Breathing retraining, exposure and a combination of both, in the treatment of panic disorder with agoraphobia

The Importance of Including Psychophysiological Methods in Psychotherapy

This paper describes characteristics of sophisticated use of psychophysiological therapy procedures and describes a scoping review of evidence that adding psychophysiological procedures to psychotherapy improves outcome. It also reviews literature describing comparisons between psychophysiological procedures and various CBT and other verbal psychotherapy procedures when used as monotherapies. Some details of progressive muscle relaxation, autogenic training, and biofeedback are described that often are omitted in standard clinical training, including the method of diminishing tensions and differential relaxation training in progressive muscle relaxation, use of autogenic discharges and hypnotic instructions in autogenic training, and resonance frequency training in heart rate variability biofeedback and slow breathing. Although these details are often also missing in outcome studies, tentative conclusions can still be drawn from the empirical literature. As a monotherapy, psychophysiological methods are generally as powerful as verbal psychotherapies, although combining them with psychotherapy yields a larger effect than either approach alone. Psychophysiological methods have their strongest effects on anxiety and depression, with weaker effects for panic and PTSD, particularly when compared with exposure therapy, although the latter comparisons were restricted to relaxation training as a psychophysiological approach. Effects of psychophysiological interventions are weaker among elementary school children than among adults and adolescents. The results suggest that psychophysiological methods should be used along with other psychotherapeutic interventions for greatest effect.

Breathwork Interventions for Adults with Clinically Diagnosed Anxiety Disorders: A Scoping Review

Anxiety disorders are the most common group of mental disorders, but they are often underrecognized and undertreated in primary care. Dysfunctional breathing is a hallmark of anxiety disorders; however, mainstays of treatments do not tackle breathing in patients suffering anxiety. This scoping review aims to identify the nature and extent of the available research literature on the efficacy of breathwork interventions for adults with clinically diagnosed anxiety disorders using the DSM-5 classification system. Using the PRISMA extension for scoping reviews, a search of PubMed, Embase, and Scopus was conducted using terms related to anxiety disorders and breathwork interventions. Only clinical studies using breathwork (without the combination of other interventions) and performed on adult patients diagnosed with an anxiety disorder using the DSM-5 classification system were included. From 1081 articles identified across three databases, sixteen were included for the review. A range of breathwork interventions yielded significant improvements in anxiety symptoms in patients clinically diagnosed with anxiety disorders. The results around the role of hyperventilation in treatment of anxiety were contradictory in few of the examined studies. This evidence-based review supports the clinical utility of breathwork interventions and discusses effective treatment options and protocols that are feasible and accessible to patients suffering anxiety. Current gaps in knowledge for future research directions have also been identified.

Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials

BACKGROUND

Psychotherapies are the treatment of choice for panic disorder, but which should be considered as first-line treatment is yet to be substantiated by evidence.

AIMS

To examine the most effective and accepted psychotherapy for the acute phase of panic disorder with or without agoraphobia via a network meta-analysis.

METHOD

We conducted a systematic review and network meta-analysis of randomised controlled trials (RCTs) to examine the most effective and accepted psychotherapy for the acute phase of panic disorder. We searched MEDLINE, Embase, PsycInfo and CENTRAL, from inception to 1 Jan 2021 for RCTs. Cochrane and PRISMA guidelines were used. Pairwise and network meta-analyses were conducted using a random-effects model. Confidence in the evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). The protocol was published in a peer-reviewed journal and in PROSPERO (CRD42020206258).

RESULTS

We included 136 RCTs in the systematic review. Taking into consideration efficacy (7352 participants), acceptability (6862 participants) and the CINeMA confidence in evidence appraisal, the best interventions in comparison with treatment as usual (TAU) were cognitive-behavioural therapy (CBT) (for efficacy: standardised mean differences s.m.d. = -0.67, 95% CI -0.95 to -0.39; CINeMA: moderate; for acceptability: relative risk RR = 1.21, 95% CI -0.94 to 1.56; CINeMA: moderate) and short-term psychodynamic therapy (for efficacy: s.m.d. = -0.61, 95% CI -1.15 to -0.07; CINeMA: low; for acceptability: RR = 0.92, 95% CI 0.54-1.54; CINeMA: moderate). After removing RCTs at high risk of bias only CBT remained more efficacious than TAU.

CONCLUSIONS

CBT and short-term psychodynamic therapy are reasonable first-line choices. Studies with high risk of bias tend to inflate the overall efficacy of treatments. Results from this systematic review and network meta-analysis should inform clinicians and guidelines.

