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Background: Collaborative stepped care (CSC) may be an appropriate model to provide evidence-based treatment for anxiety disorders in primary care. Methods: In acluster randomised controlled trial, the effectiveness of CSC compared to care as usual (CAU) for adults with panic disorder (PD) or generalised anxiety disorder (GAD) in primary care was evaluated. Thirty-one psychiatric nurses who provided their services to 43 primary care practices in the Netherlands were randomised to deliver CSC (16 psychiatric nurses, 23 practices) or CAU (15 psychiatric nurses, 20 practices). CSC was provided by the psychiatric nurses (care managers) in collaboration with the general practitioner and a consultant psychiatrist. The intervention consisted of 3 steps, namely guided self-help, cognitive behavioural therapy and antidepressants. Anxiety symptoms were measured with the Beck Anxiety Inventory (BAI) at baseline and after 3, 6, 9 and 12 months. Results: We recruited 180 patients with a DSM-IV diagnosis of PD or GAD, of whom 114 received CSC and 66 received usual primary care. On the BAI, CSC wassuperior to CAU [difference in gain scores from baseline to 3 months: -5.11, 95% confidence interval (CI) -8.28 to -1.94; 6 months: -4.65, 95% CI -7.93 to -1.38; 9 months: -5.67, 95% CI -8.97 to -2.36; 12 months: -6.84, 95% CI -10.13 to -3.55]. Conclusions: CSC, with guided self-help as a first step, was more effective than CAU for primary care patients with PD or GAD. © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

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]

Panic-Focused Psychodynamic Psychotherapy (PFPP) is a 24-session, twice-weekly treatment that has been manualized and has demonstrated efficacy in a randomized controlled trial in the treatment of panic disorder. The treatment has recently been extended to address additional DSM-IV anxiety disorders and Cluster C personality traits and disorders. The manualized approach identifies a set of dynamisms that contribute to panic onset and persistence involving intrapsychic conflicts about separation, autonomy, anger, and guilt. The treatment aims at increasing patients' recognition and understanding of these dynamics through exploration of the meaning and circumstances of their panic attacks, related intrapsychic dynamics, developmental factors, and the transference. The termination of treatment is particularly important in working through conflicts surrounding separation and autonomy. This article describes the formulation and psychotherapeutic approach in greater depth, and a case example is provided. We then provide a summary of the research on this treatment. [ABSTRACT FROM PUBLISHER]

Objective: Although exposure-based cognitive-behavioral therapy (CBT) is an effective treatment option for panic disorder with agoraphobia, the neural substrates of treatment response remain unknown. Evidence suggests that panic disorder with agoraphobia is characterized by dysfunctional safety signal processing. Using fear conditioning as a neurofunctional probe, the authors investigated neural baseline characteristics and neuroplastic changes after CBT that were associated with treatment outcome in patients with panic disorder with agoraphobia. Method: Neural correlates of fear conditioning and extinction were measured using functional MRI before and after a manualized CBT program focusing on behavioral exposure in 49 medication-free patients with a primary diagnosis of panic disorder with agoraphobia. Treatment response was defined as a reduction exceeding 50% in Hamilton Anxiety Rating Scale scores. Results: At baseline, nonresponders exhibited enhanced activation in the right pregenual anterior cingulate cortex, the hippocampus, and the amygdala in response to a safety signal. While this activation pattern partly resolved in nonresponders after CBT, successful treatment was characterized by increased right hippocampal activation when processing stimulus contingencies. Treatment response was associated with an inhibitory functional coupling between the anterior cingulate cortex and the amygdala that did not change over time. Conclusions: This study identified brain activation patterns associated with treatment response in patients with panic disorder with agoraphobia. Altered safety signal processing and anterior cingulate cortex-amygdala coupling may indicate individual differences among these patients that determine the effectiveness of exposure-based CBT and associated neuroplastic changes. Findings point to brain networks by which successful CBT in this patient population is mediated. [ABSTRACT FROM AUTHOR]

Internet-based cognitive behaviour therapy (ICBT) can be equally effective as traditional face-to-face cognitive behaviour therapy (CBT) for treating panic disorder (PD). However, little is known about the predictors and moderators of outcome of ICBT when delivered in psychiatric outpatient settings. This study investigated a selection of outcome predictors and moderators of ICBT for panic disorder based on data from a randomised controlled trial where therapist-guided ICBT was compared with group CBT (GCBT) for panic disorder. Participants (N = 104) received 10 weeks of ICBT or GCBT and were assessed before and after treatment, and after six months. Multiple regression analyses were used to test for significant predictors of treatment outcome. Predictors of positive treatment response for both modalities were having low levels of symptom severity and work impairment. In addition, anxiety sensitivity was found to have a small negative relationship with treatment outcome, suggesting that anxiety sensitivity may slightly enhance treatment response. Treatment modality had a moderating effect on the relationship between domestic impairment and outcome and on the relationship between initial age of onset of panic symptoms and treatment outcome, favouring ICBT for patients having had an early onset of PD symptoms and for patients having a high domestic functional impairment. These results suggest that both ICBT and GCBT are effective treatment modalities for PD and that it is possible to predict a significant proportion of the long-term outcome variance based on clinical variables. [ABSTRACT FROM AUTHOR]

Abstract: Objective: This study was aimed to study the treatment effects of antidepressant for regional homogeneity (ReHo), an indicator of synchronization of brain function, in panic disorder (PD) patients. Method: Twenty-one remitted PD patients with escitalopram treatment and 21 healthy controls all received 3-T magnetic resonance imaging scanning at baseline and sixth week. We utilized REST (Resting State FMRI Data Analysis Toolkit, version 1.4) to calculate regional homogeneity (ReHo) of patients and controls at baseline and sixth week. We compared the ReHo at baseline with the ReHo at sixth week to estimate the treatment effects for the ReHo of remitted patients. Besides, inter-scan effects were evaluated in the control group. The group-related differences between remitted patients and controls were also estimated. Results: Remitted PD patients had increases in ReHo of right Heschl gyrus (superior temporal lobe) and decreases in ReHo of right angular gyrus (parietal lobe). The improvements in severity of panic symptoms were negatively correlated with the changes of ReHo in right superior parietal lobe. However, remitted patients still had lower ReHo than controls in right Heschl gyrus and left thalamus. Conclusion: The changes in ReHo of temporo-parietal regions might represent treatment-related ReHo changes for remission of PD. The residual alterations in ReHo of temporo-thalamic regions might represent group-related ReHo differences for patients with PD. [Copyright &y& Elsevier]

