1
|
Ustrup M, Christensen T, Curth NK, Heine K, Bojesen AB, Eplov LF. Predictors of Symptom Reduction and Remission Among People with Anxiety: Secondary Analyses from a Randomized Controlled Trial. Psychiatr Q 2024:10.1007/s11126-024-10081-y. [PMID: 39023677 DOI: 10.1007/s11126-024-10081-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2024] [Indexed: 07/20/2024]
Abstract
Despite the substantial disease burden of anxiety disorders, only limited or conflicting data on prognostic factors is available. Most studies include patients in the secondary healthcare sector thus, the generalizability of findings is limited. The present study examines predictors of symptom reduction and remission in patients with anxiety disorders in a primary care setting. 214 patients with anxiety disorders, recruited as part of the Collabri Flex trial, were included in secondary analyses. Data on potential predictors of anxiety symptoms at 6-month follow-up was collected at baseline, including patient characteristics related to demography, illness, comorbidity, functional level, life quality, and self-efficacy. The outcomes were symptom reduction and remission. Univariate and multivariate linear and logistic regression analyses were conducted to assess the associations between predictor variables and the outcome, and machine-learning methods were also applied. In multiple linear regression analysis, anxiety severity at baseline (β = -6.05, 95% CI = -7.54,-4.56, p < 0.001) and general psychological problems and symptoms of psychopathology (SCL-90-R score) (β = 2.19, 95% CI = 0.24,4.14, p = 0.028) were significantly associated with symptom change at 6 months. Moreover, self-efficacy was associated with the outcome, however no longer significant in the multiple regression model. In multiple logistic regression analysis, anxiety severity at baseline (OR = 0.54, 95% CI = -1.13,-0.12, p = 0.018) was significantly associated with remission at 6 months. There was no predictive performance of the machine-learning models. Our study contributes with information that could be valuable knowledge for managing anxiety disorders in primary care.
Collapse
Affiliation(s)
- Marte Ustrup
- Copenhagen Research Unit for Recovery, Mental Health Center Amager, Mental Health Services in the Capital Region of Denmark, Hans Bogbinders Allé 3, 2300, Copenhagen, Denmark.
| | - Thomas Christensen
- Copenhagen Research Unit for Recovery, Mental Health Center Amager, Mental Health Services in the Capital Region of Denmark, Hans Bogbinders Allé 3, 2300, Copenhagen, Denmark
| | - Nadja Kehler Curth
- Copenhagen Research Unit for Recovery, Mental Health Center Amager, Mental Health Services in the Capital Region of Denmark, Hans Bogbinders Allé 3, 2300, Copenhagen, Denmark
| | - Kimmie Heine
- Copenhagen Research Unit for Recovery, Mental Health Center Amager, Mental Health Services in the Capital Region of Denmark, Hans Bogbinders Allé 3, 2300, Copenhagen, Denmark
| | - Anders Bo Bojesen
- Copenhagen Research Unit for Recovery, Mental Health Center Amager, Mental Health Services in the Capital Region of Denmark, Hans Bogbinders Allé 3, 2300, Copenhagen, Denmark
| | - Lene Falgaard Eplov
- Copenhagen Research Unit for Recovery, Mental Health Center Amager, Mental Health Services in the Capital Region of Denmark, Hans Bogbinders Allé 3, 2300, Copenhagen, Denmark
| |
Collapse
|
2
|
Heinig I, Weiß M, Hamm AO, Hein G, Hollandt M, Hoyer J, Kanske P, Richter J, Wittchen HU, Pittig A. Exposure traced in daily life: improvements in ecologically assessed social and physical activity following exposure-based psychotherapy for anxiety disorders. J Anxiety Disord 2024; 101:102792. [PMID: 37989038 DOI: 10.1016/j.janxdis.2023.102792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 10/02/2023] [Accepted: 10/30/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Although exposure-based cognitive-behavioral therapy for anxiety disorders has frequently been proven effective, only few studies examined whether it improves everyday behavioral outcomes such as social and physical activity. METHODS 126 participants (85 patients with panic disorder, agoraphobia, social anxiety disorder, or specific phobias, and 41 controls without mental disorders) completed smartphone-based ambulatory ratings (activities, social interactions, mood, physical symptoms) and motion sensor-based indices of physical activity (steps, time spent moving, metabolic activity) at baseline, during, and after exposure-based treatment. RESULTS Prior to treatment, patients showed reduced mood and physical activity relative to healthy controls. Over the course of therapy, mood ratings, interactions with strangers and indices of physical activity improved, while reported physical symptoms decreased. Overall results did not differ between patients with primary panic disorder/agoraphobia and social anxiety disorder. Higher depression scores at baseline were associated with larger changes in reported symptoms and mood ratings, but smaller changes in physical activity CONCLUSIONS: Exposure-based treatment initiates increased physical activity, more frequent interaction with strangers, and improvements in everyday mood. The current approach provides objective and fine-graded process and outcome measures that may help to further improve treatments and possibly reduce relapse.
Collapse
Affiliation(s)
- Ingmar Heinig
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany.
| | - Martin Weiß
- Department of Psychiatry, Psychosomatics, and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
| | - Alfons O Hamm
- Department of Biological and Clinical Psychology/Psychotherapy, University of Greifswald, Greifswald, Germany
| | - Grit Hein
- Department of Psychiatry, Psychosomatics, and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
| | - Maike Hollandt
- Department of Biological and Clinical Psychology/Psychotherapy, University of Greifswald, Greifswald, Germany
| | - Jürgen Hoyer
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Philipp Kanske
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Jan Richter
- Department of Biological and Clinical Psychology/Psychotherapy, University of Greifswald, Greifswald, Germany; Department of Experimental Psychopathology University of Hildesheim, Hildesheim, Germany
| | - Hans-Ulrich Wittchen
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Andre Pittig
- Translational Psychotherapy, Institute of Psychology, University of Goettingen, Germany
| |
Collapse
|
3
|
Zainal NH, Hellberg SN, Kabel KE, Hotchkin CM, Baker AW. Cognitive behavioral therapy (CBT) plus attention bias modification (ABM) reduces anxiety sensitivity and depressive symptoms in panic disorder: A pilot randomized trial. Scand J Psychol 2023. [PMID: 36707979 DOI: 10.1111/sjop.12902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND Cognitive bias theories propose that reducing threat hypervigilance in mental disorders can augment cognitive behavioral therapy (CBT) outcomes. However, no studies have tested whether adding attention bias modification (ABM) can effectively enhance CBT's effects on anxiety sensitivity (AS), electromyography (EMG), and skin conductance (SC) for panic disorder (PD). This pilot randomized controlled trial (RCT) thus aimed to evaluate the efficacy of CBT + ABM (vs. CBT plus attention training placebo; PBO) on those outcomes. METHOD This study is a secondary analysis (Baker et al., 2020). Adults with PD were randomized to receive CBT + ABM (n = 11) or CBT + PBO (n = 12). Before each of the first five CBT sessions, CBT + ABM and CBT + PBO participants completed a 15-min ABM task or attention training PBO, respectively. AS and depression severity as well as SC and EMG during habituation to a loud-tone startle paradigm were assessed. Hierarchical Bayesian analyses were conducted. RESULTS During pre-post-treatment and pre-follow-up, CBM + ABM (vs. CBT + PBO) led to a notably greater reduction in ASI-Physical (between-group d = -1.26 to -1.25), ASI-Cognitive (d = -1.16 to -1.10), and depression severity (d = -1.23 to -0.99). However, no between-group difference was observed for ASI-Social, EMG, or SC indices. DISCUSSION Adding a brief computerized ABM intervention to CBT for PD protocols may enhance therapeutic change.
