Behaviour therapy and benzodiazepines: allies or antagonists?

Developmental psychopathology as a meta-paradigm: From zero-sum science to epistemological pluralism in theory and research

In a thoughtful commentary in this journal a decade ago, Michael Rutter reviewed 25 years of progress in the field before concluding that developmental psychopathology (DP) initiated a paradigm shift in clinical science. This deduction requires that DP itself be a paradigm. According to Thomas Kuhn, canonical paradigms in the physical sciences serve unifying functions by consolidating scientists' thinking and scholarship around single, closed sets of discipline-defining epistemological assumptions and methods. Paradigm shifts replace these assumptions and methods with a new field-defining framework. In contrast, the social sciences are multiparadigmatic, with thinking and scholarship unified locally around open sets of epistemological assumptions and methods with varying degrees of inter-, intra-, and subdisciplinary reach. DP challenges few if any of these local paradigms. Instead, DP serves an essential pluralizing function, and is therefore better construed as a metaparadigm. Seen in this way, DP holds tremendous untapped potential to move the field from zero-sum thinking and scholarship to positive-sum science and epistemological pluralism. This integrative vision, which furthers Dante Cicchetti's legacy of interdisciplinarity, requires broad commitment among scientists to reject zero-sum scholarship in which portending theories, useful principles, and effective interventions are jettisoned based on confirmation bias, errors in logic, and ideology.

Absence of definitive scientific evidence that benzodiazepines could hinder the efficacy of exposure-based interventions in adults with anxiety or posttraumatic stress disorders: A systematic review of randomized clinical trials

BACKGROUND AND OBJECTIVES

Exposure-based interventions (EBIs) are the first-line treatment for anxiety disorders and posttraumatic stress disorder. Although common, the association between EBIs and benzodiazepines is controversial. Therefore, we systematically reviewed the literature to evaluate if benzodiazepines could undermine the efficacy of EBIs in treating these disorders.

METHODS

We conducted a systematic review aiming for randomized clinical trials (RCTs) in ISI Web of Science, Scopus, PubMed/MEDLINE, and PsycINFO databases. We scrutinized the reference list of selected papers and other systematic reviews. Finally, we evaluated the methodological quality and the scientific evidence of the studies.

RESULTS

We screened 1,529 studies and included 12 RCTs in this review (all showing some concerns or high risk of bias). Benzodiazepines did not impact the efficacy of EBIs in nine studies at posttreatment, improved efficacy in two, and reduced it in one. In the follow-up, benzodiazepines (after its discontinuation) did not impact the efficacy in six studies and reduced it in five. The scientific level of evidence achieved was B for both phases.

CONCLUSIONS

Until now there is no definitive evidence that benzodiazepines could hinder the EBIs' efficacy for treating posttraumatic stress disorder and anxiety disorders.

Trauma Management Therapy and Prolonged Exposure Therapy for PTSD in an active duty sample: Design and methodology of a randomized clinical trial

Posttraumatic stress disorder (PTSD) resulting from military service is a common, yet often chronic condition. Treatment outcome often is attenuated by programs that are (a) lengthy in nature and (b) constricted in their target outcomes. These limitations leave much of the emotional and behavioral impairment that accompanies PTSD unaddressed and/or unassessed. Typical PTSD treatment programs are 3–4 months in length, which is challenging for the pace of the nation's military. In this investigation, we will compare two treatments, Trauma Management Therapy (TMT) and Prolonged Exposure (PE), both redesigned to address the needs of active duty personnel (300 participants at 3 military installations). Specifically, we will compare the TMT Intensive Outpatient Program (IOP; 3 weeks) to PE's compressed (2 week) format. Both interventions will be compared to a standard course of PE (12 weeks). In addition to PTSD symptomatology, outcome measurement includes other aspects of psychopathology as well as changes in social, occupational, and familial impairment. Potential negative outcomes of massed treatment, such as increased suicidal ideation or increased alcohol use, will be assessed, as will genetic predictors of PTSD subtype and treatment outcome. This study will inform the delivery of care for military-related PTSD and particularly the use of intensive or compressed treatments for active duty personnel.

