Panic disorder and agoraphobia: an overview and commentary on DSM-5 changes

The recently published DSM-5 contains a number of changes pertinent to panic disorder and agoraphobia. These changes include separation of panic disorder and agoraphobia into separate diagnoses, the addition of criteria and guidelines for distinguishing agoraphobia from specific phobia, the addition of a 6-month duration requirement for agoraphobia, the addition of panic attacks as a specifier to any DSM-5 diagnosis, changes to descriptors of panic attack types, as well as various changes to the descriptive text. It is crucial that clinicians and researchers working with individuals presenting with panic attacks and panic-like symptoms understand these changes. The purpose of the current paper is to provide a summary of the main changes, to critique the changes in the context of available empirical evidence, and to highlight clinical implications and potential impact on mental health service utilization. Several of the changes have the potential to improve access to evidence-based treatment; yet, although certain changes appear justified in that they were based on converging evidence from different empirical sources, other changes appear questionable, at least based on the information presented in the DSM-5 text and related publications. Ongoing research of DSM-5 panic disorder and agoraphobia as well as application of the new diagnostic criteria in clinical contexts is needed to further inform the strengths and limitations of DSM-5 conceptualizations of panic disorder and agoraphobia.

Cognitive-behavioral therapy for hypochondriasis/health anxiety: a meta-analysis of treatment outcome and moderators

The present investigation employed meta-analysis to examine the efficacy of cognitive-behavioral therapy (CBT) for hypochondriasis/health anxiety as well as potential moderators that may be associated with outcome. A literature search revealed 15 comparisons among 13 randomized-controlled trials (RCTs) with a total sample size of 1081 participants that met inclusion criteria. Results indicated that CBT outperformed control conditions on primary outcome measures at post-treatment (Hedges's g = 0.95) and at follow-up (Hedges's g = 0.34). CBT also outperformed control conditions on measures of depression at post-treatment (Hedges's g = 0.64) and at follow-up (Hedges's g = 0.35). Moderator analyses revealed that higher pre-treatment severity of hypochondriasis/health anxiety was associated with greater effect sizes at follow-up visits and depression symptom severity was significantly associated with a lower in effect sizes at post-treatment. Although effect size did not vary as a function of blind assessment, smaller effect sizes were observed for CBT vs. treatment as usual control conditions than for CBT vs. waitlist control. A dose response relationship was also observed, such that a greater number of CBT sessions was associated with larger effect sizes at post-treatment. This review indicates that CBT is efficacious in the treatment of hypochondriasis/health anxiety and identifies potential moderators that are associated with outcome. The implications of these findings for further delineating prognostic and prescriptive indicators of CBT for hypochondriasis/health anxiety are discussed.

Behavioral therapies for treatment-seeking cannabis users: a meta-analysis of randomized controlled trials

Narrative reviews conclude that behavioral therapies (BTs) produce better outcomes than control conditions for cannabis use disorders (CUDs). However, the strength and consistency of this effect has not been directly empirically examined. The present meta-analysis combined multiple well-controlled studies to help clarify the overall impact of behavioral interventions in the treatment of CUDs. A comprehensive literature search produced 10 randomized controlled trials (RCTs; n = 2,027) that were included in the final analyses. Analyses indicated an effect of BTs (including contingency management, relapse prevention, and motivational interviewing, and combinations of these strategies with cognitive behavioral therapy) over control conditions (including waitlist [WL], psychological placebo, and treatment as usual) across pooled outcomes and time points (Hedges' g = 0.44). These results suggest that the average patient receiving a behavioral intervention fared better than 66% of those in the control conditions. BT also outperformed control conditions when examining primary outcomes alone (frequency and severity of use) and secondary outcomes alone (psychosocial functioning). Effect sizes were not moderated by inclusion of a diagnosis (RCTs including treatment-seeking cannabis users who were not assessed for abuse or dependence vs. RCTs including individuals diagnosed as dependent), dose (number of treatment sessions), treatment format (either group vs. individual treatment or in-person vs. non-in-person treatment), sample size, or publication year. Effect sizes were significantly larger for studies that included a WL control comparison versus those including active control comparisons, such that BT significantly outperformed WL controls but not active control comparisons.

