Self-monitoring of panic attacks and retrospective estimates of panic: discordant findings

The memory-experience gap for PTSD symptoms: The correspondence between experience sampling and past month retrospective reports of traumatic stress symptoms

Posttraumatic stress disorder assessments typically require individuals to provide an aggregate report on the frequency or severity of symptoms they have experienced over a particular time period. Yet retrospective aggregate assessments are susceptible to memory recall and retrieval difficulties. This study examined the correspondence between a month of real-time experience sampling methodology (ESM) reports of traumatic stress symptoms and a retrospective assessment of past-month traumatic stress symptoms for that same period. Participants were a convenience community sample (n=96) from Southern and Central Israel exposed to rocket fire during the Israel-Gaza July-Aug 2014 conflict. Participants provided ESM reports on traumatic stress symptoms twice a day for 30 days via smartphone. Average ESM scores, rather than peak or most recent reports, were most highly correlated with retrospective assessments. For individual symptoms, concentration difficulties had the highest correspondence between ESM and retrospective reports, while amnesia had the lowest correspondence. Regression analysis found that average ESM scores and younger age significantly predicted past-month retrospective assessments of PTSD symptoms. Additionally, previously experiencing more types of trauma predicted PTSD symptoms, but did not moderate the relationship between ESM and retrospective assessments. These findings have implications for assessment.

A Review of Explicit and Implicit Assumptions When Providing Personalized Feedback Based on Self-Report EMA Data

Ecological Momentary Assessment (EMA) in which participants report on their moment-to-moment experiences in their natural environment, is a hot topic. An emerging field in clinical psychology based on either EMA, or what we term Ecological Retrospective Assessment (ERA) as it requires retrospectivity, is the field of personalized feedback. In this field, EMA/ERA-data-driven summaries are presented to participants with the goal of promoting their insight in their experiences. Underlying this procedure are some fundamental assumptions about (i) the relation between true moment-to-moment experiences and retrospective evaluations of those experiences, (ii) the translation of these experiences and evaluations to different types of data, (iii) the comparison of these different types of data, and (iv) the impact of a summary of moment-to-moment experiences on retrospective evaluations of those experiences. We argue that these assumptions deserve further exploration, in order to create a strong evidence-based foundation for the personalized feedback procedure.

[Sleep behavior and problems in children and adolescents of a psychiatric day clinic sample: results and requirements for systematic diagnostic]

Sleep behavior and problems in children and adolescents of a psychiatric day clinic sample: results and requirements for systematic diagnostic Abstract. Sleep disorders are common in adults as well as children and adolescents. Children and adolescents in psychiatric treatment (CAP) are especially affected by sleep problems. Cognitive behavioral therapy represents the first-line treatment, preceded by a standardized procedure for sleep diagnostics. To date, no study has investigated sleep behavior in CAP day clinics in Germany. In this study, N = 46 children/adolescents receiving CAP treatment in a day clinic completed a sleep diary (7 days) and a sleep anamnesis scheme with the help of their parents, and their sleep behavior was assessed by a clinician. Furthermore, a parent- and a self-report questionnaire plus a clinical assessment of the mental disorders in the children/adolescents were collected. 52 % of the children/ adolescents exhibited sleep disorders or sleep abnormalities (= sleep disorder symptoms in the context of comorbid disorders), in particular problems falling asleep or to falling asleep and sleeping through the night (26 %). In addition, 33 % reported having nightmares. Their sleep behavior correlated significantly with their external behavior problems (r = .38 .61, p = .02-.04); their sex (female: p = .01-≤ .001, |d| = 1.57-2.50) and their age (older: p = .05, |d| = .78) also significantly influenced sleep behavior. Particularly external behavior problems were associated with sleep problems in this day-care population. In summary, a multi-method-multi-informant procedure should be established for the systematic diagnostics of sleep abnormalities, together with individualized cognitive-behavioral therapy of sleep problems, especially in patients with external behavior problems.