Dismantling cognitive-behaviour therapy for panic disorder: a systematic review and component network meta-analysis

Cognitive-behaviour therapy (CBT) for panic disorder may consist of different combinations of several therapeutic components such as relaxation, breathing retraining, cognitive restructuring, interoceptive exposure and/or in vivo exposure. It is therefore important both theoretically and clinically to examine whether specific components of CBT or their combinations are superior to others in the treatment of panic disorder. Component network meta-analysis (NMA) is an extension of standard NMA that can be used to disentangle the treatment effects of different components included in composite interventions. We searched MEDLINE, EMBASE, PsycINFO and Cochrane Central, with supplementary searches of reference lists and clinical trial registries, for all randomized controlled trials comparing different CBT-based psychological therapies for panic disorder with each other or with control interventions. We applied component NMA to disentangle the treatment effects of different components included in these interventions. After reviewing 2526 references, we included 72 studies with 4064 participants. Interoceptive exposure and face-to-face setting were associated with better treatment efficacy and acceptability. Muscle relaxation and virtual-reality exposure were associated with significantly lower efficacy. Components such as breathing retraining and in vivo exposure appeared to improve treatment acceptability while having small effects on efficacy. The comparison of the most v. the least efficacious combination, both of which may be provided as 'evidence-based CBT,' yielded an odds ratio for the remission of 7.69 (95% credible interval: 1.75 to 33.33). Effective CBT packages for panic disorder would include face-to-face and interoceptive exposure components, while excluding muscle relaxation and virtual-reality exposure.

Psychological therapies for panic disorder with or without agoraphobia in adults: a network meta-analysis

BACKGROUND

Panic disorder is characterised by the presence of recurrent unexpected panic attacks, discrete periods of fear or anxiety that have a rapid onset and include symptoms such as racing heart, chest pain, sweating and shaking. Panic disorder is common in the general population, with a lifetime prevalence of 1% to 4%. A previous Cochrane meta-analysis suggested that psychological therapy (either alone or combined with pharmacotherapy) can be chosen as a first-line treatment for panic disorder with or without agoraphobia. However, it is not yet clear whether certain psychological therapies can be considered superior to others. In order to answer this question, in this review we performed a network meta-analysis (NMA), in which we compared eight different forms of psychological therapy and three forms of a control condition.

OBJECTIVES

To assess the comparative efficacy and acceptability of different psychological therapies and different control conditions for panic disorder, with or without agoraphobia, in adults.

SEARCH METHODS

We conducted the main searches in the CCDANCTR electronic databases (studies and references registers), all years to 16 March 2015. We conducted complementary searches in PubMed and trials registries. Supplementary searches included reference lists of included studies, citation indexes, personal communication to the authors of all included studies and grey literature searches in OpenSIGLE. We applied no restrictions on date, language or publication status.

SELECTION CRITERIA

We included all relevant randomised controlled trials (RCTs) focusing on adults with a formal diagnosis of panic disorder with or without agoraphobia. We considered the following psychological therapies: psychoeducation (PE), supportive psychotherapy (SP), physiological therapies (PT), behaviour therapy (BT), cognitive therapy (CT), cognitive behaviour therapy (CBT), third-wave CBT (3W) and psychodynamic therapies (PD). We included both individual and group formats. Therapies had to be administered face-to-face. The comparator interventions considered for this review were: no treatment (NT), wait list (WL) and attention/psychological placebo (APP). For this review we considered four short-term (ST) outcomes (ST-remission, ST-response, ST-dropouts, ST-improvement on a continuous scale) and one long-term (LT) outcome (LT-remission/response).

DATA COLLECTION AND ANALYSIS

As a first step, we conducted a systematic search of all relevant papers according to the inclusion criteria. For each outcome, we then constructed a treatment network in order to clarify the extent to which each type of therapy and each comparison had been investigated in the available literature. Then, for each available comparison, we conducted a random-effects meta-analysis. Subsequently, we performed a network meta-analysis in order to synthesise the available direct evidence with indirect evidence, and to obtain an overall effect size estimate for each possible pair of therapies in the network. Finally, we calculated a probabilistic ranking of the different psychological therapies and control conditions for each outcome.