Predictors of PTSD symptoms in adults admitted to a Level I trauma center: a prospective analysis

Trauma centers are an ideal point of intervention in efforts to prevent posttraumatic stress disorder (PTSD). In order to assist in the development of prevention efforts, this study sought to identify early predictors of PTSD symptoms among adults admitted to a Level I trauma center using a novel analytic strategy (Fournier et al., 2009). Upon admission, participants (N=327) were screened for PTSD symptoms and provided information on potential predictor variables. Their PTSD symptoms were assessed again 3 months later (N=227). Participants were classified as symptomatic (positive PTSD screen) or asymptomatic (negative PTSD screen) at the follow-up assessment. Multinomial logistic regression showed that age, depression, number of premorbid psychiatric disorders, gunshot wound, auto vs. pedestrian injury, and alcohol use predicted who had PTSD symptoms at FU with 76.3% accuracy. However, when controlling for PTSD severity at baseline, only age, number of premorbid psychiatric disorders, and gunshot wounds predicted PTSD symptoms at FU but with 78.5% accuracy. These findings suggest that psychological prevention efforts in trauma centers may be best directed toward adults who are young, have premorbid psychiatric disorders, and those admitted with gunshot wounds.

Prescriptive variables for d-cycloserine augmentation of exposure therapy for posttraumatic stress disorder

In recent years, several studies have demonstrated efficacy of d-cycloserine (DCS) enhanced exposure therapy across anxiety disorders. In this study we examined person-level variables that predicted response to DCS enhanced exposure therapy in a chronic, mixed trauma PTSD sample. The sample consisted of 67 treatment-seeking individuals, randomly allocated to receive exposure therapy augmented with DCS (50 mg) or identical looking placebo. We examined the following baseline predictors of treatment response: (1) demographic characteristics (age, gender, marital status, and education); (2) clinical characteristics (initial PTSD symptom severity, Axis I comorbidity, depression symptom severity, and antidepressants use); (3) personality characteristics (openness, conscientiousness, extraversion, agreeableness, and neuroticism). Outcome was measured with the PTSD Symptom Scale, Self-Report, which was assessed weekly during treatment. Two prescriptive variables were identified: conscientiousness and extraversion. For high conscientious participants, those who received DCS showed better outcome than those who received placebo. And for low extraversion, DCS showed superior outcome relative to placebo. Education was identified as a prognostic variable, it predicted response across both groups: higher education was related to worse outcome. Our results provide support for the influence of personality traits on DCS augmented exposure outcome and give more insight into possible working mechanisms of this novel treatment strategy. Ultimately, this may contribute to treatment matching strategies in order to improve treatment efficacy of exposure therapy for PTSD.

Development of a brief version of the Social Phobia Inventory using item response theory: the Mini-SPIN-R

The Social Phobia Inventory (SPIN) is a widely used measure in mental health settings and a 3-item version (mini-SPIN) has been developed as a screening instrument for social anxiety disorder. In the present study, we examined the psychometric properties of the SPIN and developed a brief version (mini-SPIN-R) designed to assess social anxiety severity using item response theory. Our sample included 569 individuals with social anxiety disorder who participated in 2 clinical trials and filled out a battery of self-report measures. Using a nonparametric kernel smoothing method we identified the most sensitive items of the SPIN. These 3 items comprised the mini-SPIN-R, which was found to have greater internal consistency, and to capture a greater range of symptoms compared to the mini-SPIN. The mini-SPIN-R evidenced superior convergent validity compared to the mini-SPIN and both measures had similar divergent validity. Thus, the mini-SPIN-R is a promising brief measure of social anxiety severity.

Sleep quality predicts treatment outcome in CBT for social anxiety disorder

BACKGROUND

Sleep quality may be an important, yet relatively neglected, predictor of treatment outcome in cognitive-behavioral therapy (CBT) for anxiety disorders. Specifically, poor sleep quality may impair memory consolidation of in-session extinction learning. We therefore examined sleep quality as a predictor of treatment outcome in CBT for social anxiety disorder and the impact of d-cycloserine (DCS) on this relationship.

METHODS

One hundred sixty-nine participants with a primary diagnosis of DSM-IV generalized social anxiety disorder were recruited across three sites. Participants were enrolled in 12 weeks of group CBT. Participants randomly received 50 mg of DCS (n = 87) or pill placebo (n = 82) 1 hr prior to sessions 3-7. Participants completed a baseline measure of self-reported sleep quality and daily diaries recording subjective feelings of being rested upon wakening. Outcome measures including social anxiety symptoms and global severity scores were assessed at each session.