Degree of Correspondence Between Retrospective and Proximal Reports of Borderline Personality Disorder Symptoms, Symptom Triggers, and Emotions

This study investigated the degree of correspondence of retrospective reports of personality disorder symptoms, triggers, and emotions with reports closer in time to the actual experiences. Retrospective reports of symptoms, triggers, and emotions are heavily used in both clinical and research settings, yet no study has investigated the correspondence for symptoms or triggers of personality disorders. A total of 257 participants, including 75 with BPD, completed overlapping daily, weekly, monthly, and semi-annual questionnaires. Retrospective reports showed: (1) systematic biases, reporting fewer symptom and situational trigger occurrences, and greater emotion intensities; but (2) little unsystematic error, largely reproducing bias-adjusted individual levels of symptoms, situational triggers, and emotions (rs generally .70-.80). People with BPD did not retrospectively misremember their symptoms, triggers, or emotions much more than others. Thus, retrospective reports of symptoms, triggers, and emotions should be adjusted for systematic bias, but after such adjustment can be taken as relatively faithful accounts of individuals' experiences.

General or specific? The memory-experience gap for individuals diagnosed with a major depressive disorder or a social phobia diagnosis, and individuals without such diagnoses

Psychological treatment and assessment necessarily rely on patients' recall. Yet several empirical studies have documented a gap between memory and real-life experience (i.e., memory-experience gap; MeG). We investigated and compared the MeG of sadness, social anxiety, happiness, and physical activity for participants diagnosed with a major depressive disorder (MDD), a social phobia (SP), and participants without such diagnoses (CG). The study included 118 participants diagnosed with a MDD, 47 with a SP, and 119 CG. Using event-sampling methods (ESM), participants were asked via smartphone to report their experiences throughout a week and then to recall those again retrospectively at the end of the study week. Results indicate significant differences in the MeG with respect to the experience that was salient to them (e.g., MDD group - sadness; SP group - social anxiety; CG group - happiness). Furthermore, all groups showed a MeG for physical activity and, the results indicate significant group differences in the magnitude of the MeGs. This study demonstrated the presence of a MeG in individuals in a MDD, SP, and CG group and in positive and negative affective experiences. Differential patterns across the samples contribute to a better understanding of this gap and its implications.

The Role of Patient Characteristics in the Concordance of Daily and Retrospective Reports of PTSD

Research has documented discrepancies between daily and retrospective reports of psychological symptoms in a variety of conditions. A limited number of studies have assessed these discrepancies in samples of individuals with posttraumatic stress disorder (PTSD), with even less research addressing potential covariates that may influence such discrepancies. In the current study, 65 individuals with co-occurring PTSD and alcohol use disorder (AUD) completed daily assessments of their PTSD symptoms for 1 month, followed by a standard retrospective report of PTSD over the same month. Initial analyses explored the mean levels of daily and retrospective PTSD symptoms, while multilevel models assessed the level of agreement between daily and retrospective reports and the role of demographic variables and comorbid psychopathology (e.g., depression) or substance use (e.g., alcohol use) in moderating the association of daily and retrospective reports. Results showed that retrospective reports of arousal and avoidance symptoms were weakly related to daily reports of these symptoms, while reports of reexperiencing and numbing symptoms showed better agreement. Intra-individual alcohol consumption also moderated associations of reexperiencing and avoidance symptoms, such that on days individuals drank more, their daily reports resembled their retrospective reports less well. Future research should explore the degree to which these results generalize to nondually diagnosed samples, as well as the role such reporting discrepancies may play in PTSD treatment.

'I feel better when…': An analysis of the memory-experience gap for peoples' estimates of the relationship between health behaviours and experiences

OBJECTIVE

People often overestimate how strongly behaviours and experiences are related. This memory-experience gap might have important implications for health care settings, which often require people to estimate associations, such as "my mood is better when I exercise". This study examines how subjective correlation estimates between health behaviours and experiences relate to calculated correlations from online reports and whether subjective estimates are associated with engagement in actual health behaviour.

DESIGN

Seven-month online study on physical activity, sleep, affect and stress, with 61 online assessments.

MAIN OUTCOME MEASURES

University students (N = 168) retrospectively estimated correlations between physical activity, sleep, positive affect and stress over the seven-month study period.