Collapse
Affiliation(s)
- Nur Hani Zainal
- Department of Healthcare Policy, Harvard Medical School, Boston, MA, USA
| | - Samantha N Hellberg
- Department of Psychology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Katherine E Kabel
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Claire M Hotchkin
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Amanda W Baker
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
4
|
Pittig A, Heinig I, Goerigk S, Thiel F, Hummel K, Scholl L, Deckert J, Pauli P, Domschke K, Lueken U, Fydrich T, Fehm L, Plag J, Ströhle A, Kircher T, Straube B, Rief W, Koelkebeck K, Arolt V, Dannlowski U, Margraf J, Totzeck C, Schneider S, Neudeck P, Craske MG, Hollandt M, Richter J, Hamm A, Wittchen HU. Efficacy of temporally intensified exposure for anxiety disorders: A multicenter randomized clinical trial. Depress Anxiety 2021; 38:1169-1181. [PMID: 34293223 DOI: 10.1002/da.23204] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/25/2021] [Accepted: 07/12/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The need to optimize exposure treatments for anxiety disorders may be addressed by temporally intensified exposure sessions. Effects on symptom reduction and public health benefits should be examined across different anxiety disorders with comorbid conditions. METHODS This multicenter randomized controlled trial compared two variants of prediction error-based exposure therapy (PeEx) in various anxiety disorders (both 12 sessions + 2 booster sessions, 100 min/session): temporally intensified exposure (PeEx-I) with exposure sessions condensed to 2 weeks (n = 358) and standard nonintensified exposure (PeEx-S) with weekly exposure sessions (n = 368). Primary outcomes were anxiety symptoms (pre, post, and 6-months follow-up). Secondary outcomes were global severity (across sessions), quality of life, disability days, and comorbid depression. RESULTS Both treatments resulted in substantial improvements at post (PeEx-I: dwithin = 1.50, PeEx-S: dwithin = 1.78) and follow-up (PeEx-I: dwithin = 2.34; PeEx-S: dwithin = 2.03). Both groups showed formally equivalent symptom reduction at post and follow-up. However, time until response during treatment was 32% shorter in PeEx-I (median = 68 days) than PeEx-S (108 days; TRPeEx-I = 0.68). Interestingly, drop-out rates were lower during intensified exposure. PeEx-I was also superior in reducing disability days and improving quality of life at follow-up without increasing relapse. CONCLUSIONS Both treatment variants focusing on the transdiagnostic exposure-based violation of threat beliefs were effective in reducing symptom severity and disability in severe anxiety disorders. Temporally intensified exposure resulted in faster treatment response with substantial public health benefits and lower drop-out during the exposure phase, without higher relapse. Clinicians can expect better or at least comparable outcomes when delivering exposure in a temporally intensified manner.
Collapse
Affiliation(s)
- Andre Pittig
- Department of Psychology (Biological Psychology Clinical Psychology, and Psychotherapy), Center of Mental Health, University of Würzburg, Würzburg, Germany.,Institute of Clinical Psychology & Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Ingmar Heinig
- Institute of Clinical Psychology & Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Stephan Goerigk
- Institute of Clinical Psychology & Psychotherapy, Technische Universität Dresden, Dresden, Germany.,Department of Psychiatry and Psychotherapy, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Freya Thiel
- Institute of Clinical Psychology & Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Katrin Hummel
- Institute of Clinical Psychology & Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Lucie Scholl
- Institute of Clinical Psychology & Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Jürgen Deckert
- Department of Psychiatry, Psychosomatics, and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
| | - Paul Pauli
- Department of Psychology (Biological Psychology Clinical Psychology, and Psychotherapy), Center of Mental Health, University of Würzburg, Würzburg, Germany
| | - Katharina Domschke
- Department of Psychiatry, Psychosomatics, and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Center for Basics in NeuroModulation, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrike Lueken
- Department of Psychiatry, Psychosomatics, and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany.,Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Thomas Fydrich
- Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lydia Fehm
- Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jens Plag
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Ströhle
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tilo Kircher
- Department of Psychiatry and Psychotherapy & Center for Mind Brain and Behavior - CMBB, Philipps-University Marburg, Marburg, Germany
| | - Benjamin Straube
- Department of Psychiatry and Psychotherapy & Center for Mind Brain and Behavior - CMBB, Philipps-University Marburg, Marburg, Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Faculty of Psychology & Center for Mind, Brain and Behavior - CMBB, Philipps-University of Marburg, Marburg, Germany
| | - Katja Koelkebeck
- Institute for Translational Psychiatry, University of Muenster, Muenster, Germany
| | - Volker Arolt
- Institute for Translational Psychiatry, University of Muenster, Muenster, Germany
| | - Udo Dannlowski
- Institute for Translational Psychiatry, University of Muenster, Muenster, Germany
| | - Jürgen Margraf
- Mental Health Research and Treatment Center, Ruhr-Universität Bochum, Bochum, Germany
| | - Christina Totzeck
- Mental Health Research and Treatment Center, Ruhr-Universität Bochum, Bochum, Germany
| | - Silvia Schneider
- Mental Health Research and Treatment Center, Ruhr-Universität Bochum, Bochum, Germany
| | - Peter Neudeck
- Institute of Clinical Psychology & Psychotherapy, Technische Universität Dresden, Dresden, Germany.,Protect-AD Study Site Cologne, Cologne, Germany
| | - Michelle G Craske
- Department of Psychology and Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USA
| | - Maike Hollandt
- Department of Psychology, Biological and Clinical Psychology, University of Greifswald, Greifswald, Germany
| | - Jan Richter
- Department of Psychology, Biological and Clinical Psychology, University of Greifswald, Greifswald, Germany
| | - Alfons Hamm
- Department of Psychology, Biological and Clinical Psychology, University of Greifswald, Greifswald, Germany
| | - Hans-Ulrich Wittchen
- Institute of Clinical Psychology & Psychotherapy, Technische Universität Dresden, Dresden, Germany.,Department of Psychiatry and Psychotherapy, University Hospital, Ludwig Maximilians University, Munich, Germany
| |
Collapse
|
5
|
Cosci F, Fava GA. When Anxiety and Depression Coexist: The Role of Differential Diagnosis Using Clinimetric Criteria. PSYCHOTHERAPY AND PSYCHOSOMATICS 2021; 90:308-317. [PMID: 34344013 DOI: 10.1159/000517518] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 05/31/2021] [Indexed: 11/19/2022]
Abstract
Depressive and anxiety disorders are frequently associated. Depression may be a complication of anxiety and anxiety can complicate depression. The nature of their relationship has been a source of controversy. Reviews generally base their conclusions on randomized controlled trials and meta-analyses that refer to the average patient and often clash with the variety of clinical presentations that may occur when anxiety and depression coexist. The aim of this review was to examine the literature according to profiling of subgroups of patients based on clinimetric criteria, in line with the recently developed concept of medicine-based evidence. We critically reviewed the literature pertaining to the specific presentations of anxiety and depression, outlining the advantages and disadvantages of each treatment approach. The following prototypic cases were presented: depression secondary to an active anxiety disorder, depression in patients with anxiety disorders under treatment, anxious depression, anxiety as a residual component of depression, and demoralization secondary to anxiety disorder. We argue that the selection of treatment when anxiety and depression coexist should take into account the modalities of presentation and be filtered by clinical judgment. Very different indications may ensue when the literature is examined according to this perspective.