RESULTS

Poorer baseline sleep quality was associated with slower improvement and higher posttreatment social anxiety symptom and severity scores. Moreover, patients who felt more "rested" after sleeping the night following a treatment session had lower levels of symptoms and global severity at the next session, controlling for their symptoms and severity scores the previous session. Neither of these effects were moderated by DCS condition.

CONCLUSIONS

Our findings suggest that poor sleep quality diminishes the effects of CBT for social anxiety disorder and this relation is not attenuated by DCS administration. Therapeutic attention to sleep quality prior to initiation of CBT and during the acute treatment phase may be clinically indicated.

D-cycloserine enhancement of exposure therapy for social anxiety disorder depends on the success of exposure sessions

OBJECTIVE

The evidence for the efficacy of D-cycloserine (DCS) for augmenting cognitive behavioral therapy (CBT) for anxiety disorders has been mixed. Guided by preclinical research and initial findings from a small-scale study involving humans, we tested the hypothesis that DCS enhancement of exposure therapy would be specific to successful exposure sessions.

METHOD

Medication-free adults with generalized social anxiety disorder (N = 145) received 50 mg of DCS or placebo 1 h before each of 5 exposure sessions that were part of a standardized 12-session group CBT protocol. Participants provided fear ratings at the beginning and just before the end of exposure exercises. Independent raters, blind to group assignment, administered the clinical global impression improvement and severity scales at each session and at posttreatment.

RESULTS

Mixed-effects analyses revealed that, among patients who reported low fear at the end of an exposure session, those who had received DCS evidenced significantly greater clinical improvement at the next session, relative to those who had received placebo. In contrast, when exposure end fear was high, patients receiving DCS exhibited less clinical improvement at the following session than patients receiving placebo. Similarly, patients who had received DCS evidenced lower clinical severity at posttreatment, relative to patients who had received placebo, only when their average end fear for medication-augmented sessions had been in the low to moderate range. Finally, these moderating effects of exposure success as indexed by end fear were not better accounted for by within-session extinction.

CONCLUSIONS

The efficacy of DCS for augmenting exposure-based CBT depends on the success of exposure sessions. These findings may help guide the development of an algorithm for the effective use of DCS for augmenting exposure-based CBT.

TRIAL REGISTRY

http://www.ClinicalTrials.gov, ID# NCT00633984, http://www.clinicaltrials.gov/ct2/show/NCT00633984.

Associations Between Fear of Negative Evaluation and Eating Pathology During Intervention and 12-Month Follow-up

Fear of negative evaluation, a core feature of social anxiety disorder, has been prospectively related to eating pathology over and above other established risk factors, suggesting that it may be an important cognitive risk factor for eating disorders. The present study examined reciprocal longitudinal relations among fear of negative evaluation and eating disorder risk factors using a female undergraduate sample (N=82) enrolled in an eating disorder prevention program. Cross-lagged panel analysis revealed that fear of negative evaluation was a determinant of subsequent body dissatisfaction and eating disorder symptoms. Fear of negative evaluation also predicted subsequent thin-ideal internalization among participants with high BMI, but not among those with low BMI. Fear of negative evaluation did not predict future dietary restraint or negative affect but was itself predicted by prior levels of thin ideal internalization, body dissatisfaction, dietary restraint, and negative affect. Findings suggest that fear of negative evaluation may be a useful target for reducing body image concerns and maladaptive eating behavior.

D-cycloserine augmentation of cognitive behavioral group therapy of social anxiety disorder: prognostic and prescriptive variables

OBJECTIVE

The aim of the current study was to identify individual characteristics that (a) predict symptom improvement with group cognitive behavioral therapy (CBT) for social anxiety disorder (SAD; i.e., prognostic variables) or (b) moderate the effects of d-cycloserine (DCS) versus placebo augmentation of CBT for SAD (i.e., prescriptive variables).

METHOD

Adults with SAD (N = 169) provided Liebowitz Social Anxiety Scale scores in a trial evaluating DCS augmentation of group CBT. Rate of symptom improvement during therapy and posttreatment symptom severity were evaluated using multilevel modeling. As predictors of these 2 parameters, we selected the range of variables assessed at baseline (demographic characteristics, clinical characteristics, personality traits). Using step-wise analyses, we first identified prognostic and prescriptive variables within each of these domains and then entered these significant predictors simultaneously in 1 final model.

