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Background Psychological flexibility theory (PFT) suggests three key processes of change: increases in value-directed behaviors, reduction in struggle with symptoms, and reduction in suffering. We hypothesized that Acceptance and Commitment Therapy (ACT) would change these processes and that increases in valued action and decreases in struggle would precede change in suffering. Method Data were derived from a randomized clinical trial testing ACT (vs. waitlist) for treatment-resistant patients with primary panic disorder with/without agoraphobia (n = 41). Valued behavior, struggle, and suffering were assessed at each of eight sessions. Results Valued actions, struggle, and suffering all changed over the course of therapy. Overall changes in struggle and suffering were inter dependent whereas changes in valued behavior were largely in dependent. Levels of valued behaviors influenced subsequent suffering, but the other two variables did not influence subsequent levels of valued action. Discussion This finding supports a central tenet of PFT that increased (re-)engagement in valued behaviors precedes reductions in suffering. Possible implications for a better understanding of response and non-response to psychotherapy are discussed. [ABSTRACT FROM AUTHOR]

Confusion between panic and asthma symptoms can result in serious self-management errors. A cognitive behavior psychophysiological therapy (CBPT) intervention was culturally adapted for Latinos consisting of CBT for panic disorder (PD), asthma education, differentiation between panic and asthma symptoms, and heart rate variability biofeedback. An RCT compared CBPT to music and relaxation therapy (MRT), which included listening to relaxing music and paced breathing at resting respiration rates. Fifty-three Latino (primarily Puerto Rican) adults with asthma and PD were randomly assigned to CBPT or MRT for 8 weekly sessions. Both groups showed improvements in PD severity, asthma control, and several other anxiety and asthma outcome measures from baseline to post-treatment and 3-month follow-up. CBPT showed an advantage over MRT for improvement in adherence to inhaled corticosteroids. Improvements in PD severity were mediated by anxiety sensitivity in CBPT and by depression in MRT, although earlier levels of these mediators did not predict subsequent improvements. Attrition was high (40%) in both groups, albeit comparable to CBT studies targeting anxiety in Latinos. Additional strategies are needed to improve retention in this high-risk population. Both CBPT and MRT may be efficacious interventions for comorbid asthma-PD, and CBPT may offer additional benefits for improving medication adherence. [ABSTRACT FROM AUTHOR]

Objective To investigate predictors and moderators of treatment outcome by comparing immediate face-to-face cognitive behavioral therapy (FtF-CBT) to a Stepped Care treatment model comprising three steps: Psychoeducation, Internet-delivered CBT, and FtF-CBT for panic disorder (PD) and social anxiety disorder (SAD). Method Patients ( N = 173) were recruited from nine public mental health out-patient clinics and randomized to immediate FtF-CBT or Stepped Care treatment. Characteristics related to social functioning, impairment from the anxiety disorder, and comorbidity was investigated as predictors and moderators by treatment format and diagnosis in multiple regression analyses. Results Lower social functioning, higher impairment from the anxiety disorder, and a comorbid cluster C personality disorder were associated with significantly less improvement, particularly among patients with PD. Furthermore, having a comorbid anxiety disorder was associated with a better treatment outcome among patients with PD but not patients with SAD. Patients with a comorbid depression had similar outcomes from the different treatments, but patients without comorbid depression had better outcomes from immediate FtF-CBT compared to guided self-help. Conclusions In general, the same patient characteristics appear to be associated with the treatment outcome for CBT provided in low- and high-intensity formats when treated in public mental health care clinics. The findings suggest that patients with lower social functioning and higher impairment from their anxiety disorder benefit less from these treatments and may require more adapted and extensive treatment. ClinicalTrials.gov Identifier: NCT00619138 . [ABSTRACT FROM AUTHOR]