RESULTS

Correlations between experiences and behaviours (online data) were small (r = -.12-.14), estimated correlations moderate (r = -.35-.24). Correspondence between calculated and estimated correlations was low. Importantly, estimated correlations of physical activity with stress, positive affect and sleep were associated with actual engagement in physical activity.

CONCLUSION

Estimation accuracy of relations between health behaviours and experiences is low. However, association estimates could be an important predictor of actual health behaviours. This study identifies and quantifies estimation inaccuracies in health behaviours and points towards potential systematic biases in health settings, which might seriously impair intervention efficacy.

Next-generation psychiatric assessment: Using smartphone sensors to monitor behavior and mental health

OBJECTIVE

Optimal mental health care is dependent upon sensitive and early detection of mental health problems. We have introduced a state-of-the-art method for the current study for remote behavioral monitoring that transports assessment out of the clinic and into the environments in which individuals negotiate their daily lives. The objective of this study was to examine whether the information captured with multimodal smartphone sensors can serve as behavioral markers for one's mental health. We hypothesized that (a) unobtrusively collected smartphone sensor data would be associated with individuals' daily levels of stress, and (b) sensor data would be associated with changes in depression, stress, and subjective loneliness over time.

METHOD

A total of 47 young adults (age range: 19-30 years) were recruited for the study. Individuals were enrolled as a single cohort and participated in the study over a 10-week period. Participants were provided with smartphones embedded with a range of sensors and software that enabled continuous tracking of their geospatial activity (using the Global Positioning System and wireless fidelity), kinesthetic activity (using multiaxial accelerometers), sleep duration (modeled using device-usage data, accelerometer inferences, ambient sound features, and ambient light levels), and time spent proximal to human speech (i.e., speech duration using microphone and speech detection algorithms). Participants completed daily ratings of stress, as well as pre- and postmeasures of depression (Patient Health Questionnaire-9; Spitzer, Kroenke, & Williams, 1999), stress (Perceived Stress Scale; Cohen et al., 1983), and loneliness (Revised UCLA Loneliness Scale; Russell, Peplau, & Cutrona, 1980).

RESULTS

Mixed-effects linear modeling showed that sensor-derived geospatial activity (p < .05), sleep duration (p < .05), and variability in geospatial activity (p < .05), were associated with daily stress levels. Penalized functional regression showed associations between changes in depression and sensor-derived speech duration (p < .05), geospatial activity (p < .05), and sleep duration (p < .05). Changes in loneliness were associated with sensor-derived kinesthetic activity (p < .01).

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Smartphones can be harnessed as instruments for unobtrusive monitoring of several behavioral indicators of mental health. Creative leveraging of smartphone sensing could provide novel opportunities for close-to-invisible psychiatric assessment at a scale and efficiency that far exceeds what is currently feasible with existing assessment technologies.

A clinical case study of the use of ecological momentary assessment in obsessive compulsive disorder

Accurate assessment of obsessions and compulsions is a crucial step in treatment planning for Obsessive-Compulsive Disorder (OCD). In this clinical case study, we sought to determine if the use of Ecological Momentary Assessment (EMA) could provide additional symptom information beyond that captured during standard assessment of OCD. We studied three adults diagnosed with OCD and compared the number and types of obsessions and compulsions captured using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) compared to EMA. Following completion of the Y-BOCS interview, participants then recorded their OCD symptoms into a digital voice recorder across a 12-h period in reply to randomly sent mobile phone SMS prompts. The EMA approach yielded a lower number of symptoms of obsessions and compulsions than the Y-BOCS but produced additional types of obsessions and compulsions not previously identified by the Y-BOCS. We conclude that the EMA-OCD procedure may represent a worthy addition to the suite of assessment tools used when working with clients who have OCD. Further research with larger samples is required to strengthen this conclusion.

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.