MAIN RESULTS

We identified 1432 references; after screening, we included 60 studies in the final qualitative analyses. Among these, 54 (including 3021 patients) were also included in the quantitative analyses. With respect to the analyses for the first of our primary outcomes, (short-term remission), the most studied of the included psychological therapies was CBT (32 studies), followed by BT (12 studies), PT (10 studies), CT (three studies), SP (three studies) and PD (two studies).The quality of the evidence for the entire network was found to be low for all outcomes. The quality of the evidence for CBT vs NT, CBT vs SP and CBT vs PD was low to very low, depending on the outcome. The majority of the included studies were at unclear risk of bias with regard to the randomisation process. We found almost half of the included studies to be at high risk of attrition bias and detection bias. We also found selective outcome reporting bias to be present and we strongly suspected publication bias. Finally, we found almost half of the included studies to be at high risk of researcher allegiance bias.Overall the networks appeared to be well connected, but were generally underpowered to detect any important disagreement between direct and indirect evidence. The results showed the superiority of psychological therapies over the WL condition, although this finding was amplified by evident small study effects (SSE). The NMAs for ST-remission, ST-response and ST-improvement on a continuous scale showed well-replicated evidence in favour of CBT, as well as some sparse but relevant evidence in favour of PD and SP, over other therapies. In terms of ST-dropouts, PD and 3W showed better tolerability over other psychological therapies in the short term. In the long term, CBT and PD showed the highest level of remission/response, suggesting that the effects of these two treatments may be more stable with respect to other psychological therapies. However, all the mentioned differences among active treatments must be interpreted while taking into account that in most cases the effect sizes were small and/or results were imprecise.

AUTHORS' CONCLUSIONS

There is no high-quality, unequivocal evidence to support one psychological therapy over the others for the treatment of panic disorder with or without agoraphobia in adults. However, the results show that CBT - the most extensively studied among the included psychological therapies - was often superior to other therapies, although the effect size was small and the level of precision was often insufficient or clinically irrelevant. In the only two studies available that explored PD, this treatment showed promising results, although further research is needed in order to better explore the relative efficacy of PD with respect to CBT. Furthermore, PD appeared to be the best tolerated (in terms of ST-dropouts) among psychological treatments. Unexpectedly, we found some evidence in support of the possible viability of non-specific supportive psychotherapy for the treatment of panic disorder; however, the results concerning SP should be interpreted cautiously because of the sparsity of evidence regarding this treatment and, as in the case of PD, further research is needed to explore this issue. Behaviour therapy did not appear to be a valid alternative to CBT as a first-line treatment for patients with panic disorder with or without agoraphobia.

A randomized clinical trial of transdiagnostic cognitve-behavioral treatments for anxiety disorder by comparison to relaxation training

Transdiagnostic cognitive-behavioral treatments (CBT) for anxiety disorders have been gaining increased attention and empirical study in recent years. Despite this, all of the research on transdiagnostic anxiety treatments to date have either not used a control condition, or have relied on no-treatment or delayed-treatment controls, thus limiting inferences about comparative efficacy. The current study was a randomized clinical trial examining the efficacy of a 12-week transdiagnostic cognitive-behavioral group treatment in comparison to a 12-week comprehensive relaxation training program. Results from 87 treatment initiators suggested significant and statistically equivalent/noninferior outcomes across conditions, although relaxation was associated with a greater rate of dropout despite no differences in treatment credibility. No evidence was found for any differential effects of transdiagnostic CBT for any primary or comorbid diagnoses.

Coping skills and exposure therapy in panic disorder and agoraphobia: latest advances and future directions

Although cognitive-behavioral treatments for panic disorder have demonstrated efficacy, a considerable number of patients terminate treatment prematurely or remain symtpomatic. Cognitive and biobehavioral coping skills are taught to improve exposure therapy outcomes but evidence for an additive effect is largely lacking. Current methodologies used to study the augmenting effects of coping skills test the degree to which the delivery of coping skills enhances outcomes. However, they do not assess the degree to which acquisition of coping skills and their application during exposure therapy augment outcomes. We examine the extant evidence on the role of traditional coping skills in augmenting exposure for panic disorder, discuss the limitations of existing research, and offer recommendations for methodological advances.

Was wirkt in der Kognitiven Verhaltenstherapie der Panikstörung mit Agoraphobie?