Abstract: Abnormal gyrification patterns may reflect aberrant cortical connectivity during an early period of brain maturation. We here investigated anatomical distribution of cortical gyrification deficits underlying panic disorder and the relationships of these potential neurodevelopmental markers with panic symptom severity. High-resolution three-dimensional T1-weighted structural images were obtained from 23 patients with panic disorder and 33 matched healthy individuals. Local gyrification indices were measured in each genetically-based parcellated cortical subregion and regional gyrification patterns were compared between groups. Cortical areas in which gyrification patterns were associated with panic symptom severity were also determined. Significant reductions in cortical gyrification were observed in panic patients compared with healthy individuals, which were mainly distributed in the lateral brain extending from the fronto-parietal to the temporal areas. In contrast, hyper-gyrification in the posteromedial cortical regions which exert interconnecting roles in the default mode network, was associated with less severe panic symptoms. Post-hoc analysis for the inter-regional covariance of local gyrification indices revealed that interconnections of the posteromedial cortical regions with other cortical areas which belong to the default mode network were reduced in panic patients with severe symptoms relative to either less severe patients or healthy individuals. Our findings suggest not only substantial perturbation in cortical gyrification patterns in panic disorder but also potential contribution of integrated cortical folding pattern of the default mode network to alleviated panic severity. [Copyright &y& Elsevier]

Abstract: Objective: Low serum phosphate level is considered one of the metabolic adaptations to the respiratory alkalosis induced by hyperventilation associated with panic disorder. The aim of this study was to assess phosphatemia as a possible state marker for panic disorder. Methods: Sixteen panic disorder patients underwent clinical assessment with a semi-structured interview, a set of rating scales and the self-rated State and Trait Anxiety Inventory (STAI), as well as extraction of venous blood samples at baseline and after 12 weeks of pharmacological treatment. Ten healthy volunteers of similar sex, age and educational level filled out the STAI and gave blood samples at baseline and 12 weeks later. Results: The median (25th–75th percentiles) of phosphate levels (mg/dl) was 2.68 (2.22–3.18) among patients and 4.13 (3.74–4.70) among healthy volunteers respectively (P < 0.001). Seven (44%) patients and no healthy volunteers presented low serum phosphate (<2.50 mg/dl) at baseline; this patient abnormality was corrected in all cases after successful treatment. At baseline, the age-adjusted correlation between phosphate levels and state-anxiety was −0.66 (P < 0.001) among all 26 participants and −0.51 (P = 0.05) among the 16 panic disorder patients. Conclusions: Measurement of phosphate levels could be easily introduced into clinical practice as a possible marker for chronic hyperventilation in panic disorder, although further investigations with larger sample sizes are necessary to characterize panic disorder patients with low versus normal phosphate levels. [Copyright &y& Elsevier]

Objective: Short-term clinical trials have demonstrated the efficacy and safety of pregabalin in the treatment of generalized anxiety disorder (GAD). This study examined long-term safety and tolerability of pregabalin in patients with GAD, social anxiety disorder (SAD), or panic disorder (PD). Research design and methods: Patients (n=528) completing one of four randomized, double-blind, placebo-controlled trials of pregabalin for GAD, SAD, or PD were treated, open label, with flexible-dose pregabalin (150–600 mg/day) for 1 year. Main outcome measures: The primary outcomes were safety and tolerability. Illness severity was assessed at baseline and Weeks 27/ 52 using the Clinical Global Impression of Severity (CGI-S) scale. Patients were characterized as 'responders' or 'non-responders' based on CGI-S scores ≤2 and ≥2, respectively. Analyses were performed on the total anxiety (GAD, SAD and PD) and GAD groups. Results: During 1 year of treatment with pregabalin, dizziness (12.5%) was the only treatment-related adverse event (AE) occurring ≥10%. Somnolence, weight gain, headache and insomnia occurred at 7.6%, 5.5%, 5.3% and 4.7%, respectively. Few treatment-related AEs were rated as severe in the total anxiety (5.1%) or GAD (3.6%) groups. Discontinuation rates due to AEs were similar (9.7% and 10.6%, respectively). No clinically significant laboratory, electrocardiogram, or other treatment-related safety findings were noted, except for treatment-related weight gain, which occurred in both the total (24.4%) and GAD (19.4%) groups. Mean CGI-S scores were similar at baseline in the total (n=528; score, 3.4) and GAD groups (n=330; score, 3.6), and CGI-S responder rates were similar at last-observation-carried-forward endpoint (51.3% and 48.1%, respectively). Conclusions: Pregabalin was generally well tolerated in the long-term treatment of anxiety disorders. Improvement in illness severity was maintained over time. The key limitations of this study were that it was not randomized and neither placebo- nor active-comparator-controlled. [ABSTRACT FROM AUTHOR]

Abstract: Objective:: We designed this study to investigate neural correlates of white matter micro-structural integrity of remitted patients with first-episode, medication-naïve and very late-onset panic disorder Method:: Twenty-one remitted patients with panic disorder completed treatment course with treatment of escitalopram (dose range around 10–15mg/d). Twenty-one healthy controls were also enrolled into this study. Patients and controls all received 3-Tesla magnetic resonance imaging diffusion tensor imaging scanning at baseline and 6th week. We utilized FDT (FMRIB's Diffusion Toolbox v2.0) function of FSL (FMRIB Software Library) to calculate fractional anisotropy (FA). We compared FA values of patients and controls at baseline and 6th week to estimate the changes of FA of remitted patient group and inter-scan bias of controls. FA outputs of remitted patients and controls were compared by independent t test. Results:: We found increased FA in some regions of right uncinate fasciculus and left fronoto-occipital fasciculus after remission in patient group (corrected p<0.05). Reduced FA of other regions of right uncinate fasciculus was still observed in remitted patients when they were compared to the control group. Conclusion:: Subtle changes of white matter micro-structural integrity after remission might represent neural correlates of treatment effects for first-episode, medication-naïve and very late-onset panic disorder. [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]

