Treatment of anxiety and mood comorbidities in cognitive-behavioral and psychodynamic therapies for panic disorder

Affect-Focused and Exposure-Focused Psychotherapies

The authors discuss the two broad domains of affect-focused and exposure-focused psychotherapies, defining the characteristics and potential advantages and disadvantages of each. The two domains differ in their theoretical approaches, structures, and techniques. Exposure-focused therapies have come to dominate research and practice, leading to the relative neglect of affect-focused therapies. When the two approaches have been examined in well-conducted clinical trials, they generally appear to be equally beneficial for treating common mood, anxiety, and trauma disorders, although further research may better define differential therapeutics. The authors argue for better training in affect awareness and tolerance across psychotherapies and use a brief case vignette to illustrate several aspects of these different approaches.

Investigating Relations Between the Symptoms of Panic, Agoraphobia, and Suicidal Ideation: The Significance of Comorbid Depressive Symptoms in Veterans with Panic Disorder

Although panic disorder has been frequently associated with increased suicidal ideation and behaviors, there are multiple explanations for this association in the literature. For example, some research has demonstrated panic disorder symptoms to mediate agoraphobia and suicidal ideation, while other researchers have hypothesized that comorbid depression symptoms contribute to suicidal ideation across anxiety disorders. Of note, none of these studies were completed in veterans, a population at higher risk for suicide relative to civilian samples. The present study investigated relations between the symptoms of panic, agoraphobia, depression, and suicidal ideation in 58 veterans diagnosed with panic disorder via correlations, hierarchical regression, and exploratory path analyses. Multiple models were investigated based on prior research. The final path model demonstrated that symptoms of panic disorder predicted agoraphobia symptoms, with agoraphobia predicting symptoms of depression. Symptoms of depression, then, predicted suicidal ideation. Discussion of the findings related to comorbid depressive symptoms highlight considerations for the assessment and treatment practices for panic disorder, with a particular focus on veterans receiving care within Veterans Affairs Healthcare System.

Open Trial of Trauma-Focused Psychodynamic Psychotherapy for Posttraumatic Stress Disorder Among LGBTQ Individuals

OBJECTIVE

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals report higher rates of exposure to traumatic events and posttraumatic stress disorder (PTSD) compared with heterosexual and cisgender individuals. No treatment outcomes research has focused on PTSD in the LGBTQ population. Trauma-focused psychodynamic psychotherapy (TFPP) is a brief, manualized, attachment- and affect-focused psychotherapy for PTSD. TFPP explicitly incorporates broad identity-related and societal factors into its conceptualization of trauma and its consequences, which may be especially helpful for LGBTQ patients with minority stress who seek affirmative care.

METHODS

Fourteen LGBTQ patients with PTSD, assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), received 24 sessions of twice-weekly (12 weeks) TFPP via teletherapy provided by supervised early-career therapists inexperienced in the modality. Sessions were videotaped to monitor therapists' treatment adherence. Patients were assessed at baseline, week 5, termination (week 12), and 3 months posttreatment for PTSD symptoms (assessed with the CAPS-5) and secondary outcomes.

RESULTS

TFPP was well tolerated by patients, with 12 (86%) completing the intervention. CAPS-5-measured PTSD symptoms, including dissociation, significantly improved during treatment (mean decrease=-21.8, d=-1.98), and treatment gains were maintained at follow-up. Most patients experienced PTSD clinical response (N=10, 71%) or diagnostic remission (N=7, 50%). Patients generally experienced significant, concomitant improvements in complex PTSD symptoms, general anxiety, depression, and psychosocial functioning. Adherence to the intervention among therapists was high, with 93% of rated sessions meeting adherence standards.

CONCLUSIONS

TFPP shows promise in the treatment of PTSD among sexual and gender minority patients seeking LGBTQ-affirmative PTSD care.

Comorbidity as a moderator of the differential efficacy of transdiagnostic behavior therapy and behavioral activation for affective disorders

OBJECTIVE

Transdiagnostic psychotherapies have been proposed as an effective means for addressing the needs of patients with multiple, comorbid disorders. Yet, it remains unknown whether transdiagnostic approaches empirically outperform disorder-specific psychotherapies for patients with comorbid disorders. Thus, this study tested whether comorbidity moderated the efficacy of transdiagnostic behavior therapy (TBT) and behavioral activation (BA) for patients with various affective disorders.

METHODS

Data derived from a randomized controlled trial in which 93 treatment-seeking veterans received 12 sessions of TBT (n = 46) or BA (n = 47). Baseline comorbidity was assessed with a diagnostic interview. Patients rated their symptoms and functioning throughout treatment, and therapists recorded premature treatment discontinuation.