Die kognitive Verhaltenstherapie (KVT) hat sich in empirischen Studien als wirksame Behandlungsform von Panikstörungen mit Agoraphobie erwiesen. Zu den zentralen Behandlungskomponenten gehören a) Psychoedukation über Angst und Panik, b) kognitive Interventionen, um die Tendenz zu Missinterpretationen körperlicher Wahrnehmungen zu vermindern, c) interozeptive und in vivo Exposition sowie d) Bewältigungskompetenzen zur Beeinflussung von körperlichen Symptomen, wie beispielsweise Entspannungs- und Atemtechniken. Empirische Befunde zur Effektivität dieser Interventionen werden vorgestellt und abschließend hinsichtlich ihrer Bedeutung im Rahmen einer evidenzbasierten Therapie der Panikstörung mit und ohne Agoraphobie in der Praxis diskutiert.

A Pilot Study of Sensation-Focused Intensive Treatment for Panic Disorder With Moderate to Severe Agoraphobia: Preliminary Outcome and Benchmarking Data

This report presents results of a treatment for panic disorder with moderate to severe agoraphobia (PDA-MS) called sensation-focused intensive treatment (SFIT). SFIT is an 8-day intensive treatment that combines features of cognitive— behavioral treatment for panic disorder, such as interoceptive exposure and cognitive restructuring with ungraded situational exposure. SFIT focuses on feared physical sensations as well as agoraphobic avoidance. Preliminary data support the utility of SFIT in improving PDA-MS. The goal of this exploratory study was to further investigate the effectiveness of SFIT and evaluate factors related to treatment outcome, including severity of panic symptoms, gender, comorbidity, self-efficacy, and place of residence (local vs. remote). SFIT was found to be effective in decreasing panic symptoms from pre- to posttreatment, with treatment gains maintained at follow-up. The implications of these findings for the treatment of PDA are discussed.

A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders

The efficacy of cognitive behavioral treatments (CBT) for anxiety in adults has been supported by multiple meta-analyses. However, most have focused on only 1 diagnosis, thereby disallowing diagnostic comparisons. This study examined the efficacy of CBT across the anxiety disorders. One hundred eight trials of CBT for an anxiety disorder met study criteria. Cognitive therapy and exposure therapy alone, in combination, or combined with relaxation training, were efficacious across the anxiety disorders, with no differential efficacy for any treatment components for any specific diagnoses. However, when comparing across diagnoses, outcomes for generalized anxiety disorder and posttraumatic stress disorder were superior to those for social anxiety disorder, but no other differences emerged. CBT effects were superior to those for no-treatment and expectancy control treatments, although tentative evidence suggested equal effects of CBT when compared with relaxation-only treatments.

A meta-analysis of the efficacy of psycho- and pharmacotherapy in panic disorder with and without agoraphobia

The efficacy of (cognitive) behavioural ((C)BT) and pharmacological therapy was investigated using meta-analytic techniques. After a comprehensive review of the literature, the results of 124 studies were included. (C)BT was more effective than a no-treatment control and a placebo control. No difference of efficacy was found when using cognitive elements compared to not using them for anxiety; for associated depressive symptoms, additional cognitive elements seems superior. Pharmacotherapy was more effective than a placebo control; there was no superiority of any drug class. Sample size was related to effect size in pharmacotherapy and publication bias was found. (C)BT was at least as effective as pharmacotherapy and depending on type of analysis even significantly more effective. There were no significant differences between (C)BT alone and a combination approach but characteristics of studies have to be considered.

Breathing training for treating panic disorder. Useful intervention or impediment?

Breathing training (BT) is commonly used for treatment of panic disorder. We identified nine studies that reported the outcome of BT. Overall, the published studies of BT are not sufficiently compelling to allow an unequivocal judgment of whether such techniques are beneficial. This article discusses problems with the underlying rationale, study design, and techniques used in BT, and it identifies factors that may have determined therapy outcomes. The idea that hypocapnia and respiratory irregularities are underlying factors in the development of panic implies that these factors should be monitored physiologically throughout therapy. Techniques taught in BT must take account of respiration rate and tidal volume in the regulation of blood gases (pCO2). More studies are needed that are designed to measure the efficacy of BT using an adequate rationale and methodology. Claims that BT should be rejected in favor of cognitive or other forms of intervention are premature.