A pilot comparison was made between two treatments for panic disorder, eye movement desensitization and reprocessing (EMDR) and cognitive behavioral therapy (CBT). Treatment was provided in the private practice settings of 7 credentialed therapists, whose treatment fidelity was monitored throughout the study. Five outcome measures were administered at pretreatment, posttreatment, and 1-year follow-up. There was significant improvement for participants in both groups (N = 19) after 12 sessions of treat-ment. No significant differences in outcome were seen between the 2 therapies, except for lower fre-quency of panic attacks reported by those in the EMDR group. The current study reanalyzed the data previously reported in Faretta (2012). Further research in this area is suggested. [ABSTRACT FROM AUTHOR]

The aim of this research was to examine the efficacy of two cognitive-behavioral treatment modalities for panic disorder (PD) with nocturnal panic (NP). The first study was conducted to determine whether conventional CBT for PD was effective for PD with NP in three participants. A second study sought to explore whether a CBT adapted to NP would lead to different clinical outcomes in three other participants. A multiple-baseline single-case design across individuals was used in both studies. Treatment outcome was assessed with standardized clinician ratings, self-report questionnaires, and daily self-monitoring. Results revealed that both the conventional and the adapted treatments showed a faster decrease in NPs versus daytime panics and significant clinical changes in all measures for up to a year after therapy. Hence, the changes brought about by the adapted treatment seemed to be similar to those obtained using conventional treatment. In light of these results, it can be presumed that conventional strategies may be sufficient for the treatment of NP. These observations raise questions regarding the real need to adapt treatments specifically to NP. [ABSTRACT FROM AUTHOR]

Background: Previous studies have suggested that physical exercise can reduce symptoms for subjects suffering from panic disorder (PD). The efficacy of this intervention has so far not been compared to an established psychotherapy, such as cognitive behaviour therapy (CBT). Assessment of controlled long-term effects and the clinical significance of the treatment are also lacking. Aim: To compare physical exercise to CBT as treatment for PD, and assess controlled long-term and clinically significant effects. Method: PD-patients were randomized to either three weekly sessions of physical exercise (n = 17), or one weekly session of CBT (n = 19). Both treatments ran for 12 weeks, were manualized and administered in groups. Patients were assessed twice before the start of treatment, at post-treatment and at 6 and 12 months thereafter. Primary outcome-measures consisted of the Mobility Inventory (MI), the Agoraphobia Cognitions Questionnaire (ACQ) and the Body Sensations Questionnaire (BSQ). Results: A two-way repeated measures MANOVA of these measures demonstrated a significant effect of time, F{ 16, 544) = 7.28, p < .01, as well as a significant interaction effect, F{ 16, 544) = 1.71, p < .05, in favour of CBT. This finding was supported by the assessment of clinically significant changes of avoidant behaviour and of treatment-seeking one year later. Conclusion: Group CBT is more effective than group physical exercise as treatment of panic disorder, both immediately following treatment and at follow-up assessments. [ABSTRACT FROM AUTHOR]

Background Most patients with noncardiac chest pain experience anxiety and depressive symptoms. Commonly they are reassured and referred back to primary care, leaving them undiagnosed and untreated. Some small studies have suggested efficacy of 12 cognitive behavioral therapy ( CBT) sessions. Our aim was to examine efficacy of brief CBT in reducing anxiety and depressive symptoms in patients with noncardiac chest pain and comorbid panic and/or depressive disorders. Methods In this 24-week randomized controlled trial comparing CBT (n = 60) versus treatment as usual ( TAU, n = 53), we included all adults who presented at the cardiac emergency unit of a university hospital with noncardiac chest pain, scored ≥8 on the hospital anxiety and depression scale ( HADS) and were diagnosed with a comorbid panic and/or depressive disorder with the Mini International Neuropsychiatric Interview. CBT consisted of six individual sessions. Main outcome was disease severity assessed with the clinical global inventory ( CGI) by a blinded independent rater. Results ANCOVA in the intention-to-treat and completer sample showed that CBT was superior to TAU after 24 weeks in reducing disease severity assessed with CGI (P < .001). Secondary outcomes on anxiety ( HADS-anxiety, state trait anxiety inventory ( STAI)-trait) and depressive symptoms (Hamilton depression rating scale) were in line with these results except for HADS-depression (P = .10), fear questionnaire (P = .13), and STAI-state (P = .11). Conclusions Brief CBT significantly reduces anxiety and depressive symptoms in patients with noncardiac chest pain who are diagnosed with panic and/or depressive disorders. Patients presenting with noncardiac chest pain should be screened for psychopathology and if positive, CBT should be considered. [ABSTRACT FROM AUTHOR]

Background: Some data suggest that older adults with anxiety disorders do not respond as well to treatment as do younger adults.Aims: We examined age differences in outcomes from the Coordinated Anxiety Learning and Management (CALM) study, an effectiveness trial comparing usual care to a computer-assisted collaborative care intervention for primary care patients with panic disorder, generalised anxiety disorder, post-traumatic stress disorder (PTSD), and/or social anxiety disorder. This is the first study to examine the efficacy of a collaborative care intervention in a sample that included both younger and older adults with anxiety disorders. We hypothesised that older adults would show a poorer response to the intervention than younger adults.Method: We examined findings for the overall sample, as well as within each diagnostic category (clinicaltrials.gov identifier: NCT00347269).Results: The CALM intervention was more effective than usual care among younger adults overall and for those with generalised anxiety disorder, panic disorder and social anxiety disorder. Among older adults, the intervention was effective overall and for those with social anxiety disorder and PTSD but not for those with panic disorder or generalised anxiety disorder. The effects of the intervention also appeared to erode by the 18-month follow-up, and there were no significant effects on remission among the older adults.Conclusions: These results are consistent with the findings of other investigators suggesting that medications and psychotherapy for anxiety disorders may not be as effective for older individuals as they are for younger people. [ABSTRACT FROM AUTHOR]