Collapse
Affiliation(s)
- Fiammetta Cosci
- Department of Health Sciences, University of Florence, Florence, Italy.,Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands
| | - Giovanni A Fava
- Department of Psychiatry, University at Buffalo, State University of New York, New York, New York, USA
| |
Collapse
|
6
|
Fundamental frequency during cognitive preparation and its impact on therapy outcome for panic disorder with Agoraphobia. Behav Res Ther 2020; 135:103728. [PMID: 32987282 DOI: 10.1016/j.brat.2020.103728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/04/2020] [Accepted: 09/14/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cognitive preparation plays a crucial role in CBT with exposure for panic disorder and agoraphobia. High emotional arousal while developing the exposure rationale might impair patients' cognitive capacities for processing information about treatment and impede therapeutic outcome. OBJECTIVE This study investigates whether patients' vocally encoded emotional arousal, assessed by fundamental frequency (f0), during rationale development is associated with premature treatment dropout, insight into the rationale, and symptom reduction. METHODS Patients' (N = 197, mean age 36.1 years, 79.2% female) f0 during rationale development was measured based on treatment videos from a randomized controlled trial of CBT for panic disorder and agoraphobia. Insight was rater assessed. Symptom severity was self- and rater assessed at the beginning and end of therapy. RESULTS Higher f0 mean during rationale development was associated with lower probability of insight and less reduction in avoidance behavior. f0 was not associated with dropout. Insight was associated with lower probability of dropout and partially mediated the association between f0 and avoidance reduction. DISCUSSION This study highlights the importance of emotional arousal during cognitive preparation for exposure. Therapists should ensure that patients are not too highly aroused while learning about the exposure rationale as an important step in treatment.
Collapse
|
7
|
Walderhaug EP, Gjestad R, Egeland J, Havik OE, Nordgreen T. Relationships between depressive symptoms and panic disorder symptoms during guided internet-delivered cognitive behavior therapy for panic disorder. Nord J Psychiatry 2019; 73:417-424. [PMID: 31373520 DOI: 10.1080/08039488.2019.1646803] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aims: The current study explore the relationship between the trajectories of primary panic disorder symptoms and secondary depressive symptoms during guided internet-delivered cognitive behaviour therapy for panic disorder. Materials and methods: The patients (N=143) were recruited from an ongoing effectiveness study in secondary mental health outpatient services in Norway. Weekly self-reported primary panic disorder symptoms and secondary depressive symptoms were analysed. Results: primary panic disorder symptoms and secondary depressive symptoms improved significantly during the course of treatment, and at six months follow-up. Parallel process latent growth curve modelling showed that the trajectory of depressive symptoms and trajectory of panic disorder symptoms were significantly related. A supplementary analysis with cross-lagged panel modelling showed that (1) pre-treatment depressive symptoms predicted a positive effect of panic disorder symptoms early in treatment; (2) high early treatment panic disorder symptoms predicted low depressive symptoms at post-treatment. Conclusions: Guided ICBT for panic disorder is effective for both primary panic disorder symptoms and secondary depressive symptoms. Patients with high pre-treatment secondary depressive symptoms may constitute a vulnerable subgroup. A high level of panic disorder symptoms early in treatment seems beneficiary for depressive symptoms outcome. A time-dependent model may be necessary to describe the relationship between PAD symptoms and depressive symptoms during the course of treatment.
Collapse
Affiliation(s)
- Eirik P Walderhaug
- Division of Mental Health and Addiction, Vestfold Hospital , Tønsberg , Norway
| | - Rolf Gjestad
- Research department/Centre for Research and Education in Forensic Psychiatry, Division of Mental Health, Haukeland University Hospital , Bergen , Norway
| | - Jens Egeland
- Division of Mental Health and Addiction, Vestfold Hospital , Tønsberg , Norway.,Department of Psychology, University of Oslo , Oslo , Norway
| | - Odd E Havik
- Department of Clinical Psychology, Faculty of Psychology, University of Bergen , Bergen , Norway
| | - Tine Nordgreen
- Department of Clinical Psychology, Faculty of Psychology, University of Bergen , Bergen , Norway.,eMeistring, Division of Psychiatry, Haukeland University Hospital , Bergen , Norway
| |
Collapse
|
8
|
Does prior traumatization affect the treatment outcome of CBT for panic disorder? The potential role of the MAOA gene and depression symptoms. Eur Arch Psychiatry Clin Neurosci 2019; 269:161-170. [PMID: 28712090 DOI: 10.1007/s00406-017-0823-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 07/09/2017] [Indexed: 01/27/2023]
Abstract
Although cognitive behavioral therapy (CBT) is highly effective in the treatment of anxiety disorders, many patients still do not benefit. This study investigates whether a history of traumatic event experience is negatively associated with outcomes of CBT for panic disorder. The moderating role of the monoamine oxidase A (MAOA) gene and depression symptoms as well as the association between trauma history and fear reactivity as a potential mechanism are further analyzed. We conducted a post-hoc analysis of 172 male and 60 female patients with panic disorder treated with CBT in a multi-center study. Treatment outcome was assessed at post-treatment using self-report and clinician rating scales. Fear reactivity before treatment was assessed via heart rate and self-reported anxiety during a behavioral avoidance test. Among females, we did not find any differences in treatment response between traumatized and non-traumatized individuals or any two-way interaction trauma history × MAOA genotype. There was a significant three-way interaction trauma history × MAOA genotype × depression symptoms on all treatment outcomes indicating that in traumatized female patients carrying the low-activity allele, treatment effect sizes decreased with increasing depression symptoms at baseline. No such effects were observed for males. In conclusion, we found no evidence for a differential treatment response in traumatized and non-traumatized individuals. There is preliminary evidence for poorer treatment outcomes in a subgroup of female traumatized individuals carrying the low-active variant of the MAOA gene. These patients also report more symptoms of depression symptomatology and exhibit a dampened fear response before treatment which warrants further investigation.
Collapse
|
9
|
Pittig A, Kotter R, Hoyer J. The Struggle of Behavioral Therapists With Exposure: Self-Reported Practicability, Negative Beliefs, and Therapist Distress About Exposure-Based Interventions. Behav Ther 2019; 50:353-366. [PMID: 30824251 DOI: 10.1016/j.beth.2018.07.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 07/05/2018] [Accepted: 07/09/2018] [Indexed: 01/30/2023]
Abstract
Exposure-based interventions are a core ingredient of evidence-based cognitive-behavioral treatment (CBT) for anxiety disorders, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). However, previous research has documented that exposure is rarely utilized in routine care, highlighting an ongoing lack of dissemination. The present study examined barriers for the dissemination of exposure from the perspective of behavioral psychotherapists working in outpatient routine care (N = 684). A postal survey assessed three categories of barriers: (a) practicability of exposure-based intervention in an outpatient private practice setting, (b) negative beliefs about exposure, and (c) therapist distress related to the use of exposure. In addition, self-reported competence to conduct exposure for different anxiety disorders, PTSD, and OCD was assessed. High rates of agreement were found for single barriers within each of the three categories (e.g., unpredictable time management, risk of uncompensated absence of the patient, risk of decompensation of the patient, superficial effectiveness, or exposure being very strenuous for the therapist). Separately, average agreement to each category negatively correlated with self-reported utilization of exposure to a moderate degree (-.35 ≤ r ≤ -.27). In a multiple regression model, only average agreement to barriers of practicability and negative beliefs were significantly associated with utilization rates. Findings illustrate that a multilevel approach targeting individual, practical, and systemic barriers is necessary to optimize the dissemination of exposure-based interventions. Dissemination efforts may therefore benefit from incorporating strategies such as modifying negative beliefs, adaptive stress management for therapists, or increasing practicability of exposure-based interventions.