RESULTS

African American ethnicity and cohabitation status were associated with greater overall rates of improvement during therapy and lower posttreatment severity. Higher initial severity was associated with a greater improvement during therapy but also higher posttreatment severity (the greater improvement was not enough to overcome the initial higher severity). DCS augmentation was evident only among individuals low in conscientiousness and high in agreeableness.

CONCLUSIONS

African American ethnicity, cohabitation status, and initial severity are prognostic of favorable CBT outcomes in SAD. DCS augmentation appears particularly useful for patients low in conscientiousness and high in agreeableness. These findings can guide clinicians in making decisions about treatment strategies and can help direct research on the mechanisms of these treatments.

Enhancing exposure therapy for PTSD with yohimbine HCL: protocol for a double-blind, randomized controlled study implementing subjective and objective measures of treatment outcome

Prolonged exposure (PE) therapy is considered a gold standard protocol for the treatment of PTSD, and it is associated with large treatment effect sizes in combat veteran samples. However, considering high rates of PTSD in the present veteran population, ongoing research work is important toward improving treatment efficiency by decreasing time to symptom amelioration and increasing the amount of symptom amelioration. The proposed research aims to enhance exposure therapy outcomes for veterans with PTSD via combination treatment with PE and yohimbine hydrochloride (HCL), an alpha-2 adrenergic receptor antagonist. The proposed investigation entails a randomized, placebo-controlled trial investigating the effect of a single administration of yohimbine HCL (paired with the first session of imaginal exposure) on outcome of PE in 40 veterans with PTSD. An additional goal is to establish a pragmatic method of tracking psychophysiological measures over the course of therapy for incorporation into future clinical psychotherapy trials. Thus, in addition to traditional self- and clinician-reported psychological outcomes, heart rate and skin conductance reactivity will be measured during a standard trauma-specific imagery task before, during, and after PE treatment. We will further investigate whether changes in psychophysiological measures predict changes in patient- and clinician-reported outcome measures.

D-Cycloserine as an augmentation strategy with cognitive-behavioral therapy for social anxiety disorder

OBJECTIVE

The authors examined whether D-cycloserine, a partial agonist at the glutamatergic N-methyl-d-aspartate receptor, augments and accelerates a full course of comprehensive cognitive-behavioral therapy (CBT) in adults with generalized social anxiety disorder.

METHOD

This was a multisite randomized placebo-controlled efficacy study with 169 medication-free adults with generalized social anxiety disorder, of whom 144 completed the 12-week treatment and 131 completed the three follow-up assessments. Patients were randomly assigned to receive 50 mg of D-cycloserine or placebo 1 hour before each of five exposure sessions that were part of a 12-session cognitive-behavioral group treatment. Response and remission status was determined at baseline, throughout treatment, at end of treatment, and at 1-, 3-, and 6-month follow-up assessments by assessors who were blind to treatment condition.

RESULTS

D-Cycloserine-augmented and placebo-augmented CBT were associated with similar completion rates (87% and 82%), response rates (79.3% and 73.3%), and remission rates (34.5% and 24.4%) at the posttreatment assessment; response and remission rates were largely maintained at the follow-up assessments. Although D-cycloserine was associated with a 24%-33% faster rate of improvement in symptom severity and remission rates relative to placebo during the treatment phase, the groups did not differ in response and remission rates.

CONCLUSIONS

D-Cycloserine did not augment a full course of comprehensive CBT for social anxiety disorder.

D-cycloserine enhancement of fear extinction is specific to successful exposure sessions: evidence from the treatment of height phobia

BACKGROUND

Whereas some studies have shown clear evidence for an augmentation effect of D-cycloserine (DCS) on exposure therapy for anxiety disorders, other studies have shown weak effects or no effect at all. Some preclinical data suggest that the DCS augmentation effect is moderated by the success of extinction learning. Therefore, we conducted a reanalysis of existing data to examine whether the effects of DCS on clinical outcome would vary as a function of response to the exposure session (i.e., exposure success).

METHODS

In a clinical trial, patients with height phobia received two sessions involving 30 minutes of virtual reality exposure therapy and were randomly assigned to a pill placebo (n = 14) or 50 mg of DCS (n = 15) immediately after each session.