Background: Cognitive behavioral therapy (CBT) is an effective treatment for emotional disorders such as anxiety or depression, but the mechanisms underlying successful intervention are far from understood. Although it has been a long-held view that psychopharmacological approaches work by directly targeting automatic emotional information processing in the brain, it is usually postulated that psychological treatments affect these processes only over time, through changes in more conscious thought cycles. This study explored the role of early changes in emotional information processing in CBT action. Methods: Twenty-eight untreated patients with panic disorder were randomized to a single session of exposure-based CBT or waiting group. Emotional information processing was measured on the day after intervention with an attentional visual probe task, and clinical symptoms were assessed on the day after intervention and at 4-week follow-up. Results: Vigilance for threat information was decreased in the treated group, compared with the waiting group, the day after intervention, before reductions in clinical symptoms. The magnitude of this early effect on threat vigilance predicted therapeutic response after 4 weeks. Conclusions: Cognitive behavioral therapy rapidly affects automatic processing, and these early effects are predictive of later therapeutic change. Such results suggest very fast action on automatic processes mediating threat sensitivity, and they provide an early marker of treatment response. Furthermore, these findings challenge the notion that psychological treatments work directly on conscious thought processes before automatic information processing and imply a greater similarity between early effects of pharmacological and psychological treatments for anxiety than previously thought. [ABSTRACT FROM AUTHOR]

Although associations with outcome have been inconsistent, therapist adherence and competence continues to garner attention, particularly within the context of increasing interest in the dissemination, implementation, and sustainability of evidence-based treatments. To date, research on therapist adherence and competence has focused on average levels across therapists. With a few exceptions, research has failed to address multiple sources of variability in adherence and competence, identify important factors that might account for variability, or take these sources of variability into account when examining associations with symptom change. Objective: (a) statistically demonstrate between- and within-therapist variability in adherence and competence ratings and examine patient characteristics as predictors of this variability and (b) examine the relationship between adherence/competence and symptom change. Method: Randomly selected audiotaped sessions from a randomized controlled trial of cognitive-behavioral therapy for panic disorder were rated for therapist adherence and competence. Patients completed a self-report measure of panic symptom severity prior to each session and the Inventory of Interpersonal Problems-Personality Disorder Scale prior to the start of treatment. Results: Significant between- and within-therapist variability in adherence and competence were observed. Adherence and competence deteriorated significantly over the course of treatment. Higher patient interpersonal aggression was associated with decrements in both adherence and competence. Neither adherence nor competence predicted subsequent panic severity. Conclusions: Variability and "drift" in adherence and competence can be observed in controlled trials. Training and implementation efforts should involve continued consultation over multiple cases in order to account for relevant patient factors and promote sustainability across sessions and patients. [ABSTRACT FROM AUTHOR]

Objectives Although homework assignments are an integral component of cognitive-behavioral therapy (CBT) and relate to positive therapy outcomes, it is unclear whether specific homework types and their completion have specific effects on outcome. Method Data from N = 292 patients (75% female, mean age 36 years) with panic disorder and agoraphobia and treated with standardized CBT were analyzed with homework compliance quality and quantity for different types of homework serving as predictors for different outcome variables. Results Quality ratings of homework completion were stronger outcome predictors than quantitative compliance ratings. Exposure homework was a better outcome predictor than homework relating to psychoeducation and self-monitoring. Conclusion Different aspects of homework compliance and specific homework types might differentially relate to CBT outcome. [ABSTRACT FROM AUTHOR]

Cognitive behavioral theorists have suggested that breathing retraining may be used as a safety behavior. Safety behaviors are acts aimed at preventing or minimizing feared catastrophe and may maintain pathologic anxiety by hindering resolution of maladaptive cognitive processes. An opposing position is that breathing retraining is an effective coping aid. This study examined the safety behavior and coping aid hypotheses as they apply to breathing retraining. Individuals high in fear of respiratory sensations were randomly assigned to a psychoeducation control condition (EDU; n = 27) or a psychoeducation plus breathing retraining condition (EDU+BR; n = 30). As compared to psychoeducation alone, the addition of breathing retraining neither limited improvement of cognitive processes (e.g., anxiety sensitivity) nor added to the gains observed on measures of coping (e.g., perceived control). The findings are evaluated in light of the available literature regarding breathing retraining and the safety behavior and coping aid hypotheses. [ABSTRACT FROM AUTHOR]

Abstract: Background and objectives: Cognitive-behavioral therapies are currently the gold standard for panic disorder treatment, with well-documented treatment response. However, following interventions, some individuals continue to improve, while others experience a return of symptoms. The field lacks reliable ways to predict follow-up symptomatology. In the current study, a cluster analysis with a repeated measures design was conducted to examine change patterns over 12 weeks of cognitive behavioral group therapy for panic disorder. The central aim of the study was to evaluate if change patterns predict level of panic symptom severity at a six month follow-up in this sample. Methods: Individuals with panic disorder (N = 36) completed a measure of panic symptoms (Panic Disorder Severity Scale) at the outset of every therapy session and at a six month follow-up. Results: Results revealed three patterns of change in this specific trial, which significantly predicted level of panic symptoms six months post-treatment, beyond initial or final level of panic symptoms, and beyond total symptom change. Limitations: Given the relatively small, lab-based sample, replications in other settings and samples will be important. Conclusions: Overall, results provide initial evidence that change patterns are meaningful predictors of panic symptom severity well after the final session of treatment. [Copyright &y& Elsevier]

Abstract: Background: The catechol-O-methyltransferase (COMT) gene val158met polymorphism (rs4680) has been found to be associated with various psychiatric phenotypes including panic disorder. Considering the probable genetic influence of COMT on the pathogenesis of panic disorder and white matter connectivity, the present study investigated white matter connectivity using diffusion tensor imaging in relation to the COMT genotype in panic disorder. Methods: Twenty-six patients with panic disorder and twenty-six age- and gender-matched healthy controls participated in this study. Brain magnetic resonance scans and genotype analysis for COMT rs4680 were conducted. Panic Disorder Severity Scale, Albany Panic and Phobia Questionnaire, and Anxiety Sensitivity Inventory-Revised were assessed. Tract-based spatial statistics (TBSS) were used for image analysis. Results: There was no significant difference in white matter analysis between panic disorder and healthy controls. However, TBSS analysis showed increased fractional anisotropy (FA) in posterior thalamic radiation, posterior and superior corona radiata, superior longitudinal fasciculus, and sagittal stratum, all located in the right hemisphere in COMT AA/AG genotype group compared to GG genotype in panic disorder. Voxelwise correlational analysis revealed the symptom severity scores are correlated with the FA in white matter tracts that previously showed significant group differences between AA/AG and GG genotypes in COMT AA/AG genotype group, while no significant correlation was found in GG genotype group. Limitations: The sample size in each group was small, hence, further studies with larger numbers of patients are needed to confirm our findings. Conclusions: These data suggested that COMT rs4680 could affect the white matter connectivity in panic disorder. [Copyright &y& Elsevier]