Collapse
Affiliation(s)
- Andre Pittig
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany.
| | - Roxana Kotter
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany
| | - Jürgen Hoyer
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany
| |
Collapse
|
10
|
Kunas SL, Yang Y, Straube B, Kircher T, Gerlach AL, Pfleiderer B, Arolt V, Wittmann A, Stroehle A, Wittchen HU, Lueken U. The impact of depressive comorbidity on neural plasticity following cognitive-behavioral therapy in panic disorder with agoraphobia. J Affect Disord 2019; 245:451-460. [PMID: 30428445 DOI: 10.1016/j.jad.2018.11.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 10/09/2018] [Accepted: 11/03/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Depressive disorders are a frequent comorbidity of panic disorder with agoraphobia (PD/AG). Cognitive-behavioral therapy (CBT) for PD/AG effectively reduces anxiety and depressive symptoms, irrespective of comorbidities. However, as depressive comorbidities can confound fear circuitry activation (i.e. amygdalae, insulae, anterior cingulate cortex) in PD/AG, we investigated whether comorbid depressive disorders alter neural plasticity following CBT. METHODS Within a randomized, controlled clinical trial on exposure-based CBT, forty-two PD/AG patients including fifteen (35.7%) with a comorbid depressive disorder (PD/AG + DEP) participated in a longitudinal functional magnetic resonance imaging (fMRI) study. A differential fear conditioning task was used as probe of interest. A generalized psycho-physiological interaction analysis (gPPI) served to study functional connectivity patterns. RESULTS After CBT, only PD/AG patients without comorbid depressive disorders (PD/AG-DEP) showed reduced activation in the left inferior frontal gyrus (IFG) extending to the insula. While PD/AG-DEP patients showed enhanced functional connectivity (FC) between the left IFG and subcortical structures (anterior cingulate cortex, thalamus and midbrain), PD/AG + DEP patients exhibited increased FC between the left IFG and cortical structures (prefrontal, parietal regions). In both groups, FC decreased following CBT. LIMITATIONS Primary depressed and medicated patients were excluded. Major depression and dysthymia were collapsed. CONCLUSIONS Reduced activation in the left IFG, as previously shown in PD/AG, appears to be a specific substrate of CBT effects in PD/AG-DEP patients only. Differential patterns of FC pertaining to fear circuitry networks in patients without depression vs. cognitive networks in patients with comorbid depression may point towards different pathways recruited by CBT as a function of comorbidity.
Collapse
Affiliation(s)
- Stefanie L Kunas
- Center of Mental Health, Department of Psychiatry, Psychosomatics, and Psychotherapy, University Hospital Würzburg, Würzburg, Germany; Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany.
| | - Yunbo Yang
- Department of Psychiatry and Psychotherapy, Phillipps-University Marburg, Marburg, Germany
| | - Benjamin Straube
- Department of Psychiatry and Psychotherapy, Phillipps-University Marburg, Marburg, Germany
| | - Tilo Kircher
- Department of Psychiatry and Psychotherapy, Phillipps-University Marburg, Marburg, Germany
| | | | - Bettina Pfleiderer
- Department of Clinical Radiology, University Hospital Münster, Münster, Germany
| | - Volker Arolt
- Department of Psychiatry and Psychotherapy, University Hospital Münster, Münster, Germany
| | - André Wittmann
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Stroehle
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Hans-Ulrich Wittchen
- Institute of Clinical Psychology and Psychotherapy, Department of Psychology, Technische Universität Dresden, Dresden, Germany
| | - Ulrike Lueken
- Center of Mental Health, Department of Psychiatry, Psychosomatics, and Psychotherapy, University Hospital Würzburg, Würzburg, Germany; Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
| |
Collapse
|
11
|
Analysis of brief Cognitive Behavioral Therapy for panic discorder. REVISTA IBEROAMERICANA DE PSICOLOGÍA 2018. [DOI: 10.33881/2027-1786.rip.11206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The aim of this study was to determine if a modification made to the traditional treatments for panic disorder (PD) proved to be effective in adjusting to the cultural and economic characteristics of patients in the southern Andean Region of Colombia. A quasi-experimental model was used, measurements were taken before and after treatment and follow-ups took place after 1 and 2 years; the sample was made up of 82 people (47 women and 35 men, with an average age of 34 and 29 years respectively). Results showed a reduction of PD clinical symptoms after the treatment (d>0.8), the significance in all cases was p <0.001 and changes maintained throughout the follow up period. In conclusion, it is posible to draw the treatment closer to the socio-cultural characteristics of patients to whom it is directed and the number of sessions could be reduced maintaining the effectiveness of the treatment.
Collapse
|
12
|
Richter J, Pittig A, Hollandt M, Lueken U. Bridging the Gaps Between Basic Science and Cognitive-Behavioral Treatments for Anxiety Disorders in Routine Care. ZEITSCHRIFT FUR PSYCHOLOGIE-JOURNAL OF PSYCHOLOGY 2017. [DOI: 10.1027/2151-2604/a000309] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract. As a core component of cognitive-behavioral therapies (CBT), behavioral exposure is an effective treatment for anxiety disorders. Still, recent treatment studies demonstrate relatively high rates of treatment dropout, nonresponse, and relapse, indicating a substantial need for optimizing and personalizing existing treatment procedures. In the present article, we aim to address current challenges and future demands for translational research in CBT for the anxiety disorders, including (a) a better understanding of those mechanisms conferring behavioral change, (b) identifying important sources of individual variation that may act as moderators of treatment response, and (c) targeting practical barriers for dissemination of exposure therapy to routine care. Based on a recursive process model of psychotherapy research we will describe distinct steps to systematically translate basic and clinical research “from bench to bedside” to routine care, but also vice versa. Some of these aspects may stimulate the future roadmap for evidence-based psychotherapy research in order to better target the treatment of anxiety disorders as one core health challenge of our time.
