Mechanisms of change of panic attacks with exposure treatment of agoraphobia

Well-Being Therapy for Depression

Well-being therapy (WBT) is a short-term psychotherapeutic strategy, based on the technique of self-observation via the use of a structured diary and the guide of a therapist, with the goal of increasing psychological well-being, thus reaching euthymia and a balance among psychic forces. WBT showed to be suitable for application in residual symptoms of unipolar and bipolar depression, since the sequential combination with cognitive-behavioural therapy (CBT) led to a decrease in the relapse rate of recurrent depression. WBT also showed clinical utility in the treatment of cyclothymia, which represents one of the stages of bipolar disorder. Further, WBT seems to have efficacy in treatment-resistant depression and in case of withdrawal syndromes (in particular the so-called persistent post-withdrawal disorder) following antidepressant decrease, switch or discontinuation. In brief, WBT is a rather new but promising therapeutic strategy in the management of unipolar and bipolar depression. This chapter offers an overview of WBT possible applications.

The Clinical Science of Euthymia: A Conceptual Map

Euthymia is a trans-diagnostic construct characterized by lack of mood disturbances; presence of positive affect; balance of psychological well-being dimensions, flexibility, consistency, and resistance to stress. The aim of this critical review is to draw a conceptual map of euthymia. Relationships with other constructs, continuum between euthymia and dysthymia with discomfort as an intermediate area, associations with lifestyle, clinimetric assessment, role of psychotherapeutic interventions, establishment of therapeutic targets, and neurobiological mechanisms are discussed. The model is based on the bipolar nature of well-being dimensions. Euthymia means using allostasis optimally and maintaining a healthy balance that promotes positive aspects of brain and body health through health-promoting behaviors. It may provide a framework for a renewed definition of recovery, for measuring treatment outcome and for targeting interventions, including the sequential administration of therapeutic components. Clinical assessment requires a clinimetric approach encompassing a broad range of aspects, such as allostatic load and lifestyle behaviors, all interacting with each other and contributing to the euthymia/dysthymia balance. Clinimetric indices for assessing euthymia (the Clinical Interview for Euthymia and the Euthymia Scale) and related constructs (the Clinical Interview for Dysthymia and the Semi-Structured Interview for the Diagnostic Criteria for Psychosomatic Research) are presented here. Well-Being Therapy, a psychotherapeutic strategy specifically aimed at pursuing euthymia, relies on self-observation of well-being episodes using a structured diary as a distinct therapeutic ingredient. The clinical science of euthymia may unravel innovative approaches to assessment and treatment of psychiatric and medical disorders, according to a unitary conceptual framework.

Depression does not affect the treatment outcome of CBT for panic and agoraphobia: results from a multicenter randomized trial

BACKGROUND

Controversy surrounds the questions whether co-occurring depression has negative effects on cognitive-behavioral therapy (CBT) outcomes in patients with panic disorder (PD) and agoraphobia (AG) and whether treatment for PD and AG (PD/AG) also reduces depressive symptomatology.

METHODS

Post-hoc analyses of randomized clinical trial data of 369 outpatients with primary PD/AG (DSM-IV-TR criteria) treated with a 12-session manualized CBT (n = 301) and a waitlist control group (n = 68). Patients with comorbid depression (DSM-IV-TR major depression, dysthymia, or both: 43.2% CBT, 42.7% controls) were compared to patients without depression regarding anxiety and depression outcomes (Clinical Global Impression Scale [CGI], Hamilton Anxiety Rating Scale [HAM-A], number of panic attacks, Mobility Inventory [MI], Panic and Agoraphobia Scale, Beck Depression Inventory) at post-treatment and follow-up (categorical). Further, the role of severity of depressive symptoms on anxiety/depression outcome measures was examined (dimensional).

RESULTS

Comorbid depression did not have a significant overall effect on anxiety outcomes at post-treatment and follow-up, except for slightly diminished post-treatment effect sizes for clinician-rated CGI (p = 0.03) and HAM-A (p = 0.008) when adjusting for baseline anxiety severity. In the dimensional model, higher baseline depression scores were associated with lower effect sizes at post-treatment (except for MI), but not at follow-up (except for HAM-A). Depressive symptoms improved irrespective of the presence of depression.

CONCLUSIONS

Exposure-based CBT for primary PD/AG effectively reduces anxiety and depressive symptoms, irrespective of comorbid depression or depressive symptomatology.