The efficacy of Trauma Management Therapy: A controlled pilot investigation of a three-week intensive outpatient program for combat-related PTSD

Despite the 8-18.5% of returning Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF) and Operation New Dawn (OND) veterans who are suffering from posttraumatic stress disorder (PTSD), few receive empirically supported treatments. Among those that do, the dropout rate is high and more than 50% retain their diagnosis after treatment. This study evaluated the efficacy of Trauma Management Therapy (TMT), delivered in a 3-week intensive outpatient (IOP) format. TMT combines virtual-reality augmented individual exposure therapy with a group intervention to address social isolation, anger, and depression. One hundred twelve (112) OIF/OEF/OND veterans and active duty personnel participated. Assessment included measures of PTSD, sleep, depression, anger, guilt, and social isolation, administered at post-treatment, 3-month, and 6-month follow-up. The effect size for TMT delivered in an IOP format was 2.06, with 65.9% no longer meeting diagnostic criteria for PTSD. There were similar positive effects in other domains and treatment gains were maintained at 6-month follow-up. The results are discussed regarding the need for efficacious, multi-component interventions that can be delivered safely and rapidly, and the potential of this approach towards that end.

Clinical effectiveness of a cognitive behavioral group treatment program for anxiety disorders: a benchmarking study

Previous research has established efficacy of cognitive behavioral therapy (CBT) for anxiety disorders, yet it has not been widely assessed in routine community clinic practices. Efficacy research sacrifices external validity to achieve maximum internal validity. Recently, effectiveness research has been advocated as more ecologically valid for assessing routine clinical work in community clinics. Furthermore, there is a lack of effectiveness research in group CBT. This study aims to extend existing research on the effectiveness of CBT from individual therapy into group therapy delivery. It aimed also to examine outcome using not only symptom measures, but also measures of related symptoms, cognitions, and life quality and satisfaction. Results from a cohort of patients with various anxiety disorders demonstrated that treatment was effective in reducing anxiety symptoms to an extent comparable with other effectiveness studies. Despite this, only 43% of individuals showed reliable change, and 17% were 'recovered' from their anxiety symptoms, and the post-treatment measures were still significantly different from the level of anxiety symptoms observed in the general population.

Combined psychotherapy plus benzodiazepines for panic disorder

BACKGROUND

The efficacy of combining psychotherapy and benzodiazepines for panic disorder is unclear, despite widespread use.

OBJECTIVES

To examine the efficacy of the combination compared with either treatment alone.

SEARCH STRATEGY

Randomised trials comparing the combination of psychotherapy and benzodiazepine with either therapy alone for panic disorder were identified. The Cochrane Depression, Anxiety and Neurosis Group Studies and References Registers were searched. References of relevant trials and other reviews were checked. Experts in the field were contacted. Additional unpublished data were sought from authors of the original trials.

SELECTION CRITERIA

Two authors independently checked the records retrieved by the searches to identify randomised trials comparing the combined therapy versus either of the monotherapies, among adults with panic disorder.

DATA COLLECTION AND ANALYSIS

Two authors independently checked eligibility, assessed quality and extracted data from the eligible trials using a standardised data extraction form. The primary outcome was "response" based on global judgement. Random-effects meta-analyses were conducted, combining data from included trials.

MAIN RESULTS

Three trials met eligibility criteria. A 16-week behaviour therapy intervention was used in two trials, and a 12-week cognitive-behaviour therapy intervention in the third. Duration of follow-up varied, ranging from 0 to 12 months. Two trials (total 166 participants) provided data comparing combination with psychotherapy alone (both using behaviour therapy). No statistically significant differences were observed in response during the intervention (relative risk (RR) for combination 1.25, 95% CI 0.78 to 2.03, P = 0.35), at the end of the intervention (RR 0.78, 0.45 to 1.35, P = 0.37), or at the last follow-up time point, although the follow-up data suggested that the combination might be inferior to behaviour therapy alone (RR 0.62, 0.36 to 1.07, P = 0.08). One trial (77 participants) compared combination with a benzodiazepine alone. No differences were found in response during the intervention (RR 1.57, 0.83 to 2.98, P = 0.17). Although the combination appeared to be superior to the benzodiazepine alone at the end of treatment (RR 3.39, 1.03 to 11.21, P = 0.05) the finding was only borderline statistically significant, and no significant differences were observed at the 7-month follow-up (RR 2.31, 0.79 to 6.74, P = 0.12).