Abstract: Background: The hypothalamus is a brain structure involved in the neuroendocrine aspect of stress and anxiety. Evidence suggests that generalized anxiety disorder (GAD) and panic disorder (PD) might be accompanied by dysfunction of the hypothalamus-pituitary-adrenal axis (HPA), but so far structural alterations were not studied. We investigated hypothalamic volumes in patients with either GAD or PD and in healthy controls. Methods: Twelve GAD patients, 11 PD patients and 21 healthy controls underwent a 1.5T MRI scan. Hypothalamus volumes were manually traced by a rater blind to subjects'' identity. General linear model for repeated measures (GLM-RM) was used to compare groups on hypothalamic volumes, controlling for total intracranial volume, age and sex. Results: The hypothalamus volume was significantly reduced (p=0.04) in GAD patients, with significant reductions in both the left (p=0.02) and right side (p=0.04). Patients with PD did not differ significantly (p=0.73). Anxiety scores were inversely correlated with hypothalamic volumes. Limitations: The small sample size could reduce the generalizability of the results while the lack of stress hormone measurements renders functional assessment of the hypothalamus-pituitary-adrenal axis not feasible. Conclusions: The present study showed decreased hypothalamic volumes in GAD patients but not in those with PD. Future longitudinal studies should combine volumetric data with measurements of stress hormones to better elucidate the role of the HPA axis in GAD. [Copyright &y& Elsevier]

Abstract: Background: Research on the generalizability of clinical trials in panic disorder is limited. The present study sought to quantify the generalizability of clinical trials'' results of individuals with DSM-IV panic disorder (PD) to a large community sample. Methods: Data were derived from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), a large national representative sample of 43,093 adults of the United States population. We applied a standard set of eligibility criteria representative of PD clinical trials to all adults with past 12 months PD (n=907), and then to a subgroup of participants seeking treatment (n=105). Our aim was to determine the proportion of participants with PD who would have been excluded by typical eligibility criteria. Results: We found that more than 8 out of ten participants (80.52%; 95% CI=77.13–83.52%) with PD were excluded by at least one criterion. In the subgroup of participants who sought treatment, the exclusion rate by at least one criterion was higher (92.40%; 95% CI=84.60–96.42%). For the full sample and the treatment-seeking subsample, having currently a depression and a diagnosis of alcohol or drug abuse/dependence were the criteria excluding the highest percentage of participants. Having a lifetime history of bipolar disorder and a current significant medical condition also excluded a substantial proportion of individuals in both samples. Exclusion rates were similar when considering panic disorder with and without agoraphobia. Conclusions: Clinical trials, that exclude a majority of adults with panic disorder, should carefully consider the impact of eligibility criteria on the generalizability of their results. As required by CONSORT guidelines, reporting exclusion rate estimate and reasons of eligibility should be mandatory in both clinical trials and meta-analyses. [Copyright &y& Elsevier]

Abstract: Interoceptive exposure (IE) is widely regarded as an essential procedure in the cognitive-behavioral treatment of panic disorder (PD). However, treatment manuals differ substantially in their prescribed delivery of IE, and little research exists to inform the optimal manner of its implementation. The present study examined therapists’ perceptions and delivery of IE for PD. Results revealed substantial variability in how clinicians provide IE. In contrast to the prolonged and intense manner in which exposure techniques are traditionally applied, many therapists reported delivering a low dose of IE accompanied by controlled breathing strategies. Concerns about the potential adverse effects of IE were common despite the fact that participants reported the actual occurrence of negative outcomes of IE in their own practice to be extremely infrequent. It is possible that some therapists deliver IE in a cautious manner in an attempt to minimize the perceived risks associated with this treatment. [Copyright &y& Elsevier]

Dissociative symptoms including depersonalization and derealization are commonly experienced by individuals suffering from panic disorder or posttraumatic stress disorder (PTSD). Few studies have been published investigating the specific treatment of these symptoms in individuals diagnosed with panic disorder or PTSD, despite evidence that the subset of individuals with panic disorder who experience depersonalization and derealization report more panic attacks as well as greater panic severity and functional impairment. Furthermore, it has been shown that these symptoms can impede treatment and recovery in PTSD. Finally, recent research has shown that interoceptive exposure generally enhances the efficacy of treatment outcome for PTSD and PTSD with comorbid panic. This study investigated the use of a novel interoceptive exposure technique for treatment of depersonalization and derealization in individuals with high anxiety sensitivity and/or symptoms of PTSD. Results indicated significant reductions on six of seven items as well as total score on an outcome measure of depersonalization and derealization. Thus, this technique appears to hold promise for utilization as a form of interoceptive exposure in the treatment of these symptoms. [ABSTRACT FROM AUTHOR]

Despite the well-established effectiveness of exposure-based cognitive-behavioral therapy (CBT) in the treatment of anxiety disorders, therapists have been slow to adopt CBT into their clinical practice. The present study was conducted to examine the utilization of psychotherapy techniques for anxiety disorders among community practitioners in a rural setting in order to determine the current status of the dissemination of CBT. A sample of 51 licensed psychotherapists from various mental health professions was recruited from online practice listings in the state of Wyoming. Participants completed a survey assessing their use of various psychotherapy techniques in the past 12 months for clients with obsessive-compulsive disorder, post-traumatic stress disorder, panic disorder, and social phobia. Nearly all psychotherapists reported providing CBT, and techniques such as cognitive restructuring, arousal-reduction strategies, and mindfulness were used by the vast majority of respondents. Therapist-assisted exposure was rarely utilized, and providers who delivered exposure therapy often did so alongside other techniques of questionable compatibility with this approach. Non-evidence-based techniques were frequently used, particularly by self-proclaimed anxiety specialists. Our findings highlight the successes and failures of efforts to disseminate exposure-based CBT to community practitioners. Implications for clinical training and practice are discussed. [ABSTRACT FROM AUTHOR]