Respiratory dysregulation in anxiety, functional cardiac, and pain disorders. Assessment, phenomenology, and treatment

Respiration is a complex physiological system affecting a variety of physical processes that can act as a critical link between mind and body. This review discusses the evidence for dysregulated breathing playing a role in three clinical syndromes: panic disorder, functional cardiac disorder, and chronic pain. Recent technological advances allowing the ambulatory assessment of endtidal partial pressure of CO2 (PCO2) and respiratory patterns have opened up new avenues for investigation and treatment of these disorders. The latest evidence from laboratories indicates that subtle disturbances of breathing, such as tidal volume instability and sighing, contribute to the chronic hypocapnia often found in panic patients. Hypocapnia is also common in functional cardiac and chronic pain disorders, and studies indicate that it mediates some of their symptomatology. Consistent with the role of respiratory dysregulation in these disorders, initial evidence indicates efficacy of respiration-focused treatment.

Respiratory biofeedback-assisted therapy in panic disorder

The authors describe a new methodologically improved behavioral treatment for panic patients using respiratory biofeedback from a handheld capnometry device. The treatment rationale is based on the assumption that sustained hypocapnia resulting from hyperventilation is a key mechanism in the production and maintenance of panic. The brief 4-week biofeedback therapy is aimed at voluntarily increasing self-monitored end-tidal partial pressure of carbon dioxide (PCO2) and reducing respiratory rate and instability through breathing exercises in patients' environment. Preliminary results from 4 patients indicate that the therapy was successful in reducing panic symptoms and other psychological characteristics associated with panic disorder. Physiological data obtained from home training, 24-hour ambulatory monitoring pretherapy and posttherapy, and laboratory assessment at follow-up indicate that patients started out with low resting PCO2 levels, increased those levels during therapy, and maintained those levels at posttherapy and/or follow-up. Partial dissociation between PCO2 and respiratory rate questions whether respiratory rate should be the main focus of breathing training in panic disorder.

The somatic symptom paradox in DSM-IV anxiety disorders: suggestions for a clinical focus in psychophysiology

Although DSM-IV criteria for anxiety disorders include physiological symptoms, these symptoms are evaluated exclusively by verbal report. The current review explores the background for this paradox and tries to demonstrate on theoretical and empirical grounds how it could be resolved, providing new insights about the role of psychophysiological measures in the clinic. The three-systems approach to evaluating anxiety argues that somatic measures as well as verbal and behavioral ones are indispensable. However, the low concordance between these domains of measurement impugns their reliability and validity. We argue that concordance can be improved by examining the relationship of variables less global than anxiety and by restriction to specific anxiety disorders. For example, recent evidence from our and other laboratories indicate a prominent role of self-reported and physiologically measured breathing irregularities in panic disorder. Nonetheless, even within a diagnosis, anxiety patients vary radically in which somatic variables are deviant. Thus, in clinical practice, individual profiles of psychological and physiological anxiety responses may be essential to indicate distinct therapeutic approaches and ways of tracking improvement. Laboratory provocations specific to certain anxiety disorders and advances in ambulatory monitoring vastly expand the scope of self-report and physiological measurement and will likely contribute to a refined assessment of anxiety disorders.

Dismantling cognitive-behavioral treatment for panic disorder: questioning the utility of breathing retraining

Cognitive-behavioral treatment (CBT) protocols for panic disorder (PD) consist of a set of interventions that often includes some form of breathing retraining (BR). A controlled outcome study was designed to assess the necessity of BR in the context of a multicomponent CBT protocol. To accomplish this, patients with PD (N = 77) were randomly assigned to receive CBT with or without BR or to a delayed-treatment control. The main study hypothesis was that patients receiving BR would display a less complete recovery relative to the other active-treatment condition given that BR appears to be a more attractive (but less adaptive) option for some patients. Some data suggested that the addition of BR yielded a poorer outcome. However, findings were generally more consistent with treatment equivalence, questioning whether BR produces any incremental benefits in the context of other CBT interventions for PD.

Does preference for type of treatment matter? A study of exposure in vivo with or without hypnosis in the treatment of panic disorder with agoraphobia

There is evidence that preference for a given therapy may influence results. Literature also suggests that hypnotizability may be elevated in agoraphobic patients, making hypnosis a potentially powerful method for treatment. Agoraphobic patients (N = 64) were treated with either exposure in vivo or exposure combined with hypnosis in a crossover design. Half of the patients started with the treatment they preferred and the other half received the other treatment first. Although patients' preference clearly shifted in favor of the combined therapy in the course of the study, no effect of preference on outcome was evident. Although hypnotizability clearly correlated to outcome in the combined therapy, no difference in effect between the two therapies was found on behavioral, self-report, and observer measures. No additional effect of hypnosis could be shown and preference was not found to be a powerful mediator of effect.