AUTHORS' CONCLUSIONS

The review established the paucity of high quality evidence investigating the efficacy of psychotherapy combined with benzodiazepines for panic disorder. Currently, there is inadequate evidence to assess the clinical effects of psychotherapy combined with benzodiazepines for patients who are diagnosed with panic disorder.

Combining alprazolam with systematic desensitization therapy for dental injection phobia

To determine whether a benzodiazepine facilitates systematic desensitization, 144 subjects with dental injection phobia received systematic desensitization in combination with placebo or one of two doses of alprazolam (0.5mg or 0.75mg). Systematic desensitization therapy included computer-controlled presentation of digitized video segments followed by in vivo exposure segments, culminating in an actual dental injection. Subjects advanced to the next hierarchy segment when low anxiety was reported during a segment. Alprazolam and placebo groups progressed at the same rate. The 0.75mg group had elevated heart rates while watching video segments compared with placebo. In a subsequent behavioral avoidance test (during which subjects were randomized to a new drug condition), there was no indication that state-dependent learning had occurred. Dental fear was reduced similarly in all groups for 1 year after study completion. No advantage was found to combining alprazolam with systematic desensitization for dental injection phobia.

Combination of psychotherapy and benzodiazepines versus either therapy alone for panic disorder: a systematic review

BACKGROUND

The efficacy of combined psychotherapy and benzodiazepine treatment for panic disorder is still unclear despite its widespread use. The present systematic review aims to examine its efficacy compared with either monotherapy alone.

METHODS

All randomised trials comparing combined psychotherapy and benzodiazepine for panic disorder with either therapy alone were identified by comprehensive electronic search on the Cochrane Registers, by checking references of relevant studies and of other reviews, and by contacting experts in the field. Two reviewers independently checked eligibility of trials, assessed quality of trials and extracted data from eligible trials using a standardized data extraction form. Our primary outcome was "response" defined by global judgement. Authors of the original trials were contacted for further unpublished data. Meta-analyses were undertaken synthesizing data from all relevant trials.

RESULTS

Only two studies, which compared the combination with behaviour (exposure) therapy, met our eligibility criteria. Both studies had a 16-week intervention. Unpublished data were retrieved for one study. The relative risk for response for the combination was 1.25 (95%CI: 0.78 to 2.03) during acute phase treatment, 0.78 (0.45 to 1.35) at the end of treatment, and 0.62 (0.36 to 1.07) at 6-12 months follow-up. Some secondary outcomes hinted at superiority of the combination during acute phase treatment. One study was identified comparing the combination to benzodiazepine. The relative risk for response was 1.57 (0.83 to 2.98), 3.39 (1.03 to 11.21, statistically significant) and 2.31 (0.79 to 6.74) respectively. The superiority of the combination was observed on secondary outcomes at all the time points. No sub-group analyses were conducted due to the limited number of included trials.

CONCLUSION

Unlike some narrative reviews in the literature, our systematic search established the paucity of high quality evidence for or against the combined psychotherapy plus benzodiazepine therapy for panic disorder. Based on limited available published and unpublished data, however, the combined therapy is probably to be recommended over benzodiazepine alone for panic disorder with agoraphobia. The combination might be superior to behaviour therapy alone during the acute phase, but afterwards this trend may be reversed. We know little from these trials about their adverse effects.

Benzodiazepines and anxiety disorders: a review for the practicing physician

OBJECTIVES AND SCOPE: The objective of this article is to briefly review for practicing clinicians differences among the benzodiazepines (BZDs) that are commonly used to treat anxiety, the efficacy of BZDs in various anxiety disorders, and potential safety issues associated with BZDs, including adverse events, tolerance, dependence, and withdrawal.

METHODOLOGY

Information for this review was obtained using literature searches through PubMed (1966-2004), Google, and the Food and Drug Administration Catalog of Approved Drugs. Data sources were searched for information regarding anxiety disorders and the safety and efficacy of BZDs. Wherever possible and appropriate, information from randomized controlled trials was given priority.