Cognitive behavioral therapy (CBT) is an evidence-based treatment for mental disorders. Several meta-analytical reviews supported its efficacy and effectiveness in the treatment of panic disorder with agoraphobia (PD/AG). Recently, it has been shown that neurobiological changes are associated with the process and outcome of CBT. However, the general and specific neurobiological effects of CBT are still widely unknown. Therefore, the potential of applying neuroscience to clinical practice and optimizing CBT is still limited. The current review summarizes recent findings about the neural correlates of CBT in PD/AG measured with fMRI. Furthermore, the current review will focus on neural activation patterns predicting and moderating therapeutic success of CBT, due to its potential application in personalized treatment in the future. Finally, we will discuss some future perspectives of the neurosciences in CBT research. [ABSTRACT FROM AUTHOR]

Although cognitive-behavioural therapy (CBT) is an effective first-line intervention for anxiety disorders, treatments remain long and cost-intensive, difficult to access, and a subgroup of patients fails to show any benefits at all. This study aimed to identify functional and structural brain markers that predict a rapid response to CBT. Such knowledge will be important to establish the mechanisms underlying successful treatment and to develop more effective, shorter interventions. Fourteen unmedicated patients with panic disorder underwent 3 T functional and structural magnetic resonance imaging (MRI) before receiving four sessions of exposure-based CBT. Symptom severity was measured before and after treatment. During functional MRI, patients performed an emotion regulation task, either viewing negative images naturally, or intentionally down-regulating negative affect by using previously taught strategies of cognitive reappraisal. Structural MRI images were analysed including left and right segmentation and volume estimation. Improved response to brief CBT was predicted by increased pre-treatment activation in bilateral insula and left dorsolateral prefrontal cortex (dlPFC) during threat processing, as well as increased right hippocampal gray matter volume. Previous work links these regions to improved threat processing and fear memory activation, suggesting that the activation of such mechanisms is crucial for exposure-based CBT to be effective. [ABSTRACT FROM AUTHOR]

Cognitive models of panic disorder (PD) with or without agoraphobia have stressed the role of catastrophic beliefs of bodily symptoms as a central mediating variable of the efficacy of cognitive behavioral therapy (CBT). Perceived ability to cope with or control panic attacks, panic self-efficacy, has also been proposed to play a key role in therapeutic change; however, this cognitive factor has received much less attention in research. The aim of the present review is to evaluate panic self-efficacy as a mediator of therapeutic outcome in CBT for PD using descriptive and meta-analytic procedures. We performed systematic literature searches, and included and evaluated 33 studies according to four criteria for establishing mediation. Twenty-eight studies, including nine randomized waitlist-controlled studies, showed strong support for CBT improving panic self-efficacy (criterion 1); ten showed an association between change in panic self-efficacy and change in outcome during therapy (criterion 2); three tested, and one established formal statistical mediation of panic self-efficacy (criterion 3); while four tested and three found change in panic self-efficacy occurring before the reduction of panic severity (criterion 4). Although none of the studies fulfilled all of the four criteria, results provide some support for panic self-efficacy as a mediator of outcome in CBT for PD, generally on par with catastrophic beliefs in the reviewed studies. [ABSTRACT FROM AUTHOR]

Abstract: Objective: This study explored the automatic and controlled processes that may influence performance on an implicit measure across cognitive-behavioral group therapy for panic disorder. Method: The Quadruple Process model was applied to error scores from an Implicit Association Test evaluating associations between the concepts Me (vs. Not Me) + Calm (vs. Panicked) to evaluate four distinct processes: Association Activation, Detection, Guessing, and Overcoming Bias. Parameter estimates were calculated in the panic group (n = 28) across each treatment session where the IAT was administered, and at matched times when the IAT was completed in the healthy control group (n = 31). Results: Association Activation for Me + Calm became stronger over treatment for participants in the panic group, demonstrating that it is possible to change automatically activated associations in memory (vs. simply overriding those associations) in a clinical sample via therapy. As well, the Guessing bias toward the calm category increased over treatment for participants in the panic group. Conclusions: This research evaluates key tenets about the role of automatic processing in cognitive models of anxiety, and emphasizes the viability of changing the actual activation of automatic associations in the context of treatment, versus only changing a person's ability to use reflective processing to overcome biased automatic processing. [Copyright &y& Elsevier]