Collapse
Affiliation(s)
- Jan Richter
- Department of Physiological and Clinical Psychology/Psychotherapy, University of Greifswald, Germany
| | - Andre Pittig
- Institute of Clinical Psychology and Psychotherapy, Department of Psychology, Technische Universität Dresden, Germany
| | - Maike Hollandt
- Department of Physiological and Clinical Psychology/Psychotherapy, University of Greifswald, Germany
| | - Ulrike Lueken
- Center of Mental Health, Department of Psychiatry, Psychosomatics, and Psychotherapy, University Hospital of Würzburg, Germany
- Department of Psychology, Humboldt University of Berlin, Germany
| |
Collapse
|
13
|
Heinig I, Pittig A, Richter J, Hummel K, Alt I, Dickhöver K, Gamer J, Hollandt M, Koelkebeck K, Maenz A, Tennie S, Totzeck C, Yang Y, Arolt V, Deckert J, Domschke K, Fydrich T, Hamm A, Hoyer J, Kircher T, Lueken U, Margraf J, Neudeck P, Pauli P, Rief W, Schneider S, Straube B, Ströhle A, Wittchen HU. Optimizing exposure-based CBT for anxiety disorders via enhanced extinction: Design and methods of a multicentre randomized clinical trial. Int J Methods Psychiatr Res 2017; 26:e1560. [PMID: 28322476 PMCID: PMC6877126 DOI: 10.1002/mpr.1560] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 01/30/2017] [Accepted: 02/07/2017] [Indexed: 12/30/2022] Open
Abstract
Exposure-based psychological interventions currently represent the empirically best established first line form of cognitive-behavioural therapy for all types of anxiety disorders. Although shown to be highly effective in both randomized clinical and other studies, there are important deficits: (1) the core mechanisms of action are still under debate, (2) it is not known whether such treatments work equally well in all forms of anxiety disorders, including comorbid diagnoses like depression, (3) it is not known whether an intensified treatment with more frequent sessions in a shorter period of time provides better outcome than distributed sessions over longer time intervals. This paper reports the methods and design of a large-scale multicentre randomized clinical trial (RCT) involving up to 700 patients designed to answer these questions. Based on substantial advances in basic research we regard extinction as the putative core candidate model to explain the mechanism of action of exposure-based treatments. The RCT is flanked by four add-on projects that apply experimental neurophysiological and psychophysiological, (epi)genetic and ecological momentary assessment methods to examine extinction and its potential moderators. Beyond the focus on extinction we also involve stakeholders and routine psychotherapists in preparation for more effective dissemination into clinical practice.
Collapse
Affiliation(s)
- Ingmar Heinig
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Andre Pittig
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Jan Richter
- Department of Psychology, Universität Greifswald, Greifswald, Germany
| | - Katrin Hummel
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Isabel Alt
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Kristina Dickhöver
- Center of Mental Health, Department of Biological Psychology, Clinical Psychology, and Psychotherapy, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
| | - Jennifer Gamer
- Center of Mental Health, Department of Biological Psychology, Clinical Psychology, and Psychotherapy, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
| | - Maike Hollandt
- Department of Psychology, Universität Greifswald, Greifswald, Germany
| | - Katja Koelkebeck
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Münster, Münster, Germany
| | - Anne Maenz
- Clinical Psychology and Psychotherapy, Philipps-Universität Marburg, Marburg, Germany
| | - Sophia Tennie
- Clinical Psychology and Psychotherapy, Philipps-Universität Marburg, Marburg, Germany
| | - Christina Totzeck
- Mental Health Research and Treatment Center, Ruhr-Universität Bochum, Bochum, Germany
| | - Yunbo Yang
- Department of Psychiatry and Psychotherapy, Philipps-Universität Marburg, Marburg, Germany
| | - Volker Arolt
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Münster, Münster, Germany
| | - Jürgen Deckert
- Center of Mental Health, Department of Psychiatry, Psychosomatics, and Psychotherapy, University Hospital of Würzburg, Würzburg, Germany
| | - Katharina Domschke
- Center of Mental Health, Department of Psychiatry, Psychosomatics, and Psychotherapy, University Hospital of Würzburg, Würzburg, Germany.,Department of Psychiatry, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Thomas Fydrich
- Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Alfons Hamm
- Department of Psychology, Universität Greifswald, Greifswald, Germany
| | - Jürgen Hoyer
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Tilo Kircher
- Department of Psychiatry and Psychotherapy, Philipps-Universität Marburg, Marburg, Germany
| | - Ulrike Lueken
- Center of Mental Health, Department of Psychiatry, Psychosomatics, and Psychotherapy, University Hospital of Würzburg, Würzburg, Germany
| | - Jürgen Margraf
- Mental Health Research and Treatment Center, Ruhr-Universität Bochum, Bochum, Germany
| | | | - Paul Pauli
- Center of Mental Health, Department of Biological Psychology, Clinical Psychology, and Psychotherapy, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
| | - Winfried Rief
- Clinical Psychology and Psychotherapy, Philipps-Universität Marburg, Marburg, Germany
| | - Silvia Schneider
- Mental Health Research and Treatment Center, Ruhr-Universität Bochum, Bochum, Germany
| | - Benjamin Straube
- Department of Psychiatry and Psychotherapy, Philipps-Universität Marburg, Marburg, Germany
| | - Andreas Ströhle
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Hans-Ulrich Wittchen
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| |
Collapse
|
14
|
Abstract
Anxiety disorders constitute the largest group of mental disorders in most western societies and are a leading cause of disability. The essential features of anxiety disorders are excessive and enduring fear, anxiety or avoidance of perceived threats, and can also include panic attacks. Although the neurobiology of individual anxiety disorders is largely unknown, some generalizations have been identified for most disorders, such as alterations in the limbic system, dysfunction of the hypothalamic-pituitary-adrenal axis and genetic factors. In addition, general risk factors for anxiety disorders include female sex and a family history of anxiety, although disorder-specific risk factors have also been identified. The diagnostic criteria for anxiety disorders varies for the individual disorders, but are generally similar across the two most common classification systems: the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the International Classification of Diseases, Tenth Edition (ICD-10). Despite their public health significance, the vast majority of anxiety disorders remain undetected and untreated by health care systems, even in economically advanced countries. If untreated, these disorders are usually chronic with waxing and waning symptoms. Impairments associated with anxiety disorders range from limitations in role functioning to severe disabilities, such as the patient being unable to leave their home.
Collapse
Affiliation(s)
- Michelle G Craske
- Department of Psychology, University of California Los Angeles, 405 Hilgard Avenue, Los Angeles, California 90095, USA
| | - Murray B Stein
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California, USA
| | - Thalia C Eley
- King's College London, MRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Mohammed R Milad
- Department of Psychiatry, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Charleston, Massachusetts, USA
| | - Andrew Holmes
- Laboratory of Behavioral and Genomic Neuroscience, National Institute on Alcohol Abuse and Alcoholism, Rockville, Maryland, USA
| | - Ronald M Rapee
- Department of Psychology, Centre for Emotional Health, Macquarie University, Sydney, New South Wales, Australia
| | - Hans-Ulrich Wittchen
- Institute of Clinical Psychology and Psychotherapy, Faculty of Science, Technische Universitaet Dresden, Dresden, Germany
| |
Collapse
|
15
|
Payne LA, White KS, Gallagher MW, Woods SW, Shear MK, Gorman JM, Farchione TJ, Barlow DH. SECOND-STAGE TREATMENTS FOR RELATIVE NONRESPONDERS TO COGNITIVE BEHAVIORAL THERAPY (CBT) FOR PANIC DISORDER WITH OR WITHOUT AGORAPHOBIA-CONTINUED CBT VERSUS SSRI: A RANDOMIZED CONTROLLED TRIAL. Depress Anxiety 2016; 33:392-9. [PMID: 26663632 DOI: 10.1002/da.22457] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 11/05/2015] [Accepted: 11/06/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Cognitive behavioral therapy (CBT) and pharmacotherapy are efficacious for the short-term treatment of panic disorder. Less is known about the efficacy of these therapies for individuals who do not respond fully to short-term CBT. METHOD The current trial is a second-step stratified randomized design comparing two treatment conditions-selective serotonin reuptake inhibitor (SSRI; paroxetine or citalopram; n = 34) and continued CBT (n = 24)-in a sample of individuals classified as treatment nonresponders to an initial course of CBT for panic disorder. Participants were randomized to 3 months of treatment and then followed for an additional 9 months. Only treatment responders after 3 months were maintained on the treatment until 12-month follow-up. Data analysis focused on panic disorder symptoms and achievement of response status across the first 3 months of treatment. Final follow-up data are presented descriptively. RESULTS Participants in the SSRI condition showed significantly lower panic disorder symptoms as compared to continued CBT at 3 months. Results were similar when excluding individuals with comorbid major depression or analyzing the entire intent-to-treat sample. Group differences disappeared during 9-month naturalistic follow-up, although there was significant attrition and use of nonstudy therapies in both arms. CONCLUSIONS These data suggest greater improvement in panic disorder symptoms when switching to SSRI after failure to fully respond to an initial course of CBT. Future studies should further investigate relapse following treatment discontinuation for nonresponders who became responders. Clinicaltrials.gov Identifier: NCT00000368; https://clinicaltrials.gov/show/NCT00000368.