Reexperiencing symptoms, dissociation, and avoidance behaviors in daily life of patients with PTSD and patients with panic disorder with agoraphobia

Panic attacks are frequently perceived as life threatening. Panic disorder (PD) patients may therefore experience symptoms of posttraumatic stress disorder (PTSD). The authors explored this in 28 healthy controls, 17 PTSD patients, and 24 PD patients with agoraphobia who completed electronic diaries 36 times during 1 week. Patient groups frequently reported dissociation as well as thoughts, memories, and reliving of their trauma or panic attacks. PTSD patients reported more trauma/panic attack thoughts (incidence rate ratio [IRR] = 2.9) and memories (IRR = 2.8) than PD patients. Patient groups relived their trauma or panic attacks equally frequently, and reported comparable bodily reactions and distress associated with trauma or panic attack memories. Clinical groups avoided trauma or panic attack reminders more often than healthy controls (avoidance of trauma- or panic attack-related thoughts (IRR = 8.0); avoidance of things associated with the trauma or panic attack (IRR = 40.7). PD patients avoided trauma or panic attack reminders less often than PTSD patients (avoidance of trauma- or panic attack-related thoughts [IRR = 2.5]; avoidance of things associated with the trauma or panic attack [IRR = 4.1]), yet these differences were nonsignificant when controlling for functional impairment. In conclusion, trauma-like symptoms are common in PD with agoraphobia and panic attacks may be processed similarly as trauma in PTSD.

The correspondence of daily and retrospective PTSD reports among female victims of sexual assault

Research addressing the association between daily and retrospective symptom reports suggests that retrospective reports are typically inflated. The present study examined the association between daily posttraumatic stress disorder (PTSD) symptom reports over 1 month and a corresponding retrospective report (PTSD Checklist [PCL]; Weathers et al., 1993) for both total scores and symptom clusters. The authors hypothesized that greater PTSD symptom instability and greater depression would be associated with poorer agreement between daily and retrospective reports. Data were collected from 132 female college students who were sexually assaulted. Multilevel modeling indicated very strong agreement between mean daily and retrospective reports for total scores and symptom clusters, with pseudo-R2 ranging from .55 to .77. Depression symptoms did not moderate this association, but daily-retrospective agreement was lowest for the avoidance cluster, which was also the most unstable. Finally, retrospective recall for each symptom cluster showed acceptable specificity to the corresponding daily symptom clusters. Overall, these findings suggest that retrospective memories for global PTSD symptoms and symptom clusters, as assessed by the PCL, are consistent with daily reports over a 1-month period. Implications for clinical assessment methodology are discussed.

Comparing retrospective reports to real-time/real-place mobile assessments in individuals with schizophrenia and a nonclinical comparison group

Retrospective reports are often used as the primary source of information for important diagnostic decisions, treatment, and clinical research. Whether such reports accurately represent individuals' past experiences in the context of a serious mental illness such as schizophrenia is unclear. In the current study, 24 individuals with schizophrenia and 26 nonclinical participants used a mobile device to complete multiple real-time/real-place assessments daily, over 7 consecutive days. At the end of the week, participants were also asked to provide a retrospective report summarizing the same period. Comparison of the data captured by the 2 methods showed that participants from both groups retrospectively overestimated the intensity of negative and positive daily experiences. In the clinical group, overestimations for affect were greater than for psychotic symptoms, which were relatively comparable to their retrospective reports. In both samples, retrospective reports were more closely associated with the week's average than the most intense or most recent ratings captured with a mobile device. Multilevel modeling revealed that much of the variability in weekly assessments was not explained by between-person differences and could not be captured by a single retrospective estimate. Based on the findings of this study, clinicians and researchers should be aware that while retrospective summary reports of the severity of certain symptoms compare relatively well with average momentary ratings, they are limited in their ability to capture variability in one's affective or psychotic experiences over time.