Abstract: Although the alliance–outcome correlation is well established, no published studies to date have separated between therapists' and patients' contributions while controlling for early symptom change. In this study, we examined therapist effects in two trials of CBT for panic disorder with agoraphobia (PDA) and the impact of therapists' and patients' contribution to the alliance on outcome and attrition in one trial. Alliance ratings were obtained from patients and therapists early and late in treatment (n = 133). Data were analyzed using multi-level modeling controlling for early symptom change. No therapist effects were found. The patients' contribution to the alliance predicted outcome (in both panic severity and anxiety sensitivity) and attrition. The therapists' contribution to the alliance predicted attrition but not outcome. Results suggest that the patient's contribution to the alliance plays an important role in CBT for PDA and that including common factors into research on CBT may help elucidate treatment processes. [Copyright &y& Elsevier]

Abstract: The present study examined temporal dependencies of change of panic symptoms and two promising mechanisms of change (self-efficacy and anxiety sensitivity) during an 11-session course of cognitive-behavior therapy (CBT) for Panic Disorder (PD). 361 individuals with a principal diagnosis of PD completed measures of self-efficacy, anxiety sensitivity, and PD symptoms at each session during treatment. Effect size analyses indicated that the greatest changes in anxiety sensitivity occurred early in treatment, whereas the greatest changes in self-efficacy occurred later in treatment. Results of parallel process latent growth curve models indicated that changes in self-efficacy and anxiety sensitivity across treatment uniquely predicted changes in PD symptoms. Bivariate and multivariate latent difference score models indicated, as expected, that changes in anxiety sensitivity and self-efficacy temporally preceded changes in panic symptoms, and that intraindividual changes in anxiety sensitivity and self-efficacy independently predicted subsequent intraindividual changes in panic symptoms. These results provide strong evidence that changes in self-efficacy and anxiety sensitivity during CBT influence subsequent changes in panic symptoms, and that self-efficacy and anxiety sensitivity may therefore be two distinct mechanisms of change of CBT for PD that have their greatest impact at different stages of treatment. [Copyright &y& Elsevier]

Abstract: Cognitive-behavioral treatments for panic disorder (PD) emphasize interoceptive exposure (IE) to target anxiety sensitivity (AS) but vary considerably in its manner of delivery. This randomized controlled trial was conducted to compare the efficacy of the low-dose delivery of IE exercises often prescribed in treatment protocols to an intensive form of IE hypothesized to optimize inhibitory learning. Participants (N = 120) with elevated AS were randomly assigned to one of four single-session interventions: (a) low-dose IE as prescribed in Barlow and Craske's Panic Control Treatment, (b) low-dose IE without controlled breathing or a lengthy between-trial rest period, (c) intensive IE, or (d) expressive writing control. Compared to the other conditions, intensive IE produced significantly greater reductions in AS and fearful responding to a straw breathing task from pretreatment to posttreatment. Maintenance of gains during the follow-up period did not differ between conditions. Changes in fear toleration and negative outcome expectancies fully mediated the superior efficacy of intensive IE over low-dose IE. The two low intensity IE conditions produced particularly high rates of fear sensitization on between-trial and outcome variables. The findings suggest that the intensive delivery of IE exercises has the potential to improve the efficacy of exposure-based treatments for PD. [Copyright &y& Elsevier]

Abstract: The efficacy of cognitive behavioural therapy (CBT) for panic disorder with or without agoraphobia (PD) is well-established; however, little is known about the underlying change processes of clinical improvement during therapy. According to cognitive theories, CBT for PD primarily works by changing catastrophic misinterpretations of bodily symptoms and panic attacks. However, panic self-efficacy, i.e. the perceived ability to cope with panic attacks, has also been suggested as an important change mechanism in CBT for PD. The aim of the study was to investigate if change in catastrophic misinterpretations and panic self-efficacy mediated change in the level of anxiety during the course of thirteen sessions of group CBT for PD. Forty-five participants completed weekly self-report measures of the possible cognitive mediators and the level of anxiety throughout therapy. The results indicated that within-person change in panic self-efficacy in one session, but not in catastrophic misinterpretations, predicted within-person level of anxiety symptoms the following week. However, in a reversed analysis, prior change in level of anxiety symptoms also predicted change in panic self-efficacy the following session. These results support panic self-efficacy as a mediator of change in CBT for PD, although a reciprocal causal relationship between panic self-efficacy and level of anxiety seems to be implied. [Copyright &y& Elsevier]