Agoraphobia: a review of the diagnostic classificatory position and criteria

The status of agoraphobia (AG) as an independent diagnostic category is reviewed and preliminary options and recommendations for the fifth edition of The Diagnostic and Statistical Manual (DSM-V) are presented. The review concentrates on epidemiology, psychopathology, neurobiology, vulnerability and risk factors, clinical course and outcome, and correlates and consequences of AG since 1990. Differences and similarities across conventions and criteria of DSM and ICD-10 are considered. Three core questions are addressed. First, what is the evidence for AG as a diagnosis independent of panic disorder? Second, should AG be conceptualized as a subordinate form of panic disorder (PD) as currently stipulated in DSM-IV-TR? Third, is there evidence for modifying or changing the current diagnostic criteria? We come to the conclusion that AG should be conceptualized as an independent disorder with more specific criteria rather than a subordinate, residual form of PD as currently stipulated in DSM-IV-TR. Among other issues, this conclusion was based on psychometric evaluations of the construct, epidemiological investigations which show that AG can exist independently of panic disorder, and the impact of agoraphobic avoidance upon clinical course and outcome. However, evidence from basic and clinic validation studies remains incomplete and partly contradictory. The apparent advantages of a more straightforward, simpler classification without implicit hierarchies and insufficiently supported differential diagnostic considerations, plus the option for improved further research, led to favoring the separate diagnostic criteria for AG as a diagnosis independent of panic disorder.

Agoraphobia is a disease: a tribute to Sir Martin Roth

The evidence which has accumulated on the course of agoraphobia challenges the DSM view that phobic avoidance is secondary to panic attacks. In particular, a longitudinal study by Wittchen et al. indicates that agoraphobia, as a diagnostic category, is frequently independent of panic disorder and panic attacks, is unlikely to remit spontaneously and entails compromised quality of life. A staging system of agoraphobia is presented. Panic may ensue in the longitudinal development of agoraphobia, as well as of other anxiety disorders, and be conceptualized as a potential outcome in the course of anxiety, phobias and hypochondriasis as more than a specific disease entity. These recent research findings confirm the clinical observations and phenomenological research of Sir Martin Roth (1917-2006) and call for a reassessment of the concept of neurosis.

A staging approach to measuring patient-centred subjective outcomes

INTRODUCTION

In assessing clinical change, measurement is often based on psychometric scales. However, change is best revealed within the constellation of problems salient to the patient, rather than in alterations in the abstract constructs, psychometrically measured. These patients' problems often serially unfold in qualitative stages, even before the full-blown disorder emerges. These qualitative stages constitute the natural history extending from early to late, fluctuating from mild to severe, and progressing from full-blown disorder to recovery.

METHOD

We reviewed the literature on clinimetrics and patient-centred subjective measures, and related these findings to the use of the discretized-analogue scaling method.

RESULTS

There is increasing recognition of clinimetric approaches that structure the pre-clinical and clinical material into a scale that reflects the symptoms, consequences and complications in a manner understandable to the patient, and enabling the quantification of severity or change. This monograph provides criteria and methods for developing these building blocks that enable the assessment of severity, stage or change. We show examples of their use in quantitative clinical outcome measurement.

CONCLUSION

We encourage further studies in the ideology and procedures for measuring clinical change in terms of personally subjective experiences.

Correlates of vertigo attacks in Ménière's disease

BACKGROUND

Ménière's disease is a medical condition that involves hearing loss, tinnitus and attacks of vertigo. The attacks can be severely disabling with nausea, dizziness, and aural sensations.

METHOD

Three scales assessing the correlates of vertigo attacks in Ménière's disease were developed and completed by 514 subjects diagnosed with the disease. The three scales measured were somatic sensations (SOM), psychological state (PSYCHOL), and situational characteristics (SIT) associated with an attack.

RESULTS

Psychometric properties of the three scales were investigated showing Cronbach's alphas of 0.76, 0.80, and 0.62 for the three scales respectively. The results on the scales were related to disease progression. Principal components factor analyses showed that the SOM scale could be divided into two subscales: dizziness/vertigo/anxiety and sensations in the ear. The PSYCHOL scale showed an energy/awareness factor and a negative emotional state factor. The SIT scale, finally, showed two factors: environmental disturbances and stressful conditions.

CONCLUSIONS

Knowledge of somatic, psychological and situational premonitory characteristics of attacks in Ménière's disease could lead to improved therapy and counselling.

Subclinical symptoms of panic disorder: new insights into pathophysiology and treatment

The aim of this review was to survey the available literature on prodromal and residual symptoms of panic disorder. Both a computerized (Medline) and a manual search of the literature were performed. In a substantial proportion of patients with panic disorder with agoraphobia a prodromal phase can be identified. Most patients report residual symptoms despite successful treatment. Residual symptoms upon remission have a prognostic value. There appears to be a relationship between residual and prodromal symptomatology (the rollback phenomenon). Appraisal of subclinical symptomatology in panic disorder has important implications as to the pathophysiological model of disease, its conceptualization and treatment.

Rate of improvement during cognitive-behavioral group treatment for panic disorder

This study examined the rate of symptom improvement in patients receiving cognitive-behavioral group treatment for panic disorder in an outpatient clinic setting. Treatment was a standard program of 12 sessions that emphasized information, interoceptive and situational exposure, and cognitive restructuring, but also included diaphragmatic breathing and relaxation training as elements of treatment. Subjects were 37 patients selected from sequential admissions into an outpatient treatment program; all data were derived from ongoing quality assurance measures that are a standard part of clinical monitoring. Consequently, this study provides data not on the relative efficacy of cognitive-behavioral therapy (CBT), but on rate of improvement and effectiveness of CBT for panic disorder in actual clinical practice. Patients achieved significant treatment gains on all panic disorder dimensions assessed, and the largest reduction in symptoms was during the first third of the treatment program, thereby challenging the notion that CBT delivers its gains slowly over time. Information on rats of symptom improvement is valuable for providing patients with accurate expectations about potential treatment benefits and for helping to maintain motivation during initial treatment sessions.