Collapse
Affiliation(s)
- Laura A Payne
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Kamila S White
- Department of psychological sciences, University of Missouri - St. Louis, St. Louis, Missouri
| | | | - Scott W Woods
- Department of Psychiatry, Yale University, New Haven, Connecticut
| | | | - Jack M Gorman
- Franklin Behavioral Health Consultants, New York, New York
| | - Todd J Farchione
- Center for Anxiety and Related Disorders at Boston University, Boston, Massachusetts
| | - David H Barlow
- Center for Anxiety and Related Disorders at Boston University, Boston, Massachusetts
| |
Collapse
|
16
|
Pompoli A, Furukawa TA, Imai H, Tajika A, Efthimiou O, Salanti G. Psychological therapies for panic disorder with or without agoraphobia in adults: a network meta-analysis. Cochrane Database Syst Rev 2016; 4:CD011004. [PMID: 27071857 PMCID: PMC7104662 DOI: 10.1002/14651858.cd011004.pub2] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
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.
Collapse
Affiliation(s)
- Alessandro Pompoli
- Private practice, no academic affiliationsLe grotte 12MalcesineVeronaItaly37018
| | - Toshi A Furukawa
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Health Promotion and Human BehaviorYoshida Konoe‐cho, Sakyo‐ku,KyotoJapan606‐8501
| | - Hissei Imai
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Health Promotion and Human BehaviorYoshida Konoe‐cho, Sakyo‐ku,KyotoJapan606‐8501
| | - Aran Tajika
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Health Promotion and Human BehaviorYoshida Konoe‐cho, Sakyo‐ku,KyotoJapan606‐8501
| | - Orestis Efthimiou
- University of Ioannina School of MedicineDepartment of Hygiene and EpidemiologyIoanninaEpirusGreece45500
| | - Georgia Salanti
- University of BernInstitute of Social and Preventive Medicine (ISPM) & Bern Institute of Primary Care (BIHAM)Finkenhubelweg 11BernSwitzerland3005
| | | |
Collapse
|
17
|
A systematic review of predictors and moderators of improvement in cognitive-behavioral therapy for panic disorder and agoraphobia. Clin Psychol Rev 2015; 42:179-92. [DOI: 10.1016/j.cpr.2015.09.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 08/11/2015] [Accepted: 09/18/2015] [Indexed: 11/22/2022]
|
18
|
Bomyea J, Lang A, Craske MG, Chavira DA, Sherbourne CD, Rose RD, Golinelli D, Campbell-Sills L, Welch SS, Sullivan G, Bystritsky A, Roy-Byrne P, Stein MB. Course of symptom change during anxiety treatment: Reductions in anxiety and depression in patients completing the Coordinated Anxiety Learning and Management program. Psychiatry Res 2015; 229:133-42. [PMID: 26228164 PMCID: PMC4656042 DOI: 10.1016/j.psychres.2015.07.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 04/19/2015] [Accepted: 07/19/2015] [Indexed: 01/25/2023]
Abstract
When treating anxious patients with co-occurring depression, research demonstrates that both types of symptoms independently improve. The current analyses examined how reductions in anxiety and depression may be interrelated both during treatment, as well as over time following treatment. Participants were 503 individuals with one or more DSM-IV anxiety disorders who completed a collaborative care anxiety management program. Anxiety and depression were assessed at each treatment session (i.e., session by session data) and also at 6, 12, and 18-month post-baseline assessments (i.e., long-term outcomes data). Mediation analyses examined changes in symptoms in session by session data and long-term outcomes data. Anxiety and depression changed reciprocally in session by session data; change in anxiety mediated change in depression to a greater extent than vice versa. In the long-term outcomes data, change in anxiety mediated change in depression. However, the reverse mediation model of the long-term outcomes period revealed that accounting for changes in depression altered the effect of time on anxiety. Thus, temporal change during active treatment may share similarities with those related to maintaining gains after treatment, although differences arose in the reverse mediation models. Limitations of the methodology and implications of anxiety treatment for depression outcomes are discussed.
Collapse
Affiliation(s)
- Jessica Bomyea
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA.
| | - Ariel Lang
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA,VA San Diego Health Care System Center of Excellence for Stress and Mental Health, San Diego, La Jolla, CA, USA
| | - Michelle G. Craske
- Department of Psychology, University of California, Los Angeles, CA, USA
| | - Denise A. Chavira
- Department of Psychology, University of California, Los Angeles, CA, USA
| | | | - Raphael D. Rose
- Department of Psychology, University of California, Los Angeles, CA, USA
| | | | - Laura Campbell-Sills
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
| | - Stacy S. Welch
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine and Harborview Center for Healthcare Improvement for Addictions, Mental Illness, and Medically Vulnerable Populations (CHAMMP), Seattle, WA, USA
| | - Greer Sullivan
- RAND Corporation, Santa Monica, CA, USA,Department of Psychiatry University of Arkansas for Medical Sciences, Little Rock, AR, USA,VA South Central Mental Illness Research, Education, and Clinical Center University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Alexander Bystritsky
- Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Peter Roy-Byrne
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine and Harborview Center for Healthcare Improvement for Addictions, Mental Illness, and Medically Vulnerable Populations (CHAMMP), Seattle, WA, USA
| | - Murray B. Stein
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA,Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, USA
| |
Collapse
|
19
|
Lueken U, Straube B, Yang Y, Hahn T, Beesdo-Baum K, Wittchen HU, Konrad C, Ströhle A, Wittmann A, Gerlach AL, Pfleiderer B, Arolt V, Kircher T. Separating depressive comorbidity from panic disorder: A combined functional magnetic resonance imaging and machine learning approach. J Affect Disord 2015; 184:182-92. [PMID: 26093832 DOI: 10.1016/j.jad.2015.05.052] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 05/11/2015] [Accepted: 05/29/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Depression is frequent in panic disorder (PD); yet, little is known about its influence on the neural substrates of PD. Difficulties in fear inhibition during safety signal processing have been reported as a pathophysiological feature of PD that is attenuated by depression. We investigated the impact of comorbid depression in PD with agoraphobia (AG) on the neural correlates of fear conditioning and the potential of machine learning to predict comorbidity status on the individual patient level based on neural characteristics. METHODS Fifty-nine PD/AG patients including 26 (44%) with a comorbid depressive disorder (PD/AG+DEP) underwent functional magnetic resonance imaging (fMRI). Comorbidity status was predicted using a random undersampling tree ensemble in a leave-one-out cross-validation framework. RESULTS PD/AG-DEP patients showed altered neural activation during safety signal processing, while +DEP patients exhibited generally decreased dorsolateral prefrontal and insular activation. Comorbidity status was correctly predicted in 79% of patients (sensitivity: 73%; specificity: 85%) based on brain activation during fear conditioning (corrected for potential confounders: accuracy: 73%; sensitivity: 77%; specificity: 70%). LIMITATIONS No primary depressed patients were available; only medication-free patients were included. Major depression and dysthymia were collapsed (power considerations). CONCLUSIONS Neurofunctional activation during safety signal processing differed between patients with or without comorbid depression, a finding which may explain heterogeneous results across previous studies. These findings demonstrate the relevance of comorbidity when investigating neurofunctional substrates of anxiety disorders. Predicting individual comorbidity status may translate neurofunctional data into clinically relevant information which might aid in planning individualized treatment. The study was registered with the ISRCTN ISRCTN80046034.
