anxiety disorders

Although psychiatric comorbidity is common among patients with anxiety disorders, its impact on treatment outcome remains unclear. The present study used meta-analytic techniques to examine the relationship between diagnostic comorbidity and treatment outcome for patients with anxiety disorders. One hundred forty-eight anxiety-disordered treatment samples (combined N = 3534) were examined for post-treatment effects from the PsychINFO database. Samples consisted of those exposed to both active (CBT, dynamic therapy, drug treatment, CBT + drug treatment, mindfulness) and inactive treatments (placebo/attention control, wait-list). All treatments were associated with significant improvement at post-treatment, and active treatments were associated with greater effects than were inactive treatments. However, overall comorbidity was generally unrelated to effect size at post-treatment or at follow-up. A significant negative relationship between overall comorbidity and treatment outcome was found for mixed or “neurotic” anxiety samples when examining associations between comorbidity and specific diagnoses. Conversely, there was a significant positive relationship between overall comorbidity and treatment outcome for panic disorder and/or agoraphobia and PTSD or sexual abuse survivors. These findings suggest that while diagnostic comorbidity may not impact the effects of specific anxiety disorder treatments, it appears to differentially impact outcome for specific anxiety disorder diagnoses.     

Cognitive behavior therapy in panic disorder and comorbid major depression. A naturalistic study

BACKGROUND: There is a lack of evidence about the effectiveness of cognitive behavior therapies (CBT) in settings of routine clinical care as well as in the treatment of panic and comorbid disorders. METHODS: We investigated a group-oriented CBT approach for 80 patients with panic disorder including 35 patients with current comorbid major depression. Assessments took place 6 months before treatment, at the beginning and end of treatment, and 1 year later. Structured interviews and multiple clinical self-rating scales were used. RESULTS: Panic patients with comorbid major depression showed higher anxiety-specific and nonspecific pathology. The most striking benefits were in reducing avoidance behavior, while improvements concerning catastrophic beliefs were smaller, but still significant. For most self-rating scale results, patients with and without comorbid depression improved to a comparable degree. However, the end-state functioning of patients with panic disorder and current comorbid depression at admission is significantly lower than for patients with panic disorder alone. CONCLUSIONS: The results point to the necessity to develop and improve treatment approaches for patients with comorbidity of panic disorder and current major depression.     

Rate of improvement during and across three treatments for panic disorder with or without agoraphobia: Cognitive behavioral therapy,selective serotonin reuptake inhibitor or both combined

Background

Existing literature on panic disorder (PD) yields no data regarding the differential rates of improvement during Cognitive Behavioral Therapy (CBT), Selective Serotonin Reuptake Inhibitor (SSRI) or both combined (CBT+SSRI).

Method

Patients were randomized to CBT, SSRI or CBT+SSRI which each lasted one year including three months of medication taper. Participating patients kept record of the frequency of panic attacks throughout the full year of treatment. Rate of improvement on panic frequency and the relationship between rate of improvement and baseline agoraphobia (AG) were examined.

Results

A significant decline in frequency of panic attacks was observed for each treatment modality. SSRI and CBT+SSRI were associated with a significant faster rate of improvement as compared to CBT. Gains were maintained after tapering medication. For patients with moderate or severe AG, CBT+SSRI was associated with a more rapid improvement on panic frequency as compared to patients receiving either mono-treatment.

Limitations

Frequency of panic attacks was not assessed beyond the full year of treatment. Second, only one process variable was used.

Conclusions

Patients with PD respond well to each treatment as indicated by a significant decline in panic attacks. CBT is associated with a slower rate of improvement as compared to SSRI and CBT+SSRI. Discontinuation of SSRI treatment does not result in a revival of frequency of panic attacks. Our data suggest that for patients without or with only mild AG, SSRI-only will suffice. For patients with moderate or severe AG, the combined CBT+SSRI treatment is recommended.     

Sex differences in clinical presentation and response in panic disorder: pooled data from sertraline treatment studies

Summary Objective. Gender differences in clinical presentation and response to sertraline treatment were examined for patients diagnosed with DSM-III-R panic disorder with or without agoraphobia. Method. Data was pooled from 4 double-blind, placebo-controlled outpatient studies (males, N = 335; females, N = 338). Two were 12-week fixed-dose studies (sertraline 50 mg vs. 100 mg vs. 200 mg) and 2 were 10-week flexible-dose studies (sertraline 50–200 mg). Primary outcome measures consisted of the Clinical Global Impression-Improvement scale (CGI-I) and change in panic attack frequency. Results. The clinical presentation of panic disorder was similar except that men reported an earlier age of onset, shorter duration of illness, and significantly more frequent history of alcohol and/or substance dependence/abuse. Sertraline was significantly more effective than placebo in both women and men on the 2 primary outcome measures. When between-sex efficacy was compared, women achieved significantly greater improvement than men on panic frequency and CGI-I, but had equivalent improvement on all other measures. There was no significant between-sex difference in study completion rates, or in adverse event profiles. Conclusions. There was a modest but consistent trend for women to show superior efficacy at the end of acute sertraline treatment. This gender effect only occasionally achieved significance, and must be confirmed by future treatment research.     

Preliminary evidence for cognitive mediation during cognitive-behavioral therapy of panic disorder

Cognitive-behavioral therapy (CBT) and pharmacotherapy are similarly effective for treating panic disorder with mild or no agoraphobia, but little is known about the mechanism through which these treatments work. The present study examined some of the criteria for cognitive mediation of treatment change in CBT alone, imipramine alone, CBT plus imipramine, and CBT plus placebo. Ninety-one individuals who received 1 of these interventions were assessed before and after acute treatment, and after a 6-month maintenance period. Multilevel moderated mediation analyses provided preliminary support for the notion that changes in panic-related cognitions mediate changes in panic severity only in treatments that include CBT.