RESULTS

Mixed-effects regression analysis showed that the effects of DCS administration on clinical improvement was moderated by the level of fear experienced just before concluding exposure sessions. Patients receiving DCS exhibited significantly greater improvement in symptoms relative to patients who received placebo when fear was low at the end of the exposure. In contrast, when end fear was still elevated, patients receiving DCS improved less compared with those receiving placebo.

CONCLUSIONS

D-cycloserine appears to enhance the benefits of exposure treatment when applied after a successful session, but it seems to have detrimental effects when administered after inadequate/unsuccessful exposure sessions.

Smoking Status and Exercise in relation to PTSD Symptoms: A Test among Trauma-Exposed Adults

The present investigation examined the interactive effect of cigarette smoking status (i.e., regular smoking versus non-smoking) and weekly exercise (i.e., weekly metabolic equivalent) in terms of posttraumatic stress (PTSD) symptom severity among a community sample of trauma-exposed adults. Participants included 86 trauma-exposed adults (58.1% female; Mage = 24.3). Approximately 59.7% of participants reported regular (≥ 10 cigarettes per day) daily smoking over the past year. The interactive effect of smoking status by weekly exercise was significantly associated with hyperarousal and avoidance symptom cluster severity (p ≤ .05). These effects were evident above and beyond number of trauma types and gender, as well as the respective main effects of smoking status and weekly exercise. Follow-up tests indicated support for the moderating role of exercise on the association between smoking and PTSD symptoms, such that the highest levels of PTSD symptoms were observed among regular smokers reporting low weekly exercise levels. Theoretical and clinical implications of the findings are discussed.

Let's get physical: a contemporary review of the anxiolytic effects of exercise for anxiety and its disorders

Research over the past few decades has focused on the therapeutic effects of physical exercise among those affected by mood disorders. Only recently has attention turned to maladaptive and persistent expressions of anxiety, with a growing body of evidence indicating promise for exercise as an effective treatment for some of the anxiety disorders. The current review provides a comprehensive account of contemporary research examining the anxiolytic effects of exercise for anxiety disorders. We synthesize pertinent research regarding the effects of various types of exercise within the different anxiety disorders, consider impact of various types of exercise regimens on anxiety, and examine potential anxiolytic mechanisms responsible for positive mental health gains. We conclude with important considerations for implementing exercise as a treatment for clinically significant anxiety as well as future research directions.

Augmentation of exposure therapy with post-session administration of D-cycloserine

BACKGROUND

Pre-session administration of d-cycloserine (DCS) has been found to augment exposure therapy outcomes in a variety of anxiety disorders. To be able to enhance learning only for successful exposure sessions, it would be beneficial to have the option of administering DCS after rather than before the session, a strategy encouraged by pre-clinical work. We believe the present study is the first published report on the efficacy of post-session administration of DCS in humans.

METHOD

Adults (N = 29) with a DSM-IV diagnosis of acrophobia were randomized to receive two sessions of virtual reality exposure therapy (VRE) in combination with placebo or 50 mg of DCS. Instead of administering the pill prior to each of the sessions, as has been done in extant work, we administered the pill immediately following each session. Measures of acrophobia severity were collected at baseline, at each treatment session, 1-week post-treatment, and at 1-month follow-up.

RESULTS

Mixed-effects repeated-measures ANOVAs and GLMMs revealed significant improvement in all outcome measures over time, but no between-group differences were observed. At post-treatment, 63.5% of patients in the placebo condition vs. 60.0% of those in the DCS condition were in remission. At 1-month follow up, 63.4% of those in the placebo condition vs. 66.6% of those in the DCS condition were in remission.

CONCLUSIONS

These findings do not support the application of post-session DCS administration for augmenting the efficacy of exposure-based treatments. Possible reasons for these findings are discussed.

TRIAL REGISTRY

The Trial is registered at ClinicalTrials.gov (NCT01102803).

The effect of exercise training modality on serum brain derived neurotrophic factor levels in individuals with type 2 diabetes

Introduction

Brain derived neurotrophic factor (BDNF) has been implicated in memory, learning, and neurodegenerative diseases. However, the relationship of BDNF with cardiometabolic risk factors is unclear, and the effect of exercise training on BDNF has not been previously explored in individuals with type 2 diabetes.