Influence of breathing therapy on complaints, anxiety and breathing pattern in patients with hyperventilation syndrome and anxiety disorders

The effect of breathing therapy was evaluated in patients with hyperventilation syndrome (HVS). The diagnosis of HVS was based on the presence of several suggestive complaints occurring in the context of stress, and reproduced by voluntary hyperventilation. Organic diseases as a cause of the symptoms were excluded. Most of these patients met the criteria for an anxiety disorder. The therapy was conducted in the following sequence: (1) brief, voluntary hyperventilation to reproduce the complaints in daily life: (2) reattribution of the cause of the symptoms to hyperventilation: (3) explaining the rationale of therapy-reduction of hyperventilation by acquiring an abdominal breathing pattern, with slowing down of expiration: and (4) breathing retraining for 2 to 3 months by a physiotherapist. After breathing therapy, the sum scores of the Nijmegen Questionnaire were markedly reduced. Improvements were registered in 10 of the 16 complaints of the questionnaire. The level of anxiety evaluated by means of the State-Trait Anxiety Inventory (STAI) decreased slightly. The breathing pattern was modified significantly after breathing retraining. Mean values of inspiration and expiration time and tidal volume increased, but end-tidal CO2 concentration (FETCO2) was not significantly modified except in the group of younger women (< or = 28 years). A canonical correlation analysis relating the changes of the various complaints to the modifications of breathing variables showed that the improvement of the complaints was correlated mainly with the slowing down of breathing frequency. The favorable influence of breathing retraining on complaints thus appeared to be a consequence of its influence primarily on breathing frequency, rather than on FETCO2.

Cognitive and performance-based treatments for panic attacks in people with varying degrees of agoraphobic disability

Compared the effectiveness of cognitive therapy and performance-based exposure as treatments for panic attacks. Subjects were 48 panicky individuals selected without regard to agoraphobic disability, and who varied widely in that respect. Subjects were assigned randomly to either cognitive treatment, performance-based exposure treatment, a combined cognitive/performance treatment, or a no-treatment control condition. All three treatments led to marked and enduring improvements in panic, and did not differ from one another in effectiveness, whereas the control condition produced little benefit. However, on several measures of phobia and panic-related cognitions, performance exposure was significantly more effective than cognitive therapy. Degree of agoraphobic disability had a significant bearing on panic treatment effectiveness. Whereas 94% of the low agoraphobia Ss were free of panic after treatment, only 52% of the high agoraphobia Ss became panic-free. The findings suggest that when panic treatment research excludes people with serious phobias, as it has routinely done in recent years, an overly positive estimate of panic treatment effectiveness can result.

Stress management techniques: are they all equivalent, or do they have specific effects?

This article evaluates the hypothesis that various stress management techniques have specific effects. Studies comparing various techniques are reviewed, as well as previous literature reviews evaluating the effects of individual techniques. There is evidence that cognitively oriented methods have specific cognitive effects, that specific autonomic effects result from autonomically oriented methods, and that specific muscular effects are produced by muscularly oriented methods. Muscle relaxation and/or EMG biofeedback have greater muscular effects and smaller autonomic effects than finger temperature biofeedback and/or autogenic training. EMG biofeedback produces greater effects on particular muscular groups than progressive relaxation, and thermal biofeedback has greater finger temperature effects than autogenic training. Disorders with a predominant muscular component (e.g., tension headaches) are treated more effectively by muscularly oriented methods, while disorders in which autonomic dysfunction predominates (e.g., hypertension, migraine headaches) are more effectively treated by techniques with a strong autonomic component. Anxiety and phobias tend to be most effectively treated by methods with both strong cognitive and behavioral components.

Exposure reduced agoraphobia but not panic, and cognitive therapy reduced panic but not agoraphobia

Earlier studies showed that cognitive therapy has anti-panic effects and exposure has anti-agoraphobic effects while other studies suggest that agoraphobia is a secondary complication of panic disorder. It was therefore hypothesized that cognitive therapy not only reduces panic but also agoraphobia and that it potentiates the effects of exposure in vivo. Two groups of 12 severe agoraphobics were treated with 4 sessions of cognitive therapy followed by 8 sessions of cognitive therapy combined with in vivo exposure. The other 12 received 4 sessions of 'associative therapy', a presumably inert treatment that controls for therapist attention, followed by 8 sessions of in vivo exposure that was framed in common behavioral terms. The initial cognitive therapy produced a significant reduction in panic frequency, while associative therapy did not affect panic. Neither cognitive therapy alone, nor associate therapy alone significantly reduced depression, state or trait anxiety, self-rated agoraphobia or behavioral avoidance. After adding exposure however, these parameters were clearly and significantly reduced. Cognitive therapy did not potentiate exposure effects. The results are discussed.