FINDINGS

Benzodiazepines have demonstrated efficacy in treating patients with anxiety disorders, with varying degrees of efficacy. Use of BZDs is advantageous because they have a quick onset of action and are generally well tolerated. Extended-release formulations of BZDs may be particularly advantageous in some patients with anxiety as they allow for maximization of a drug's therapeutic window with consistent serum drug concentrations.

CONCLUSIONS

BZDs remain a mainstay in the treatment of anxiety, as both monotherapy and adjunctive therapy. Factors to consider prior to prescribing a BZD include the patient's diagnosis, as well as drug characteristics, including the potential for interactions with other drugs, the risk of dependence and withdrawal, and the required frequency of dosing.

Pharmacotherapy for social phobia

BACKGROUND

Social phobia (SP), or social anxiety disorder, is a prevalent and disabling disorder. There is growing evidence that SP is mediated by specific neurobiological factors, and increased interest in the use of medication in its treatment.

OBJECTIVES

To assess the effects of pharmacotherapy for Social Phobia, and to determine whether particular classes of medication are more effective and/or acceptable than others in its treatment.

SEARCH STRATEGY

Studies of the pharmacotherapy of SP were identified using literature searches of the Cochrane Depression, Anxiety & Neurosis Group (CCDAN) specialised register, the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 1, 2004), MEDLINE (1966 to 2003) and PsycLit (1966 to 2003). In addition, published and unpublished RCTs were requested from SP researchers and pharmaceutical companies and additional studies of any language were sought in reference lists of retrieved articles.

SELECTION CRITERIA

All RCTs of the pharmacotherapy of SP were considered for the review.

DATA COLLECTION AND ANALYSIS

The quality of selected RCTs was independently assessed by 2 raters on the CCDAN Quality Rating Scale, with the same raters collating data on treatment response and SP symptom ratings. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class (SSRIs - selective serotonin reuptake inhibitors; MAOIs - Monoamine oxidase inhibitors; RIMAs - reversible inhibitors of monoamine oxidase A), from which dichotomous and continuous measures were calculated, heterogeneity was assessed, and subgroup/sensitivity analyses undertaken.

MAIN RESULTS

36 RCTs of a range of medications were included in the analysis (4268 participants), of which 26 were short-term (14 weeks or less). A funnel plot provided evidence of publication bias. Summary statistics for responder status (assessed using the Clinical Global Impressions scale change item (CGI-C)) from 25 short-term comparisons demonstrated superiority of various medication agents over placebo (relative risk of non-response (RR) = 0.63; 95% CI = 0.55, 0.72; random effects model). Response to treatment by serotonin reuptake inhibitors (N = 11; RR = 0.67; 95% CI = 0.59, 0.76), MAOIs (N = 3; RR = 0.43; 95% CI = 0.24, 0.76) and RIMAs (N = 6; RR = 0.74; 95% CI = 0.59, 0.91) supported the value of these agents. However, the SSRIs were significantly more effective than the RIMAs (Deeks' stratified test of heterogeneity (Deeks 2001): Qb = 29.82; p < 0.00001). Summary statistics for SP symptoms from 16 comparisons using the Liebowitz Social Anxiety Scale (LSAS) showed a statistically significant difference between medication and placebo (weighed mean difference = -15.56, 95%CI = -17.95, -13.16), with this effect once again most evident for the SSRIs. Medication was also significantly superior to placebo in reducing SP symptom clusters, comorbid depressive symptoms, and associated disability. The value of long-term medication treatment in treatment responders was supported by 3 comparisons from maintenance studies (relative risk of non-response = 0.58; 95% CI = 0.39, 0.85) and 5 comparisons from relapse prevention studies (relative risk of relapse = 0.33; 95% CI = 0.22, 0.49).

REVIEWERS' CONCLUSIONS

This review provides evidence that medication can be effective in treating SP over the short term, with the strongest evidence of treatment efficacy observed amongst the SSRIs. Furthermore, the data support continued pharmacotherapy in medication responders over the longer-term. Nevertheless, the possibility of publication has to be acknowledged. Additional issues for future research include the use of medication in children and adolescents with SP, and in SP with comorbid psychiatric disorders.