Objective: We examined the possibility that maintenance cognitive behavior therapy (M--CBT) may improve the likelihood of sustained improvement and reduced relapse in a multi-site randomized controlled clinical trial of patients who met criteria for panic disorder with or without agoraphobia. Method: Participants were all patients (N = 379) who first began an open trial of acute-phase CBT. Patients completing and responding to acute-phase treatment were randomized to receive either 9 monthly sessions of M--BT (n = 79) or assessment only (n = 78) and were then followed for an additional 12 months without treatment. Results: M--CBT produced significantly lower relapse rates (5.2%) and reduced work and social impairment compared to the assessment only condition (18.4%) at a 21-month follow-up. Multivariate Cox proportional hazards models showed that residual symptoms of agoraphobia at the end of acute-phase treatment were independently predictive of time to relapse during 21-month follow-up (hazards ratio = 1.15, p < .01). Conclusions- M--CBT aimed at reinforcing acute treatment gains to prevent relapse and offset disorder recurrence may improve long-term outcome for panic disorder with and without agoraphobia. [ABSTRACT FROM AUTHOR]

Rats with chronic inhibition of GABA synthesis by infusion of l-allyglycine, a glutamic acid decarboxylase inhibitor, into their dorsomedial/perifornical hypothalamus are anxious and exhibit panic-like cardio-respiratory responses to treatment with intravenous (i.v.) sodium lactate (NaLac) infusions, in a manner similar to what occurs in patients with panic disorder. We previously showed that either NMDA receptor antagonists or metabotropic glutamate receptor type 2/3 receptor agonists can block such a NaLac response, suggesting that a glutamate mechanism is contributing to this panic-like state. Using this animal model of panic, we tested the efficacy of CBiPES and THIIC, which are selective group II metabotropic glutamate type 2 receptor allosteric potentiators (at 10–30mg/kg i.p.), in preventing NaLac-induced panic-like behavioral and cardiovascular responses. The positive control was alprazolam (3mg/kg i.p.), a clinically effective anti-panic benzodiazepine. As predicted, panic-prone rats given a NaLac challenge displayed NaLac-induced panic-like cardiovascular (i.e. tachycardia and hypertensive) responses and “anxiety” (i.e. decreased social interaction time) and “flight” (i.e. increased locomotion) -associated behaviors; however, systemic injection of the panic-prone rats with CBiPES, THIIC or alprazolam prior to the NaLac dose blocked all NaLac-induced panic-like behaviors and cardiovascular responses. These data suggested that in a rat animal model, selective group II metabotropic glutamate type 2 receptor allosteric potentiators show an anti-panic efficacy similar to alprazolam. [ABSTRACT FROM AUTHOR]

Abstract: Background: In an open-label trial low-frequency repetitive transcranial magnetic stimulation (rTMS) to the right dorsolateral prefrontal cortex (DLPFC) significantly improved symptoms of panic disorder and major depression. Here we present data of a randomized double-blind study. Methods: Twenty-five patients were assigned 4 weeks of active or sham rTMS to the right DLPFC. rTMS parameters consisted of 1800 stimuli/day, 1-Hz, at 110% of resting motor threshold. Response was defined as a ≥40% decrease on the panic disorder severity scale and a ≥50% decrease on the Hamilton depression rating scale. At the end of the randomized phase, patients were offered the option of receiving open-label rTMS for an additional 4 weeks. Results: Repeated-measures ANOVA revealed significantly better improvement in panic symptoms with active compared with sham rTMS, but no significant difference in depression. At 4 weeks, response rate for panic disorder was 50% with active rTMS and 8% with sham. After 8 weeks of active rTMS, response rate was 67% for panic and 50% for depressive symptoms. Repeated-measure ANOVA showed significant improvements in panic disorder, major depression, clinical global impression, and social adjustment. Clinical improvement was sustained at 6-month follow-up. Limitations: Limitation of this study is the relatively small sample size. Conclusions: Although 4 weeks of rTMS was sufficient to produce a significant effect in panic symptoms, a longer course of treatment resulted in better outcomes for both panic disorder and major depression. These data suggest that inhibitory rTMS to the right DLPFC affects symptoms expression in comorbid anxiety and depression. ClinicalTrials.gov Identifier: NCT00521352. [Copyright &y& Elsevier]

Panic disorder is a chronic course disorder that causes important distress and impaired social function. The relationship between personality disorders and panic disorder has been studied, and determines its severity, course and treatment, but it has not been studied the relationship between personality traits and outcome of panic disorder. 82 patients with a first episode of panic disorder are selected and followed during 1 year, to analyze the existence and kind of relationship between their personality traits and the outcome of their disorder. [ABSTRACT FROM AUTHOR]

Panic disorder is a chronic course disorder that causes important distress and impaired social function. The relationship between personality disorders and panic disorder has been studied, and determines its severity, course and treatment, but it has not been studied the relationship between personality traits and outcome of panic disorder. 82 patients with a first episode of panic disorder are selected and followed during 1 year, to analyze the existence and kind of relationship between their personality traits and the outcome of their disorder. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

A growing body of literature suggests that comorbid anxiety disorders are more common and more prognostically relevant among migraine sufferers than comorbid depression. Panic disorder ( PD) appears to be more strongly associated with migraine than most other anxiety disorders. PD and migraine are both chronic diseases with episodic manifestations, involving significant functional impairment and shared symptoms during attacks, interictal anxiety concerning future attacks, and an absence of identifiable secondary pathology. A meta-analysis of high-quality epidemiologic study data from 1990 to 2012 indicates that the odds of PD are 3.76 times greater among individuals with migraine than those without. This association remains significant even after controlling for demographic variables and comorbid depression. Other less-rigorous community and clinical studies confirm these findings. The highest rates of PD are found among migraine with aura patients and those presenting to specialty clinics. Presence of PD is associated with greater negative impact of migraine, including more frequent attacks, increased disability, and risk for chronification and medication overuse. The mechanisms underlying this common comorbidity are poorly understood, but both pathophysiological (eg, serotonergic dysfunction, hormonal influences, dysregulation of the hypothalamic-pituitary-adrenal axis) and psychological (eg, interoceptive conditioning, fear of pain, anxiety sensitivity, avoidance behavior) factors are implicated. Means of assessing comorbid PD among treatment-seeking migraineurs are reviewed, including verbal screening for core PD symptoms, ruling out medical conditions with panic-like features, and administering validated self-report measures. Finally, evidence-based strategies for both pharmacologic and behavioral management are outlined. The first-line migraine prophylactics are not indicated for PD, and the selective serotonin re-uptake inhibitors used to treat PD are not efficacious for migraine; thus, separate agents are often required to address each condition. Core components of behavioral treatments for PD are reviewed, and their integration into clinical headache practice is discussed. [ABSTRACT FROM AUTHOR]