Abstract: Despite its acute efficacy for the treatment of panic disorder, benzodiazepines (BZs) are associated with a withdrawal syndrome that closely mimics anxiety sensations, leading to difficulty with treatment discontinuation and often disorder relapse. An exposure-based cognitive-behavioral treatment for BZ discontinuation, Panic Control Treatment for BZ Discontinuation (CBT) targets the fear of these sensations and has demonstrated efficacy in preventing disorder relapse and facilitating successful BZ discontinuation among patients with panic disorder. In this randomized controlled trial, CBT was compared to taper alone and a taper plus a relaxation condition to control for the effect of therapist contact and support among 47 patients with panic disorder seeking taper from BZs. Based on the primary outcome of successful discontinuation of BZ use, results indicate that adjunctive CBT provided additive benefits above both taper alone and taper plus relaxation, with consistently medium and large effect sizes over time that reached significance at the six month follow-up evaluation. The efficacy of CBT relative to either of the other taper conditions reflected very large and significant effect sizes at that time. These findings suggest that CBT provides specific efficacy for the successful discontinuation from BZs, even when controlling for therapist contact and relaxation training. [ABSTRACT FROM AUTHOR]

Abstract: Classical fear-conditioning is central to many etiologic accounts of panic disorder (PD), but few lab-based conditioning studies in PD have been conducted. One conditioning perspective proposes associative-learning deficits characterized by deficient safety learning among PD patients. The current study of PD assesses acquisition and retention of discriminative aversive conditioning using a fear-potentiated startle paradigm. This paradigm was chosen for its specific capacity to independently assess safety- and danger learning in the service of characterizing putative anomalies in each type of learning among those with PD. Though no group difference in fear-potentiated startle was found at retention, acquisition results demonstrate impaired discriminative learning among PD patients as indexed by measures of conditioned startle-potentiation to learned safety and danger cues. Importantly, this discrimination deficit was driven by enhanced startle-potentiation to the learned safety cue rather than aberrant reactivity to the danger cue. Consistent with this finding, PD patients relative to healthy individuals reported higher expectancies of dangerous outcomes in the presence of the safety cue, but equal danger expectancies during exposure to the danger cue. Such results link PD to impaired discrimination learning, reflecting elevated fear responding to learned safety cues. [Copyright &y& Elsevier]

Presents information on a study which investigated the role of trauma and dissociation in the cognitive-behavioral treatment of panic disorder with agoraphobia (PDA). Variety of trauma-related variables considered; Symptoms of disssociation; Relationship of trauma with panic disorder and agoraphobia; Results of the study.

Examines the rate of symptom improvement in patients receiving cognitive-behavioral group treatment for panic disorder in an outpatient clinic setting. How the study was conducted; Results of the study; Discussion of the results.

Investigates the impact of pre-existing pharmacotherapy regimes on the long-term outcome of brief intensive group cognitive behavioral therapy in the treatment of panic disorder with or without agoraphobia. Social consequences and impact of agoraphobia and panic disorder on quality of life; Usefulness of combined treatment; Medication status at pre-treatment.

Presents more controversies on the cognitive-behavior therapy (CBT) as a treatment for panic disorder. Incorporation of drug and pill placebo conditions in CBT researchers trial design; Interpretation of the unreplicated drug effects; Reasons for valuing the design.

Focuses on the controversial analyses of the cognitive-behavior therapy as a treatment for panic disorders. Comparability of samples across treatment studies; Ignorance regarding the predictors of response and non-response; Treatment effectiveness; Presentation of an erroneous presumption; Explanation of the active control equivalence studies.

Criticizes Richard J. McNally's reply on cognitive-behavior therapy's (CBT's) larger effect sizes than antidepressants or benzodiazepines in the treatment for panic disorder. Panic control treatment comparison; McNally's misstatement of the author's argument on CBT; Explanation of the three-arm study of panic disorder.