Naturalistic manner of benzodiazepine use and cognitive behavioral therapy outcome in panic disorder with agoraphobia

Benzodiazepines (BZs) are commonly used in conjunction with cognitive behavioral therapy (CBT) in the treatment of panic disorder with agoraphobia (PDA). However, empirical evidence provides little support for the utility of this combined treatment approach over CBT alone. Westra and Stewart [Clin. Psychol. Rev. 18 (1998) 307] have proposed that pm or as-needed use of BZs may inhibit positive CBT outcome to a greater extent than regularly scheduled BZ use. Using a naturalistic design, the present study investigated the impact of manner of BZ use on treatment outcome from CBT in 43 patients with PDA. Among various BZ parameters (chronicity, frequency, dose, and frequency of prn use), pm use of BZs for coping with anxiety symptoms was a significant negative predictor of degree of change in both anxiety sensitivity and anxious arousal from pre- to post-CBT. Although no significant between-group differences were evident in pre-treatment symptomatology, unmedicated subjects demonstrated the most positive overall CBT outcome, while pm BZ users evidenced the fewest gains. Regular BZ users were generally not significantly differentiated from unmedicated subjects in CBT outcome and both tended to obtain post-treatment scores in the nonclinical range. Implications of these findings for clinical management of BZ use throughout CBT for PDA are discussed.

Treatment of generalized anxiety disorder in older adults

Older adults with generalized anxiety disorder (GAD; N = 75; M age = 67.1 years) were randomly assigned to cognitive-behavioral therapy (CBT), a discussion group (DG) organized around worry-provoking topics, or a waiting period. Participants in both active conditions improved relative to the waiting list. Although CBT participants improved on more measures than DG participants, the authors found only I significant difference immediately after treatment and no differences at 6-month follow-up. Effect sizes were smaller than in younger samples, but CBT showed large effects and DG showed medium-sized effects Overall, results indicate that brief treatment of late-life GAD is beneficial, but they provide only limited support for the superiority of CBT to a credible comparison intervention.

The effects of single-dose lorazepam on memory and behavioural learning

To assess the influence of lorazepam on memory and behavioural learning, a non-clinical sample of undergraduate psychology students (n = 24), received lorazepam (2.5 mg) or placebo orally. Pre-drug and post-drug neuropsychological assessment comprised the Rey auditory verbal learning test, verbal fluency test, digit span and word stem completion. Relative to placebo, lorazepam induced a marked deficit in delayed free-recall, perceptual priming, and written word fluency, with preservation of digit span. Behavioural learning was assessed on a computer-aided vicarious exposure treatment for obsessive-compulsive disorder, administered post-drug, and repeated 1 week later, drug free. Compared to placebo, lorazepam treated participants enacted 51% less exposure activity on the behavioural learning task post-drug. Whilst both groups enacted increased exposure at the drug-free session, exposure activity was 49% less in the lorazepam group, indicating a carryover effect of the impaired learning under drug 1 week before. There were no significant differences between lorazepam and placebo on indices of overall activity on the program. These results suggest lorazepam-induced impairment in the ability to learn behavioural strategies, possibly due to impaired acquisition of information into long-term episodic memory. These findings suggest caution in the co-prescribing of benzodiazepines in people undergoing behavioural therapies in clinical populations.

The psychobiology of anxiolytic drug. Part 2: Pharmacological treatments of anxiety

Benzodiazepines have been the mainstay of pharmacological treatment of anxiety over the last 4 decades. The problems associated with their use prompted the research for alternative agents that would be useful in anxiety conditions. Old classes of antidepressants, such as tricyclic antidepressants and monoamine oxidase inhibitors, showed effectiveness in some anxiety syndromes, even in areas where benzodiazepines were not very effective. Newer antidepressants, the selective serotonin-reuptake inhibitors, also appear very useful in some anxiety states, and their favourable side-effect profile has elevated them to first-line treatment tools in these conditions. However, the ideal anxiolytic does not exist. Research with other new compounds is very active, and some experimental drugs show promise for the future.