Abstract: Objective: This study was designed to investigate patterns of fractional amplitude of low-frequency fluctuations (fALFF, an indicator for the intensity of regional brain spontaneous activities) of patients with first-episode drug-naïve panic disorder (PD). Methods: Thirty patients (17 females, 13 males, age: 47.70±10.69 years old) and twenty healthy controls (10 females, 10 males, age: 41.40±13.94 years old) received 3-Tesla resting-state functional magnetic resonance imaging (RFMRI) scanning and the rating of clinical scales. RFMRI data was processed and analyzed by the REST toolbox (resting-state functional MRI data analysis toolbox) to calculate fALFF. fALFF were compared between patients and controls to detect endophenotype of fALFF in patients with first-episode drug-naïve PD. Results: We found decreased fALFF in right middle occipital gyrus [FDR (false discovery rate) corrected p<0.05, cluster >5 voxles, volume >135mm3, T threshold: 6.1168, surface connected theory] and increased fALFF in right putamen and right ventral lateral nucleus of thalamus of patients (uncorrected p<0.00005, cluster >5 voxles, volume >135mm3, T threshold: 4.5439, surface connected theory). fALFF of patients also showed a positive correlation with clinical rating scores of PD in right cuneus. Conclusions: Occipito-striato-thalamic dysfunction of fALFF might represent a kind of endophenotype biomarker of first-episode drug-naïve PD. [Copyright &y& Elsevier]

The article presents abstracts on applied psychophysiology topics which include the effect of short duration heart rate variability (HRV) biofeedback on the performance of cognitive during laboratory induced cognitive stress, treatment of panic disorder in the managed care setting by using psychophysiological protocol and the effect of heart felt emotion on heart rate variability.

Background. Interpersonal psychotherapy (IPT) seems to be as effective as cognitive behavioral therapy (CBT) in the treatment of major depression. Because the onset of panic attacks is often related to increased interpersonal life stress, IPT has the potential to also treat panic disorder. To date, a preliminary open trial yielded promising results but there have been no randomized controlled trials directly comparing CBT and IPT for panic disorder. Method. This study aimed to directly compare the effects of CBT versus IPT for the treatment of panic disorder with agoraphobia. Ninety-one adult patients with a primary diagnosis of DSM-III or DSM-1V panic disorder with agoraphobia were randomized. Primary outcomes were panic attack frequency and an idiosyncratic behavioral test. Secondary outcomes were panic and agoraphobia severity, panic-related cognitions, interpersonal functioning and general psychopathology. Measures were taken at 0, 3 and 4 months (baseline, end of treatment and follow-up). Results. Intention-to-treat (ITT) analyses on the primary outcomes indicated superior effects for CBT in treating panic disorder with agoraphobia. Per-protocol analyses emphasized the differences between treatments and yielded larger effect sizes. Reductions in the secondary outcomes were equal for both treatments, except for agoraphobic complaints and behavior and the credibility ratings of negative interpretations of bodily sensations, all of which decreased more in CBT. Conclusions. CBT is the preferred treatment for panic disorder with agoraphobia compared to IPT. Mechanisms of change should be investigated further, along with long-term outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The aim was to assess the efficacy of two brief cognitive–behavioral therapy (CBT)-based interventions (7×1-h sessions and 1×2-h session) and a pharmacological treatment (paroxetine), compared to supportive usual care, initiated in the emergency department (ED) for individuals suffering from panic disorder (PD) with a chief complain of noncardiac chest pain (NCCP). We hypothesized that the interventions would be more efficacious than supportive usual care on all outcomes. Method: A 12-month follow-up study of patients who received a diagnosis of NCCP in the ED and who met diagnostic criteria for PD (n=71) was performed. Assessments included several psychological questionnaires and a structured interview. A series of repeated-measures analyses of variances, using a split-plot design, were conducted, as well as planned comparisons to examine the differences. Results: The seven-session CBT (n=19), one-session panic management (n=24) and pharmacotherapy (n=13) led to greater improvements in PD severity (primary outcome) compared to supportive usual care (n=15) at posttest, and no significant difference was noted between the three active interventions. On the other measures, patients improved in all conditions, and the therapeutic gains were maintained up to 1 year following the visit to the ED. Conclusions: These results suggests that early intervention, in particular seven sessions of CBT, one session of PM or pharmacotherapy (generic paroxetine), should be considered for the treatment of PD patients consulting the ED with a discharge diagnosis of NCCP. [Copyright &y& Elsevier]

Abstract: Cognitive and biobehavioral coping skills are central to psychosocial therapies and are taught to facilitate and improve exposure therapy. While traditional coping skills are aimed at controlling maladaptive thoughts or dysregulations in physiology, newer approaches that explore acceptance, defusion, and values-based direction have been gaining interest. Acceptance and Commitment Therapy (ACT) involves creating an open, nonjudgmental stance toward whatever thoughts, feelings, and bodily sensations arise in a given moment, experiencing them for what they are, and moving toward them while inner experiences such as anxiety are present. This approach can be seen as consistent with exposure therapies and may be utilized to organize and facilitate engagement in exposure exercises. This study examines the feasibility and efficacy for combining a brief ACT protocol with traditional exposure therapy. Eleven patients with panic disorder with or without agoraphobia received 4 sessions of ACT followed by 6 sessions of exposure therapy, with data collected on a weekly basis. Acquisition of ACT skills and their application during exposure was monitored using a novel “think-aloud” technology. Treatment was associated with clinically significant improvements in panic symptom severity, willingness to allow inner experiences to occur, and reductions in avoidant behavior. Although preliminary, results suggest that our brief training in ACT only (as assessed prior to exposure exercises) and in combination with exposure therapy was acceptable to patients and offered benefits on the order of large effect sizes. Clinical and research implications are discussed. [Copyright &y& Elsevier]