Instability of physical anxiety symptoms in daily life of patients with panic disorder and patients with posttraumatic stress disorder

The present study examined severity as well as degree and temporal pattern of instability of DSM-IV-based bodily symptoms of anxiety (BSA) in daily life of 26 panic disorder (PD) patients, 17 posttraumatic stress disorder (PTSD) patients, and 28 healthy controls (HC) during 1 week, using electronic diaries. The ecological momentary assessment around every 3h during wake times was accepted well by patients. Compared to HC, patient groups exhibited elevated instability of BSA. BSA instability was more pronounced in PTSD than PD (p<0.005), even after controlling for mean symptom level. Numbers of symptomatic episodes were comparable in PTSD and PD, but the duration of symptom-free episodes was shorter in PTSD than PD. Results indicate that PTSD patients are particularly burdened by fluctuations in somatic symptoms of anxiety, implying perceived unpredictability and uncontrollability. Electronic diaries can be applied in innovative ways to provide novel insights into the phenomenology of anxiety disorders that may not be captured well by retrospective interviews and questionnaires.

Web-based therapist-assisted cognitive behavioral treatment of panic symptoms: a randomized controlled trial with a three-year follow-up

BACKGROUND

Internet-delivered treatment may reduce barriers to care in those unwilling or unable to access traditional forms of treatment.

OBJECTIVE

To assesses the efficacy of web-based therapist-assisted cognitive behavioral treatment (web-CBT) of panic symptoms.

DESIGN

A randomized waiting-list controlled trial with an uncontrolled three-year follow-up.

PARTICIPANTS

A community sample of 58 participants with chronic panic symptoms of varying severity (immediate treatment: n=27, waiting-list control: n=31).

OUTCOME MEASURES

The primary outcome measures were a one-week Panic Diary and the Panic Disorder Severity Scale - Self-Report (PDSS-SR); secondary measures were the Agoraphobic Cognitions Questionnaire (ACQ), the Body Sensations Questionnaire (BSQ), the Mobility Inventory - Alone subscale (MI-AAL), and the Depression Anxiety Stress Scales (DASS-42).

RESULTS

In the RCT, 54 participants (93%) completed posttest measurements. With regard to the primary outcome measures, intention-to-treat ANCOVAs revealed that participants in the treatment condition improved more than the participants in the waiting-list control condition (p<.03), with a pooled between-group effect size of d=.7. After three years (n=47; 81% study compliance), effects were more pronounced.

CONCLUSION

The results demonstrate the efficacy of therapist-assisted web-CBT in the treatment of panic symptoms.

Accuracy of hospitalized depressed patients' and healthy controls' retrospective symptom reports: an experience sampling study

A growing body of literature suggests that retrospective recall of psychiatric symptoms is often inaccurate and may distort knowledge about the course of illness and impact treatment. The current study examined the accuracy of retrospective recall of a variety of depressive symptoms in hospitalized depressed patients and nonclinical controls. Using the Experience Sampling Method, we compared average momentary symptom reports of 1 week to retrospective summaries of the same period. The depressed group exhibited negative biases in their recall of experienced anhedonia, sadness, confusion, and suicidality, but were relatively accurate in recall of helplessness, detachment, and self-control. Controls exhibited a different pattern; they were relatively accurate in their retrospective recall of confusion, suicidality and sadness, but exhibited positive biases in recall of anhedonia, helplessness, detachment, and self-control. Both groups exhibited comparable negative biases in their recall of experienced tension, difficulty concentrating, guilt, and fear. The findings suggest that for maximum accuracy in the assessment of depressive symptoms, scientists and practitioners should supplement retrospective self-reports with momentary measures, and consider using ambulatory assessment in cognitive behavioral treatments of depression.

Experience sampling research in psychopathology: opening the black box of daily life

A growing body of research suggests that momentary assessment technologies that sample experiences in the context of daily life constitute a useful and productive approach in the study of behavioural phenotypes and a powerful addition to mainstream cross-sectional research paradigms. Momentary assessment strategies for psychopathology are described, together with a comprehensive review of research findings illustrating the added value of daily life research for the study of (1) phenomenology, (2) aetiology, (3) psychological models, (4) biological mechanisms, (5) treatment and (6) gene-environment interactions in psychopathology. Overall, this review shows that variability over time and dynamic patterns of reactivity to the environment are essential features of psychopathological experiences that need to be captured for a better understanding of their phenomenology and underlying mechanisms. The Experience Sampling Method (ESM) allows us to capture the film rather than a snapshot of daily life reality of patients, fuelling new research into the gene-environment-experience interplay underlying psychopathology and its treatment.