Collapse
Affiliation(s)
- Ulrike Lueken
- Department of Psychiatry, Psychosomatics, and Psychotherapy, University Hospital Würzburg, Füchsleinstr. 15, D-97080 Würzburg, Germany; Institute of Clinical Psychology and Psychotherapy, Department of Psychology, Technische Universität Dresden, Dresden, Germany.
| | - Benjamin Straube
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Yunbo Yang
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Tim Hahn
- Department of Cognitive Psychology II, Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Katja Beesdo-Baum
- Institute of Clinical Psychology and Psychotherapy, Department of Psychology, Technische Universität Dresden, Dresden, Germany
| | - Hans-Ulrich Wittchen
- Institute of Clinical Psychology and Psychotherapy, Department of Psychology, Technische Universität Dresden, Dresden, Germany
| | - Carsten Konrad
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Andreas Ströhle
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité-University Medicine Berlin, Berlin, Germany
| | - André Wittmann
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité-University Medicine Berlin, Berlin, Germany
| | | | - Bettina Pfleiderer
- Department of Clinical Radiology, University Hospital Münster, Münster, Germany
| | - Volker Arolt
- Department of Psychiatry and Psychotherapy, University Hospital Münster, Münster, Germany
| | - Tilo Kircher
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| |
Collapse
|
20
|
Abstract
BACKGROUND Demoralization has been described as a psychological state characterized by helplessness, hopelessness, a sense of failure and the inability to cope. METHODS We conducted a systematic review with qualitative data analysis following PRISMA criteria with the following aims: to review validated assessment instruments of the demoralization syndrome, report main findings regarding demoralization as measured by validated instruments that emerge in the literature, compare and report evidence for the clinical utility of the identified instruments. Utilizing the key word 'demoralization' in PubMed and PsycINFO databases, an electronic search was performed, supplemented by Web of Science and manual searches. Study selection criteria included the assessment of medical patients and use of instruments validated to assess demoralization. Seventy-four studies were selected. RESULTS Four instruments emerged in the literature. Main findings concern prevalence rates of demoralization, evidence of discriminant validity from major depression, factors associated with demoralization and evidence of clinical utility. The instruments vary in their definition, the populations they aim to assess, prevalence rates they estimate and their ability to discriminate between different conditions. Nonetheless, demoralization appears to be a distinctive psychological state characterized by helplessness, hopelessness, giving up and subjective incompetence. It is not limited to life-threatening diseases such as cancer, but may occur in any type of clinical situation. It is associated with stress and adverse health outcomes. CONCLUSIONS Studies addressing the incremental value of demoralization in psychiatry and psychology are needed. However, demoralization appears to entail specific clinical features and may be a distinct condition from major depression.
Collapse
Affiliation(s)
- L Tecuta
- Laboratory of Psychosomatics and Clinimetrics, Department of Psychology,University of Bologna,Bologna,Italy
| | - E Tomba
- Laboratory of Psychosomatics and Clinimetrics, Department of Psychology,University of Bologna,Bologna,Italy
| | - S Grandi
- Laboratory of Psychosomatics and Clinimetrics, Department of Psychology,University of Bologna,Bologna,Italy
| | - G A Fava
- Laboratory of Psychosomatics and Clinimetrics, Department of Psychology,University of Bologna,Bologna,Italy
| |
Collapse
|
21
|
Asselmann E, Wittchen HU, Lieb R, Höfler M, Beesdo-Baum K. Does help-seeking alter the risk for incident psychopathology in adolescents and young adults with and without fearful spells or panic attacks? Findings from a 10-year prospective-longitudinal community study. J Affect Disord 2014; 169:221-7. [PMID: 25216465 DOI: 10.1016/j.jad.2014.08.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 08/06/2014] [Accepted: 08/07/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND Although fearful spells (FS) and panic attacks (PA) increase the risk for various mental disorders, few studies have examined whether help-seeking in those with FS/PA attenuates the risk for incident psychopathology. METHODS A community sample of adolescents and young adults (N=2978, aged 14-24 at baseline) was followed up in up to 3 assessment waves over 10 years. FS, PA, psychopathology, and help-seeking were assessed using the DSM-IV/M-CIDI. Logistic regressions with interaction terms (adjusted for sex and age) were used to test interactions between FS/PA and help-seeking at baseline on predicting incident psychopathology at follow-up. Cases with panic disorder (PD) at baseline were excluded from all analyses. RESULTS FS/PA at baseline predicted the onset of any disorder, any anxiety disorder, PD, agoraphobia, generalized anxiety disorder, social phobia, and depression at follow-up (Odds Ratios, OR 1.62-5.80). FS/PA and help-seeking at baseline interacted on predicting incident PD (OR=0.09) and depression (OR=0.22) at follow-up in a way that FS/PA only predicted the respective disorders in individuals not seeking help at baseline. In those with FS/PA, a higher number of panic symptoms interacted with help-seeking on predicting incident PD (OR=0.63) in a way that a higher number of panic symptoms only increased the risk for PD in those without help-seeking at baseline. LIMITATIONS Help-seeking at baseline was not restricted to panic-specific interventions, but included treatment due to other psychological problems as well. CONCLUSIONS Findings suggest that early help-seeking might modify psychopathology trajectories and prevent incident disorders in high-risk individuals with FS/PA.
Collapse
Affiliation(s)
- Eva Asselmann
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany; Behavioral Epidemiology, Technische Universität Dresden, Germany.
| | - Hans-Ulrich Wittchen
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany; Max Planck Institute of Psychiatry, Munich, Germany
| | - Roselind Lieb
- Max Planck Institute of Psychiatry, Munich, Germany; Department of Psychology, Division of Clinical Psychology and Epidemiology, University of Basel, Switzerland
| | - Michael Höfler
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany
| | - Katja Beesdo-Baum
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany; Behavioral Epidemiology, Technische Universität Dresden, Germany
| |
Collapse
|
22
|
Behandlerkontinuität bei Wechsel der Behandlung-Settings. PSYCHOTHERAPEUT 2014. [DOI: 10.1007/s00278-014-1054-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
23
|
Wesner AC, Gomes JB, Detzel T, Blaya C, Manfro GG, Heldt E. Effect of cognitive-behavioral group therapy for panic disorder in changing coping strategies. Compr Psychiatry 2014; 55:87-92. [PMID: 23958283 DOI: 10.1016/j.comppsych.2013.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 05/23/2013] [Accepted: 06/10/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Cognitive-behavioral group therapy (CBGT) is an efficient treatment for panic disorder (PD). However, the role of CBGT in enhancing strategies to cope with stressful events has not been established. AIM To evaluate the effect of CBGT on the choice of coping strategy by PD patients compared to a group of individuals without mental disorders. METHODS Forty-eight PD patients who completed a 12-session CBGT protocol were compared to 75 individuals without mental disorders regarding coping strategies as evaluated by the Coping Strategies Inventory (CSI). The severity of PD was assessed at baseline and after CBGT through the Clinical Global Impression (CGI) scale, the Hamilton Anxiety Scale (HAM-A), and the Panic Inventory (PI). RESULTS Treatment was effective in reducing PD severity in all outcome measures. Patients used significantly fewer confrontation, escape and avoidance strategies after CBGT. The use of more adaptive coping strategies was related to a decrease in panic attacks and anticipatory anxiety. Application of the CSI showed that the use of strategies was also significantly different in patients as compared to the control group, except for escape and avoidance, which became similar after the CBGT protocol. CONCLUSIONS Despite the changes observed after the CBGT protocol, the choice of coping strategy was still different in patients vs. controls. The current CBGT protocol was used specifically to assess PD symptoms. Other cognitive tools should be included to address maladaptive coping strategies.