Methods

Men and women (N = 150) with type 2 diabetes were randomized to an aerobic exercise (aerobic), resistance exercise (resistance), or a combination of both (combination) for 9 months. Serum BDNF levels were evaluated at baseline and follow-up from archived blood samples.

Results

Baseline serum BDNF was not associated with fitness, body composition, anthropometry, glucose control, or strength measures (all, p>0.05). Similarly, no significant change in serum BDNF levels was observed following exercise training in the aerobic (−1649.4 pg/ml, CI: −4768.9 to 1470.2), resistance (−2351.2 pg/ml, CI:−5290.7 to 588.3), or combination groups (−827.4 pg/ml, CI: −3533.3 to1878.5) compared to the control group (−2320.0 pg/ml, CI: −5750.8 to 1110.8). However, reductions in waist circumference were directly associated with changes in serum BDNF following training (r = 0.25, p = 0.005).

Conclusions

Serum BDNF was not associated with fitness, body composition, anthropometry, glucose control, or strength measures at baseline. Likewise, serum BDNF measures were not altered by 9 months of aerobic, resistance, or combination training. However, reductions in waist circumference were associated with decreased serum BDNF levels. Future studies should investigate the relevance of BDNF with measures of cognitive function specifically in individuals with type-2 diabetes.

Threat reappraisal as a mediator of symptom change in cognitive-behavioral treatment of anxiety disorders: a systematic review

OBJECTIVE

Identifying mediators of therapeutic change is important to the development of interventions and augmentation strategies. Threat reappraisal is considered a key mediator underlying the effects of cognitive-behavioral therapy (CBT) for anxiety disorders. The present study systematically reviewed the evidence for the threat reappraisal mediation hypothesis.

METHOD

In our review, we included studies that (a) investigated the threat reappraisal mediation hypothesis; (b) included adults with an anxiety disorder diagnosis; (c) used a longitudinal design; and (d) did not report on previously published findings (to avoid the inclusion of multiple reports of the same data). After data extraction, we made review-specific quality judgments for each study using the following a priori criteria informed by mediation theory: (a) demonstrated statistical mediation; (b) demonstrated that CBT caused threat reappraisal; (c) demonstrated that threat reappraisal caused anxiety reduction; and (d) demonstrated specificity of the threat reappraisal-anxiety reduction relation.

RESULTS

Of the 2,296 studies we identified, 25 met inclusion criteria. Of these studies, 56% tested and 52% established statistical mediation, 52% tested and 28% established CBT as a cause of threat reappraisal, 28% tested and 24% established threat reappraisal as a cause of anxiety reduction, and 44% tested and 36% established specificity of the threat reappraisal-anxiety reduction relation.

CONCLUSIONS

While threat reappraisal is related to anxiety symptom improvement with CBT, there are few extant studies that meet most of the criteria necessary to conclusively demonstrate that it causes symptom improvement in CBT and that it is not a proxy for other third variables. Recommendations for future research in this area are discussed.

Physical activity as a moderator of the association between anxiety sensitivity and binge eating

Individuals with elevated anxiety sensitivity (AS; i.e., fear of somatic arousal) may binge eat to reduce emotional distress. Because physical activity reduces stress reactivity, we predicted that: (1) the relation between AS and binge eating would be moderated by physical activity and (2) coping motives for eating would mediate the association between AS and binge eating such that the relation would be stronger for those low in physical activity. Participants (N=167) completed online self-report measures. Regression analyses revealed that moderate-intensity physical activity (MPA) moderated the relation between AS and binge eating such that AS was not related to binge eating among those who frequently engaged in MPA but was related to binge eating among those who did not report engaging in MPA. Vigorous-intensity physical activity (VPA) moderated in the opposite direction such that the relation between AS and binge eating was significant among persons reporting high levels of VPA but less strong among persons reporting low levels of VPA. The mediation model was also significant, but was not moderated by MPA or VPA. Theoretical and clinical implications are discussed.

Five sessions and counting: considering ultra-brief treatment for panic disorder

BACKGROUND

Brief cognitive-behavioral therapy for panic disorder has the potential to lower health care costs and enhance dissemination of evidence-based interventions to clinical practice. This manuscript evaluates the utility of brief cognitive-behavioral therapy for panic disorder.