Overcoming resistance to exposure in panic disorder with agoraphobia

The issue of panic disorder resistant to treatment (whether pharmacological or psychological) has attracted little research attention, despite its clinical frequency and importance. The aim of this study was to compare three treatment modalities, namely exposure alone (E), exposure associated with imipramine (EI) and cognitive therapy supplementing exposure (EC), in a sample of 21 patients with DSM-IV panic disorder and agoraphobia, who failed to respond to a first standard course of individual behavioural treatment based on exposure in vivo. Treatments were administered according to a cross-over, controlled design (E-EI-EC, EI-EC-E, EC-E-EI). Twelve of the 21 patients achieved remission (panic-free status) during the trial. In 8 cases this occurred after exposure alone (E) and in two cases each after the other treatments (EI and EC). The results revealed a significant effect of the factor time on a number of variables, and the superiority of exposure alone compared to other treatment modalities with regard to some variables. These findings suggest that long-term behavioural treatment based on exposure may be necessary in some patients, and may induce clinical remission. However, patients who do not respond to exposure show poor tolerance of and compliance with pharmacological treatment, and are unlikely to achieve remission with imipramine or cognitive therapy, even though this may occur in individual cases.

Patterns of change during cognitive behavioral treatment for panic disorder

The present investigation examined patterns of change in basic features of panic and anxiety during cognitive behavioral treatment for panic disorder. Data were collected in the context of a study comparing the efficacy of cognitive therapy (CT) and relaxation training, both administered without exposure-based treatments of any kind. Thirty-six panic disorder patients completed 10 weeks of either CT or relaxation training. Weekly measures of panic frequency, state and trait anxiety, and associated fears were obtained. Data were examined using both multivariate techniques (which conceptualize change as incremental) and analysis of response slopes (wherein change is conceptualized as continuous). Results indicated that during the first half of treatment, relaxation training led to greater reductions in state and trait anxiety and agoraphobic fear, whereas CT demonstrated a slight advantage on change in panic frequency. During the second half of treatment, CT produced faster reductions in state anxiety and agoraphobic fears. Over the entire treatment course, CT conferred an advantage in rate of change in social fears. The data provide support for the utility of a more process-oriented approach to the examination of treatment effects.

Long-term effects of behavioural treatment for panic disorder with agoraphobia

BACKGROUND

There are few long-term follow-up studies of panic disorder treatments, particularly when patients have been treated by behavioural methods only and have recovered.

METHOD

110 consecutive patients satisfying the DSM-III-R criteria for panic disorder with agoraphobia were treated in an out-patient clinic with behavioural methods based on exposure. After 12 sessions of psychotherapy, 81 patients became panic-free. A 2-9 year follow-up was available. Survival analysis was employed to characterise the clinical course of patients. Regular assessments by a clinical psychologist were based on the Clinical Interview for Depression.

RESULTS

The estimated cumulative percentage of patients remaining in remission was 96.1% for at least two years, 77.6% for at least five years, and 67.4% for at least seven years. These outcomes greatly improved in the absence of a personality disorder or residual agoraphobia after treatment.

CONCLUSIONS

The findings suggest that, even though one patient in four is unable to complete treatment or does not benefit sufficiently from it, exposure treatment can provide lasting relief for the majority of patients. Disappearance of residual and subclinical agoraphobic avoidance, and not simply of panic attacks, should be the aim of exposure therapy.

Benzodiazepines and anxiety sensitivity in panic disorder

1. Benzodiazepines were discontinued in 16 patients who had recovered from panic disorder with agoraphobia after exposure treatment. 2. Drug discontinuation yielded a significant decrease in anxiety sensitivity and state anxiety in these long-term users. 3. Several likely explanations for the findings are discussed. 4. In the short term, treatment of panic disorder with benzodiazepines may lower anxiety symptoms. However, in the long run, it may decrease the individual tolerance to anxiety and discomfort.

Staging: a neglected dimension in psychiatric classification

The staging method, whereby a disorder is characterized according to seriousness, extension and features, has achieved wide currency in medicine but is currently neglected in psychiatry. Studies addressing or related to the issue of staging in schizophrenia, unipolar depression, bipolar disorder and panic disorder are discussed. The phenomenological development of these mental disorders may be categorized according to stages.

Prodromal symptoms in panic disorder with agoraphobia: a replication study

The majority of 20 patients suffering from panic disorder with agoraphobia reported experiencing agoraphobic avoidance, generalized anxiety, and/or hypochondriacal fears and beliefs before the first panic attack. The results replicated those of a previous investigation and are in accordance with an increasing number of studies concerned with prodromal symptoms, epidemiologic surveys, and analysis of mechanisms of change upon treatment.