Fears and phobias in people with diabetes

Phobic disorders are more common in people with diabetes than in the general population. The management of phobic disorders in patients with diabetes, particularly when associated with a fear of hypoglycaemia, is especially challenging and requires close collaboration between psychological medicine and diabetes teams. Difficulty in distinguishing symptoms of anxiety from those of hypoglycaemia, and the real dangers associated with hypoglycaemia, complicate the delivery of psychological interventions that are used routinely in the treatment of phobias. Avoidance of hypoglycaemia can lead to deterioration in diabetes control. This case report describes a man with Type 1 diabetes who developed agoraphobia with panic disorder, associated with fear of hypoglycaemia and deterioration in glycaemic control. The management of patients with diabetes and phobic disorders, with particular reference to those associated with fear of hypoglycaemia, is discussed.

The use of benzodiazepines in anxiety and other disorders

Benzodiazepines have come under scrutiny and attack over recent years because of their abuse liability, withdrawal reactions and development of tolerance. Consequently, practitioners worldwide are discouraged from prescribing them. While some of these risks may have been exaggerated, benzodiazepines remain a useful therapeutic tool, alone or in combination, in a number of psychiatric and medical conditions. Withholding such treatment may be unjustified and detrimental to the patients' health. Further, benzodiazepines have helped researchers in their attempts to elucidate the neurobiological mechanisms underlying anxiety. This, in return, leads to the development of new effective anxiolytic treatments, with fewer problems compared to the traditional benzodiazepine compounds. Such new agents are already available or at the closing stages of clinical trials.

Respiratory training prior to exposure in vivo in the treatment of panic disorder with agoraphobia: efficacy and predictors of outcome

Thirty-two patients suffering from panic disorder with agoraphobia were treated with repeated hyperventilation provocations and respiratory training, followed by exposure in vivo. The treatment was evaluated with a comprehensive set of outcome measures, including self-report questionnaires, a multitask behavioural avoidance test and continuous monitoring of panic. The treatment was found effective for the majority of patients in diminishing the frequency of panic attacks and agoraphobic avoidance. The clinical relevance of the treatment effect was evidenced by the considerable number of patients that recovered. The effect of the treatment was sustained over a three and six month follow-up period. The prognostic value of a number of variables for treatment outcome was also investigated. Three variables accounted for the majority of the variance in treatment outcome: a higher pretreatment level of agoraphobic complaints, use of psychotropic medication and a longer duration of the disorder were associated with poorer outcome. Other variables, such as the therapeutic relationship and the quality of the marital bond, had no prognostic value.

Memory functions, alprazolam and exposure therapy: a controlled longitudinal study of agoraphobia with panic disorder

Benzodiazepines (BZs) produce transient anterograde amnesia when given to normal subjects. The present longitudinal study assessed whether BZs impair memory functions in a clinically anxious group. Eighty-two agoraphobics with panic disorder were randomly allocated to one of four treatment groups resulting from a combination of two drug treatments (alprazolam or placebo) and two psychological treatments (exposure or relaxation). Of these, 38 subjects were assessed on a range of objective and subjective indices of memory and mood at three time points: before treatment, after 8 weeks of treatment and again at 24 weeks when patients had been free of medication from 5-8 weeks. Alprazolam produced pronounced impairments on a word recall task. At the 24-week medication-free follow-up, alprazolam patients were still impaired on the task compared with placebo patients. Alprazolam did not impair performance on an implicit memory task and did not affect digit span. Differences between psychological treatments emerged mainly in subjective memory effects. Findings are discussed in terms of the specificity of BZ-induced amnesia and differential tolerance to the varying effects of BZs. Implications are drawn out for the patient's ability to function optimally in daily life while taking alprazolam.

Continuous monitoring of panic

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

Effects of concurrent diazepam treatment on the outcome of exposure therapy in agoraphobia