METHODS

A narrative review of studies examining the efficacy of cognitive-behavioral brief treatment of panic disorder, with a specific focus on an ultra-brief, 5-session, intervention developed by our group.

RESULTS

Brief cognitive-behavioral therapy for panic disorder is associated with clinically meaningful symptom improvement reflecting large effect sizes, comparable to those observed for standard protocols.

CONCLUSIONS

Growing evidence encourages the further evaluation and application brief cognitive-behavioral therapy for panic disorder. Controlled trials of cognitive-behavioral therapy have established the dramatic benefit that can be offered by brief treatment (often 12-15 sessions) approaches for Axis I disorders. Yet, as the field advances and core mechanisms of change are identified, there is the potential for offering efficacy in even briefer treatment protocols. In this manuscript, we describe the elements and initial efficacy estimates, based on published studies, for an ultra-brief treatment approach for panic disorder. We also discuss the potential impact, and such brief treatment can have relative to dissemination issues and the desire for the timely end to psychological suffering.

Evaluation of the glycine transporter inhibitor Org 25935 as augmentation to cognitive-behavioral therapy for panic disorder: a multicenter, randomized, double-blind, placebo-controlled trial

OBJECTIVE

A growing body of evidence supports the efficacy of D-cycloserine (DCS), a partial agonist at the N-methyl-D-aspartate (NMDA) glutamate receptor, as augmentation to cognitive-behavioral therapy (CBT) in the treatment of anxiety disorders. Org 25935 is a glycine transporter 1 inhibitor that acts to increase synaptic glycine levels and enhance NMDA-mediated glutamatergic activity. The aim of this study was to examine the efficacy of a glutamatergic compound other than DCS in a CBT augmentation paradigm.

METHOD

This was a randomized, double-blind, placebo-controlled, parallel-group clinical trial for which participants were recruited from November 2008 through February 2010. Eligible adult patients diagnosed (DSM-IV) with panic disorder with or without agoraphobia (N = 40) were scheduled to receive 5 manualized CBT treatment sessions. Participants were randomly assigned to receive either a dose of Org 25935 (4 mg or 12 mg) or placebo 2 hours prior to the start of CBT sessions 3, 4, and 5. The primary endpoint was symptomatic change as measured by the Panic Disorder Severity Scale (PDSS) 1 week following the last CBT session.

RESULTS

Although mean PDSS total scores decreased significantly from baseline to end of treatment in every group, no statistically significant benefit was observed for Org 25935 (4 or 12 mg) over placebo on the primary endpoint or on any secondary efficacy endpoint. Org 25935 showed no safety issues at either dose but was much better tolerated at the 4-mg dose level than at the 12-mg dose level.

CONCLUSIONS

Org 25935 demonstrated no benefit over placebo in augmenting CBT for panic disorder. Study limitations and implications are discussed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00725725.

Panic attack history and anxiety sensitivity in relation to cognitive-based smoking processes among treatment-seeking daily smokers

INTRODUCTION

Empirical research has found that panic attacks are related to increased risk of more severe nicotine withdrawal and poor cessation outcome. Anxiety sensitivity (AS; fear of anxiety and related sensations) has similarly been found to be related to an increased risk of acute nicotine withdrawal and poorer cessation outcome. However, research has yet to examine the relative contributions of panic attacks and AS in terms of cognitive-based smoking processes (e.g., negative reinforcement smoking expectancies, addictive and negative affect-based reduction smoking motives, barriers to cessation, problem symptoms experienced while quitting).

METHOD

Participants (n = 242; 57.4% male; M (age) = 38.1) were daily smokers recruited as a part of a larger randomized control trial for smoking cessation. It was hypothesized that both panic attacks and AS would uniquely and independently predict the studied cognitive-based smoking processes.

RESULTS

As hypothesized, AS was uniquely and positively associated with all smoking processes after controlling for average number of cigarettes smoked per day, current Axis I diagnosis, and participant sex. However, panic attack history was only significantly related to problem symptoms experienced while quitting smoking.

CONCLUSIONS

Although past research has demonstrated significant associations between panic attacks and certain aspects of cigarette smoking (e.g., severity of nicotine withdrawal; lower abstinence rates, and negative affect reduction motives), the present findings suggest that AS may be more relevant to understanding beliefs about and motives for smoking behavior as well as perceptions of cessation-related difficulties.