Ambulatory Assessment

Convergent experimental data, autobiographical studies, and investigations on daily life have all demonstrated that gathering information retrospectively is a highly dubious methodology. Retrospection is subject to multiple systematic distortions (i.e., affective valence effect, mood congruent memory effect, duration neglect; peak end rule) as it is based on (often biased) storage and recollection of memories of the original experience or the behavior that are of interest. The method of choice to circumvent these biases is the use of electronic diaries to collect self-reported symptoms, behaviors, or physiological processes in real time. Different terms have been used for this kind of methodology: ambulatory assessment, ecological momentary assessment, experience sampling method, and real-time data capture. Even though the terms differ, they have in common the use of computer-assisted methodology to assess self-reported symptoms, behaviors, or physiological processes, while the participant undergoes normal daily activities. In this review we discuss the main features and advantages of ambulatory assessment regarding clinical psychology and psychiatry: (a) the use of realtime assessment to circumvent biased recollection, (b) assessment in real life to enhance generalizability, (c) repeated assessment to investigate within person processes, (d) multimodal assessment, including psychological, physiological and behavioral data, (e) the opportunity to assess and investigate context-specific relationships, and (f) the possibility of giving feedback in real time. Using prototypic examples from the literature of clinical psychology and psychiatry, we demonstrate that ambulatory assessment can answer specific research questions better than laboratory or questionnaire studies.

Pocketcomputer-unterstütztes Assessment mit MONITOR

Zusammenfassung: Pocketcomputer eignen sich, psychologische Daten in Feldstudien technisch zuverlässiger als mit Fragebogen bzw. Tagebüchern zu erfassen. In einer Methodenstudie wurde MONITOR, ein für den Pocket-PC PSION geschriebenes, flexibles Programm eingesetzt. Unter Alltagsbedingungen wurden von 61 Studierenden verschiedener Fächer an zwei Tagen mit je fünf Eingaben Selbstprotokolle erhoben. Dazu gehörten Settingmerkmale wie Ort und Tätigkeit, Befindlichkeit sowie zwei Aufmerksamkeitstests. Zusätzlich wurde ein abendlicher und ein morgendlicher Rückblick erhoben. Zwischen den Erhebungstagen und zwischen verschiedenen Tageszeiten ergaben sich Unterschiede, die teils als Übungs- und Gewöhnungseffekte, teils als zirkadiane Effekte interpretierbar sind. Rückblickend wird das Befinden negativer beurteilt, als es aus dem Mittelwert der einzelnen Protokolle zu erwarten war. Dieser negative Retrospektionseffekt war bei emotional labilen Personen stärker ausgeprägt. Diese Befunde und andere Vorzüge der computer-unterstützten Methodik legen eine breitere Anwendung nahe.

Retrospective versus prospective self-rating of anxiety symptoms and cognitions

The discrepancy between retrospective and prospective rating of anxiety symptoms and cognition was examined in 20 agoraphobics. Subjects were required to complete a checklist of symptoms and cognitions during exposure to an agoraphobic situation. and then to complete a similar set retrospectively. More cognitions were rated retrospectively than prospectively, with the discrepancy especially evident for cognitions about physical catastrophe. In contrast, there was no discrepancy between anxiety symptoms rated prospectively versus retrospectively. This may be because anxiety symptoms are easier for patients to identify than cognitions. require less introspection. or are less affected by context than cognition. Implications of the findings are discussed and suggestions for future research are made.

Catastrophic cognitions in panic disorder with and without agoraphobia

The cognitive models of panic disorder with (PDA) or without (PD) agoraphobia are now widely recognised. These models propose that patients misinterpret external or internal cues in a catastrophic manner and as a result of these catastrophic cognitions the symptoms are maintained. There is now a large body of empirical evidence for this proposal and the aim of this paper is to systematically review the literature to evaluate whether the empirical evidence supports the contribution of catastrophic cognitions to PD and PDA. Empirical studies using different methodologies, such as interview, questionnaire, self-monitoring, and in vivo techniques are reviewed. The results indicate there is substantial empirical evidence in support of the central role of catastrophic cognition in cognitive models. Different methodologies provided convergent support for the importance of catastrophic cognitions in the maintenance of panic disorder and agoraphobia. Limitations in the interpretation of the existing research are highlighted and future research directions are proposed.