In a study designed to evaluate the impact of benzodiazepine use on the outcome of behaviour therapy, 91, severe, chronic agoraphobics (46 BDZ users and 45 non-users) were randomly allocated on a double-blind basis to in vivo exposure with low-dose diazepam (ED) or placebo (EP). Drug doses were adjusted on the basis of weekly psychiatric assessments over weeks 1-4. Patients had 8 x 2 hr exposure sessions (weeks 5-12) and were then withdrawn from medication (weeks 13-16). Re-assessments were completed at weeks 4, 12 and 16, and follow-up assessments at approx 20, 46 and 72 weeks. In the analysis of the results, the clinical outcome was evaluated in relation to the therapeutic regime (ED vs EP) and prior BDZ use (users vs non-users). The results showed that the ED group had greater changes in anxiety than the EP group during the drug manipulation phases (anxiety increasing during BDZ withdrawal). There were no group differences in agoraphobic symptoms and no evidence that the outcome of the behavior therapy was significantly affected by concurrent BDZ treatment. There were significant improvements in agoraphobic symptoms over the treatment period, with no evidence for relapse of treatment gains on withdrawal from BDZ, nor for differential responses over the one year follow-up. Initial differences between users and non-users were less marked than expected, although there was a trend for more drop-outs among users across both ED and EP groups.

Panic disorder: clinical perspectives

The evolution of the concept of panic disorder is described and its utility in identifying treatment strategies outlined. Some data are provided which may account for the female preponderance in diagnosed cases. In discussing the continuing role of benzodiazepines the curious history of their progressive restriction in Britain is described. Component and cluster analysis of the phenomena associated with panic attacks provides unexpected support for Klein's theory linking the disorder with an evolved alarm mechanism for suffocation. Current concepts on treatment are briefly reviewed.

Medication use and the assessment of agoraphobic avoidance

Many anxiety disorder patients who present for behaviour therapy are already taking anxiolytic medications. The present study added a new subscale to the Mobility Inventory labelled 'Without Medication' to assess possible reliance on medication for coping with phobic situations. 121 Patients with panic-related disorders were administered the scale. The results supported the reliability and validity of the existing Mobility Inventory subscales in general and of the new subscale in particular. It appears to reliably assess a clinically important domain that is not measured in traditional self-report measures of phobic avoidance.

A meta-analysis of treatments for panic disorder with agoraphobia: imipramine, alprazolam, and in vivo exposure

The most common pharmacological treatments for panic disorder with agoraphobia (PDA) include the use of imipramine and alprazolam while the most common behavior therapy is the use of graded in vivo exposure. Several studies have found these treatments to be superior to placebo in the treatment of PDA, but it has not been clear if there are differences among these three treatments. It has also not been clear for what aspects of PDA each treatment is the most effective. The purpose of this study was to conduct a meta-analysis of the results of relevant treatment outcome studies on a number of dependent variables (e.g., panic attack severity, dysphoria, avoidance behavior). Few studies satisfied the minimum criteria for inclusion and the final data pool consisted of 34 treatment studies. Imipramine was found to be generally ineffective for most variables. Alprazolam was significantly effective for panic and anxiety variables in PDA, while exposure was significantly effective for phobia variables. Exposure had the most consistently strong effect sizes.

A review of the psychopharmacology of panic disorder: individual differences and non specific factors

This paper critically examines the pharmacological provocation and treatment of panic disorder. An analysis of research findings on how panic attacks are induced indicates that there are psychological and non specific factors that may mediate biochemical etiological models, and these individual differences need to be investigated further. This has important implications for the psychopharmacological management of panic. A review of studies on treating panic disorder with imipramine and alprazolam emphasizes the importance of several non specific factors that include the role of self-directed in vivo exposure and changes in dysphoria and self-efficacy (subjective beliefs regarding personal competency) in predicting outcome. It is recommended that any treatment of panic-related disorders include self-directed, in vivo exposure.

Benzodiazepines, memory and mood: a review

The amnestic effects of benzodiazepines (BZs) have attracted considerable research interest. This reflects not only the clinical implications of memory failure for people prescribed these drugs but also the potential of BZs as tools in modelling organic memory problems. As well as impairing certain aspects of human memory functions, BZs affect mood states by reducing anxiety and inducing sedation. An unresolved issue is the extent to which the amnestic effects of BZs are separable from their sedative and anxiolytic effects. The present review focuses on this issue, first presenting a conceptual framework for evaluating the interrelationship between the various effects of BZs, and then summarising recent volunteer and patient research relevant to dissociating amnestic from other effects. Clinical implications are discussed in terms of the use of BZs alone or as adjuncts to psychotherapy for anxiety disorders, and attention is drawn to the need for more ecological validity in psychopharmacological research. Theoretical implications are explored in terms of BZs as tools in studying both memory failure and the relationship between mood and cognition.