Dyspneic-fear theory explains hyperventilatory panic attacks: a reply to Carr, Lehrer and Hochron

Carr, Lehrer and Hochron (Behaviour Research and Therapy, 30, 251-261, 1992) attempted to test Ley's (Behaviour Research and Therapy, 30, 549-554, 1989) dyspneic-fear theory and concluded that while their results confirmed predictions for a sample of asthmatics, their results did not confirm predictions for a sample of panic-disorder patients. The present paper points to a basic flaw in the Carr et al. study which renders their conclusions regarding panic disorder indeterminate. The flaw in the Carr et al. study lies in their selection of panic-disorder patients. Whereas dyspneic-fear theory provides an explanation for panic fear experienced in hyperventilatory panic attacks, Carr et al. overlooked this fact and selected Ss based on the DSM-IIIR classification, a set of criteria which does not distinguish between hyperventilatory panic attacks and other types of panic attacks (see Ley, Behaviour Research and Therapy, 30, 347-357, 1992).

Reply to Ley's "dyspneic-fear theory explains hyperventilatory panic attacks"

In a critique of the study by Carr, Lehrer and Hochron (1992), Ley (Behaviour Research and Therapy, 32, 109-111, 1994) attributes the lack of confirmation for his dyspneic-fear theory among panic disorder patients to a basic flaw of that study: Ss were selected according to DSM-IIIR criteria. Ley argues that dyspneic-fear theory pertains exclusively to hyperventilatory (characterized by intense dyspnea) panic attacks not to all attacks that come under the classification of DSM-IIIR. We address the premise concerning the selection of Ss and argue that cognitive theory continues to offer a more convincing explanation of our study and of more recent findings by others.

Psychological treatment of panic: work in progress on outcome, active ingredients, and follow-up

Initial interest in the causes and treatment of panic disorder was triggered by biological theories and investigators. More recently, however, research on newly developed psychological approaches for panic has advanced our understanding of the disorder and has led to the development of specific treatment programs. Typically, these programs consist of a range of treatment components that more or less directly target panic attacks and the fears and behaviors associated with them. The paper reviews four studies evaluating these programs that have recently been completed or are close to completion in different centers in the United States (Albany, New York; Austin, Texas) and Europe (Oxford, England; Marburg, Germany). Conforming to strict methodological standards, these studies report consistently high success rates and temporal stability of the treatment gains. About 80% or more of the patients receiving combined cognitive-behavioral treatments achieved panic free status as well as strong and clinically significant improvement in general anxiety, panic-related cognitions, depression, and phobic avoidance. Furthermore, these gains were maintained at follow-ups of up to 2 years. The success of these psychological treatments compares favorably with the outcome for the established pharmacological treatments. In addition, the studies provide new insights into the active ingredients that may operate in cognitive-behavioral treatments for panic disorder and show the feasibility of group treatments. Together, these studies underscore the fact that cognitive-behavioral treatments rest on firm experimental evidence that justifies their application in everyday practice as well as continued research into their mechanisms of action.

The role of hyperventilation in panic disorder: a response to Ley (1991)

Ley (Behaviour Research and Therapy, 29, 301-304, 1991) provided a reinterpretation of experimental findings on the efficacy of breathing retraining plus cognitive restructuring in reducing the symptomatology of patients with panic disorder with agoraphobia which were presented in a 1989 article in this journal. On the basis of his reinterpretation, they concluded that our findings supported the central role of hyperventilation in panic attacks. Ley's arguments are discussed and we conclude that his reinterpretation provides new arguments against a hyperventilation theory of panic. Furthermore, recent evidence from empirical studies does not support a central role for hyperventilation in panic attacks.

Personality in panic disorder with agoraphobia: a Rorschach study

In this study, we tested several hypotheses derived from self psychology (Diamond, 1987) regarding personality features of patients suffering from panic disorder and agoraphobia (PDA). PDA patients are thought to suffer from a deficit in negative affect-regulating capacity, surrounded by defenses such as avoidance, repression, denial, and reaction formation against dependency needs. These defenses are thought to lead to a greatly impoverished affective life. The Rorschach Comprehensive System was used to assess the personality features of avoidance, restricted affective life, and reaction formation against dependency needs. We found evidence for the presence of a highly avoidant information-processing style (86% of protocols had lambda [L] greater than .99) and a constricted affective life (low weighted sum color [WSumC] and low affective ratio [Afr]). Our results were consistent with the hypothesis of reaction formation against dependency needs (low food content [Fd]). Findings are discussed in light of studies that found a high incidence of avoidant personality disorder in PDA patients.