RESULTS

Multilevel models revealed significant interactive effects on changes in symptoms and functioning, but not on the posttreatment levels of these outcomes; whereas patients with more comorbidity experienced greater reductions in distress and symptom interference in TBT compared to BA, those with one disorder had better outcomes in BA. Similarly, whereas patients with more comorbidity were less likely to prematurely discontinue TBT compared to BA, those with one disorder were less likely to prematurely discontinue BA.

CONCLUSIONS

The results lend empirical support to previously untested hypotheses for potential benefits of transdiagnostic psychotherapies.Trial registration: ClinicalTrials.gov identifier: NCT01947647.

The efficacy of psychodynamic therapy for social anxiety disorder-A comprehensive meta-analysis

The efficacy of psychodynamic therapy (PDT) on social anxiety disorder (SAD) is controversial among different randomized controlled trials (RCTs), so we decide to conduct a comprehensive meta-analysis to study the efficacy of PDT on SAD. Relevant literatures were searched in PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, PsycINFO, Clinical Trails, and Ovid Medline. Twelve RCTs including 1,213 patients were identified. The primary analysis showed that the efficacy of PDT was weaker than the active group (SMD = 0.15 [0.02, 0.28]) and stronger than the inactive group (SMD = -0.77 [-0.95, -0.58]). It suggested that there was significant difference between individual PDT and group PDT (Chi² = 2.84, P = 0.09), and no difference between PDT and CBT on SAD and in the dropout rate. Secondary analysis suggested that depression may be alleviated concurrently (SMD = -0.20 [-0.40, 0.00]). Meta-regression analysis revealed no linear associations between dropout rate and effect size (t = 0.79, P = 0.449), neither does the dose-response relationship between session and effect size (t = -0.01, P = 0.992). These findings demonstrated that PDT could produce significant SAD symptoms reduction and supported its application in treating SAD.

Testing Clinical Intuitions About Barriers to Improvement in Cognitive-Behavioral Therapy for Panic Disorder

Although clinical intuitions influence psychotherapeutic practice and are a rich source of novel hypotheses for research, many remain to be empirically tested. This study evaluates whether clinicians' beliefs about barriers to progress in cognitive-behavioral therapy (CBT) for panic disorder are supported by data. Data from a randomized-controlled trial comparing CBT to panic-focused psychodynamic psychotherapy (PFPP) for adults with primary panic disorder (N = 161) were used to evaluate 15 factors endorsed by clinicians as impediments to CBT in a recent survey. Panic severity was assessed before, during (at Weeks 1, 5, and 9), and at termination of treatment (Week 12) using the Panic Disorder Severity Scale. Hierarchical linear modeling revealed that none of the perceived barriers were predictive of poor outcome. Contrary to clinicians' intuitions, dissociation during panic attacks was associated with greater symptomatic improvement in both treatment arms (β = -0.69, p < .05), above the effect of established predictors. Moderation analyses revealed that when patients had PTSD diagnosed with the Anxiety Disorders Interview Schedule (β = 1.71, p < .05) or less severe panic disorder (β = 0.45, p = .04), they changed more rapidly in CBT than in PFPP. Overall, clinician agreement was inversely related to the strength of a predictor (r = -.24, p = .39). Although clinical intuitions can be useful as clinical and empirical signals, such beliefs should be critically examined before informing practice. Dialogue between academics and clinicians might be enhanced through research that incorporates input from front-line practitioners.

Predictors and moderators of treatment dropout in cognitive-behavioral and psychodynamic therapies for panic disorder

Introduction: Panic disorder patients who drop out of treatment typically do not remit from their disorder. How patient-level moderators influence dropping out of one panic-focused treatment over another has never been examined, nor in non-CBT treatments. Method: 200 patients with panic disorder with or without agoraphobia were randomized to receive cognitive-behavioral therapy (CBT), panic-focused psychodynamic psychotherapy (PFPP), or applied relaxation training (ART) across two sites. Therapy was twice a week for 12 weeks. A two-step variable search method was applied to identify potential prognostic predictors and moderators of patient dropout. Survival models predicting hazard of session-by-session dropout tested the resulting variables. Results: Across treatments, unemployment and higher psychosocial disability on the Sheehan Disability Scale predicted increased risk of dropout, while patients with higher anxiety sensitivity were more likely to complete treatment. Patients who reported experiencing childhood abuse had heightened dropout in ART, but not CBT or PFPP. Men were especially likely to complete PFPP. Session 2 expectancies and patient-rated alliance predicted lower dropout only in CBT. Conclusions: Patient-level factors may influence both whether patients will complete any treatment, and whether they continue in a particular panic-focused therapy. Moderators of dropout (e.g., abuse history) may inform treatment decisions for specific patients.Trial registration: ClinicalTrials.gov identifier: NCT00353470.