Treatment-outcome research in panic disorder: dilemmas in reconciling the demands of pharmacological and psychological methodologies

Panic disorder with or without agoraphobia has been the subject of sustained treatment-outcome research. Studies have been conducted by both pharmacologically- and psychologically-oriented researchers each employing their own methodologies. Problems arise in attempting to reconcile the demands of these two treatment-outcome methodologies, whilst at the same time ensuring that research designs reflect the reality of wider clinical practice. In the following discussion a series of studies comparing pharmacological and psychological treatments for panic disorder and agoraphobia are reviewed. The review highlights areas where the competing demands of research design and clinical applicability lead to dilemmas for the researcher. Attempts to overcome such dilemmas are described and alternative solutions discussed.

The assessment of panic using self-report: a comprehensive survey of validated instruments

A repertoire of reliable and valid self-report instruments to assess panic and panic disorder would help both researchers and clinicians. This review presents a description and an analysis of the available instruments. Following a comprehensive search of the literature, 14 instruments with published information on reliability and validity were reviewed. The following information is reported for each instrument: brief description of the instrument and its development, mean and standard deviation for clinical and nonclinical samples, and psychometric properties. Four types of instruments are presented: general assessment and information (n = 2), severity of panic disorder (n = 2), body sensations (n = 2) and cognitive dimensions of panic (n = 8). Overall, it would seem that panic measures have moderate to excellent psychometric qualities. However, the comparison between the instruments is difficult because the amount of empirical support available varies widely from one instrument to the other.

The 'match/mismatch' model of fear: empirical status and clinical implications

This paper reviews empirical evidence for the 'match/mismatch' model of fear and defines what is currently known about the prediction of fear. It also outlines several gaps in the literature on this topic and problems with the methodology used to study this phenomenon. Some of these gaps are filled by studies on the prediction of pain and where relevant these are discussed. Important areas for future research are identified, the clinical implications of the model are outlined and specific suggestions for treatment are made.

Continuous monitoring of panic

Data on naturally occurring panic attacks were gathered through continuous self-monitoring for 94 patients suffering from panic disorder with agoraphobia. A total of 1276 panic attacks were collected. In this article various aspects of panic attacks, including severity, duration and time of onset and situations in which panic occurs are addressed. In addition, the symptoms of panic were investigated, examining the (in)variability of attacks within each patient and the patterning of symptoms in the entire group of patients. The most important findings were as follows: attacks occurred predominantly in nonphobic situations; nocturnal panic attacks were generally more severe than attacks during the day; symptom patterns across various attacks, stemming from the same patient, were rather variable; and finally, a substantial number of the attacks (40%) did not meet the DSM-III-R criteria for number of symptoms.

Agoraphobic behavior in daily life: effects of social roles and demographic characteristics

Agoraphobia is related to demographic characteristics and social roles. To unravel behavioral aspects from demographic characteristics, daily life situations were registered with the Experience Sampling Method for 65 panic patients with and without agoraphobia. Surprisingly, panic patients with and without agoraphobia did not differ as hypothesized in reported frequencies of visits to public places. Panic subjects with agoraphobia did, however, spend significantly more time at home and with their families than did panic patients without agoraphobia and normal controls. When adjusted for demographic variables such as sex, marital status, family life, and employment, no significant differences between panic patients with and without agoraphobia emerged on the avoidance variables of remaining at home or being with a family member. The lack of discrimination of the diagnosis on these crucial behavioral variables highlights the influence of demographic characteristics and social roles on agoraphobia in daily life. Such findings challenge current diagnostic conceptualizations that rely on retrospective reports by patients of the avoidance of public places. Moreover, reliance on retrospective reports obscured the important role of significant others for understanding etiology and course.