Panic symptoms in asthma and panic disorder: a preliminary test of the dyspnea-fear theory

Ley's (Behaviour Research and Therapy, 27, 549-554, 1989) dyspnea-fear theory was tested on three groups of subjects: 10 with panic disorder, 24 with asthma, and 12 who were nonanxious and nonasthmatic, using measures of pulmonary function, muscle tension; and self-report measures of generalized anxiety, dyspnea, and psychopathology. Results are supportive of dyspnea-fear theory for asthmatics but not for individuals with panic disorder. Differences between groups on panic/fear measures were explained by a combination of general anxiety and dyspnea. Within-group regression analyses showed that only generalized anxiety symptoms contributed significantly to scores on the Asthma Symptom Checklist scale of panic/fear within the panic disorder group; while only dyspnea contributed to panic/fear among asthmatics. Additional results show that panic disorder subjects performed normally on pulmonary function tests but reported respiratory symptoms as severe as did asthmatics. Compared with normal subjects, both patient groups displayed lower correlations between self-rated symptoms of bronchoconstriction and objective pulmonary measures. Panic disorder subjects showed a negative relationship between pulmonary function and hyperventilation symptoms, suggesting a heightened sensitivity to, and discomfort with, sensations associated with normal pulmonary function. Asthmatics displayed a significant relationship between degree of airway obstruction and both trapezius surface EMG and ratings of hyperventilation symptoms.

A follow-up study on short-term treatment of agoraphobia

The differential effectiveness of three treatment packages for agoraphobia was tested. Patients received one of three short-term treatments: Breathing Retraining and Cognitive Restructuring, graded Self-Exposure in vivo, or a combination of both. No differential effects were found between the treatment conditions at posttest and at an 18 months follow-up. Improvement at follow-up assessment was associated with whether patients had further treatment during the follow-up period. No relationship was found between further improvement and demographic variables, pre- and posttest scores on psychological questionnaires or the use of medication at follow-up. Implications of these findings are examined.

Elevated serum lactate associated with panic attacks induced by hyperventilation

Several lines of evidence suggest that lactate metabolism may be altered in panic disorder. We recently reported exaggerated increases in serum lactate in panic patients following hyperventilation during glucose infusion. In the current study, lactate metabolism was stimulated by hyperventilation following glucose ingestion in 12 panic patients and 12 controls. The seven patients who panicked during hyperventilation exhibited larger increases in serum lactate levels than nonpanicking patients or controls. The lactate response was significantly correlated with peak ratings of anxiety and panic symptoms, but not correlated with insulin or cortisol levels, heart rate, pCO2, adiposity, exercise habits, or diet. Hyperventilation-induced panic appears to be associated with metabolic changes leading to elevated serum lactate.

Hyperventilation-induced panic attacks in panic disorder with agoraphobia

Eight minutes of hyperventilation to an end-tidal PCO2 of less than 20 mmHg led to a panic attack in 7 of 12 patients with panic disorder with agoraphobia and only 1 of 12 normal controls. Patients experienced greater increases in panic symptoms than controls during hyperventilation. Patients who reported more distress from somatic symptoms of hyperventilation during the preceding week were more likely to panic during hyperventilation. Patients who panicked during hyperventilation exhibited a delayed recovery of normocapnia following hyperventilation. Hyperventilation by this protocol is an effective means of inducing panic attacks in the laboratory. A hyperventilation challenge may identify a subgroup of patients for whom hyperventilation symptoms are frequently associated with panic.

The efficacy of breathing retraining and the centrality of hyperventilation in panic disorder: a reinterpretation of experimental findings

The present paper addresses de Ruiter, Rijken, Garssen, and Kraaimaat's (Behaviour Research and Therapy, 27, 647-655, 1989) interpretation of data pertaining to the efficacy of breathing retraining in the treatment of panic disorder. The proffered reinterpretation of these data makes it clear that breathing retraining led to a significant reduction in the frequency of panic attacks. These findings thus lend additional support to the central role of hyperventilation in primary panic attacks.