Collapse
Affiliation(s)
- Ana Cristina Wesner
- Anxiety Disorders Program, Hospital de Clínicas de Porto Alegre, Brazil; Graduate Program in Medical Sciences: Psychiatry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | | | | | | |
Collapse
|
24
|
Fava GA, Tossani E, Bech P, Berrocal C, Chouinard G, Csillag C, Wittchen HU, Rief W. Emerging clinical trends and perspectives on comorbid patterns of mental disorders in research. Int J Methods Psychiatr Res 2014; 23 Suppl 1:92-101. [PMID: 24375537 PMCID: PMC6878355 DOI: 10.1002/mpr.1412] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Comorbidity is a well-established and documented phenomenon in mental disorders and medicine with heuristic value. The concept of comorbidity remains however poorly defined and lacks a comprehensive and coherent theoretical framework. There is a need to develop coherent methodological strategies in order to promote a fuller understanding of the implications of comorbidity and to exploit its potential value with regard to etiopathogenic and therapeutic issues. This position paper makes recommendations of improved methodological standards and procedures and discusses a range of options that can provide incremental information that is likely to improve therapeutic outcomes.
Collapse
Affiliation(s)
- Giovanni A Fava
- Laboratory of Psychosomatics and Clinimetrics, Department of Psychology, University of Bologna, Bologna, Italy
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Meyerbroeker K, Morina N, Kerkhof GA, Emmelkamp PMG. Virtual reality exposure therapy does not provide any additional value in agoraphobic patients: a randomized controlled trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2013; 82:170-6. [PMID: 23548832 DOI: 10.1159/000342715] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Accepted: 08/14/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND A number of studies have demonstrated the efficacy of virtual reality exposure therapy (VRET) in specific phobias, but research in seriously impaired patients with agoraphobia is lacking. In this randomized controlled trial with patients with agoraphobia and panic disorder, VRET and exposure in vivo were compared in terms of outcome and processes involved. METHODS Patients with panic disorder with agoraphobia (n = 55) were randomly assigned to receive 4 sessions of cognitive behavioral therapy (CBT) followed by either 6 sessions of VRET or 6 sessions of exposure in vivo or to a waiting list control condition. RESULTS Analyses showed that both active treatment packages were significantly more effective than no treatment and that no differences between VRET and exposure in vivo were found in three out of four outcome measures. On the panic disorder severity scale, however, CBT plus exposure in vivo was more effective than CBT plus VRET. The results show clear synchrony of temporal processes involved in VRET and exposure in vivo on weekly avoidance measures and cognitive measures. Further, it was shown that initial changes in agoraphobic cognitions during the CBT phase predicted later changes in agoraphobic avoidance behavior. CONCLUSION These data support the notion that therapeutic processes involved might be the same in VRET and exposure in vivo. However, given the slight superiority of exposure in vivo above VRET, the costs involved in the implementation of VRET and the lack of long-term follow-up, VRET cannot yet be recommended for patients with agoraphobia.
Collapse
Affiliation(s)
- K Meyerbroeker
- Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands.
| | | | | | | |
Collapse
|
26
|
Lindner D, Lacefield K, Tantleff Dunn S, Dunn ME. The Use of Videoconference in the Treatment of Panic Disorder With Agoraphobia in a Housebound Woman. Clin Case Stud 2013. [DOI: 10.1177/1534650113504292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Individuals with Panic Disorder With Agoraphobia (PD/A) experience recurrent unexpected panic attacks and anxiety about the attacks along with significant anxiety about being in places or situations in which it would be difficult to escape or receive assistance if a panic attack were to occur. Feared situations are endured with extreme distress or avoided entirely. Cognitive-behavioral therapy (CBT) is the treatment of choice for PD and PD/A. In this case study, interoceptive exposure (IE) therapy and in vivo exposure therapy were used to treat a 30-year-old housebound woman. Following in-home assessment, psychoeducation, and a limited number of exposure sessions, clinical services were transitioned from in-home to using videoconferencing until in vivo exposure sessions began outside the home. The client was able to meet all behavioral goals by the end of treatment and no longer met criteria for PD/A. This case demonstrates the treatment effectiveness in an individual. Future research should seek to conduct randomized control trials to determine whether videoconference is an efficacious method of delivery for PD/A. This case demonstrates evidence for videoconferencing as an effective tool in treatment delivery for PD/A.
Collapse
|
27
|
Kircher T, Arolt V, Jansen A, Pyka M, Reinhardt I, Kellermann T, Konrad C, Lueken U, Gloster AT, Gerlach AL, Ströhle A, Wittmann A, Pfleiderer B, Wittchen HU, Straube B. Effect of cognitive-behavioral therapy on neural correlates of fear conditioning in panic disorder. Biol Psychiatry 2013; 73:93-101. [PMID: 22921454 DOI: 10.1016/j.biopsych.2012.07.026] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 06/30/2012] [Accepted: 07/02/2012] [Indexed: 01/04/2023]
Abstract
BACKGROUND Learning by conditioning is a key ability of animals and humans for acquiring novel behavior necessary for survival in a changing environment. Aberrant conditioning has been considered a crucial factor in the etiology and maintenance of panic disorder with agoraphobia (PD/A). Cognitive-behavioral therapy (CBT) is an effective treatment for PD/A. However, the neural mechanisms underlying the effects of CBT on conditioning processes in PD/A are unknown. METHODS In a randomized, controlled, multicenter clinical trial in medication-free patients with PD/A who were treated with 12 sessions of manualized CBT, functional magnetic resonance imaging (fMRI) was used during fear conditioning before and after CBT. Quality-controlled fMRI data from 42 patients and 42 healthy subjects were obtained. RESULTS After CBT, patients compared to control subjects revealed reduced activation for the conditioned response (CS+ > CS-) in the left inferior frontal gyrus (IFG). This activation reduction was correlated with reduction in agoraphobic symptoms from t1 to t2. Patients compared to control subjects also demonstrated increased connectivity between the IFG and regions of the "fear network" (amygdalae, insulae, anterior cingulate cortex) across time. CONCLUSIONS This study demonstrates the link between cerebral correlates of cognitive (IFG) and emotional ("fear network") processing during symptom improvement across time in PD/A. Further research along this line has promising potential to support the development and further optimization of targeted treatments.
Collapse
Affiliation(s)
- Tilo Kircher
- Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Rudolf-Bultmann-Straße 8, Marburg, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|