This study compared the relative efficacy of intensive versus weekly panic control treatment (PCT) for adolescent panic disorder with agoraphobia (PDA). Twenty-six adolescents participated in weekly sessions and 25 received intensive treatment involving daily sessions. Both groups demonstrated significant and comparable reductions in panic disorder severity and general anxiety symptoms, which maintained over time. Participants receiving weekly treatment showed significant decreases in depressive symptoms, whereas those in the intensive program reported no change. Findings support the efficacy of the intensive approach for adolescent PDA, but suggest that adolescents receiving intensive treatment may benefit from a brief course of additional weekly sessions. [ABSTRACT FROM AUTHOR]

Objective: Fear reactivity during exposure is a commonly used indicator of learning and overall therapy outcome. The objective of this study was to assess the predictive value of fear reactivity during exposure using multimodal indicators and an advanced analytical design. We also investigated the degree to which treatment condition (cognitive training vs. respiratory skill training) moderated fear reactivity and therapeutic outcome. Method: Thirty-four patients with panic disorder and agoraphobia completed a total of 123 in-vivo exposure sessions, comprising 3 weekly sessions and a 4th session 2 months following therapy completion. Sessions varied in length and phobic stimuli. Cardiorespiratory physiology (heart rate, carbon dioxide partial pressure [PCO2], respiration rate) and experiential symptoms (panic symptoms and anxiety) were assessed repeatedly throughout exposure sessions, in addition to weekly assessments of panic cognitions, avoidance, and functioning. Results: Panic symptomatology decreased substantially in both treatment conditions during therapy and follow-up. Significant cardiorespiratory and experiential reactivity was observed during all exposures, characterized by activation followed by reduction. Greater within-session activation of anxiety and panic symptoms was inversely related to improvement in panic symptoms severity, but neither physiological activation nor within- or between-session reduction of either physiological or experiential variables was predictive of outcome. No moderating effects of treatment condition were found. Conclusions: Fear activation and reduction during exposure are weak predictors of corrective learning and fear extinction. Clinical implications for exposure therapy and directions for future research are discussed. [ABSTRACT FROM AUTHOR]

Objective: Anxiety disorders are the most prevalent psychiatric disorders in the United States and result in substantial burden to the individual and society. Although effective treatments for anxiety disorders have been developed, there has been substantially less focus on interventions aimed at the amelioration of anxiety-related risk and maintenance factors. Anxiety sensitivity (AS) is a well-established, malleable risk and maintenance factor for panic disorder and other psychopathology. The aim of the current investigation was to enhance the efficacy of AS treatment through the refinement of a previously validated intervention. Method: This 1-session intervention utilized psychoeducation and interoceptive exposure to target AS and was compared with a health-focused control intervention among a nontreatment seeking sample (N = 104) of individuals with elevated AS. Results: Study findings indicate that the active treatment group demonstrated significantly greater reductions in AS than the control group at posttreatment and across the 1-month study period. These treatment gains were seen across the ASI subscales. A Month 6 follow-up assessment indicated that the treatment group retained the majority of their AS reduction, whereas the control group retained their elevated AS scores. The intervention responses of participants meeting Axis I diagnostic criteria did not differ from the responses of those without a current diagnosis. Conclusions: Despite the brevity of the treatment intervention, findings demonstrate that it resulted in substantial reductions in AS that were largely maintained 6 months posttreatment. Anxiety treatment and prevention implications axe discussed. [ABSTRACT FROM AUTHOR]

This article, condensed from Chapter 14 of A Guide to the Standard EMDR Protocols for Clinicians, Supervisors, and Consultants (Leeds, 2009), examines applying eye movement desensitization and re-processing (EMDR) to treating individuals with panic disorder (PD) and PD with agoraphobia (PDA). The literature on effective treatments for PD and PDA is reviewed focusing on cognitive and behavioral therapies, pharmacotherapy, and EMDR. Case reports and controlled studies of EMDR treatment of PD and PDA are examined for lessons to guide EMDR clinicians. Two model EMDR treatment plans are presented: one for cases of simple PD without agoraphobia or other co-occurring disorders and the other for cases of PDA or PD with co-occurring anxiety or Axis II disorders. A more extensive literature discussion, detailed treatment guidelines, and client education resources can be found in the original chapter. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 55-year-old, married Hispanic woman with panic disorder having symptoms of anxiety. She had a traumatic childhood as she was sexually molested by two neighbors from age seven through 11. It mentions treatment given to patient is Panic-focused psychodynamic psychotherapy (PFPP) a 24-session, twice-weekly for 12 weeks program, for the patients who not respond to alternative therapy like cognitive-behavioral therapy and drug therapy.

Background: Two opposing models for the action of ghrelin in the behavioral responses to stress were recently proposed. Some studies suggest that an increase in ghrelin contributes to the mechanisms responsible for the development of stress-induced depression and anxiety, while others suggest that it helps minimize what otherwise would be more severe manifestations of depression and anxiety following stress. Methods: We measured serum ghrelin levels, Profile of Mood States (POMS) scores and State-Trait Anxiety Inventory scores in nonresponders (treatment-resistant patients; 30) and responders (38) with major depressive disorder (MDD), nonresponders (29) and responders (51) with panic disorder and 97 healthy controls. Results: The ghrelin concentration in nonresponders with MDD was higher than that of responders with MDD and normal controls. The ghrelin concentration in nonresponders with panic disorder was higher than that of normal controls. POMS vigor scores in patients with MDD and panic disorder were significantly decreased compared with those in healthy controls. Other POMS scores in patients with MDD and panic disorder were significantly increased compared with those of healthy controls. Trait and state anxiety of the State-Trait Anxiety Inventory in MDD and panic disorder patients were higher than those in healthy controls. Conclusions: These results indicate that decreased serum ghrelin levels might be associated with antidepressant treatment to confer the maximum therapeutic effect in patients with MDD and panic disorder. Copyright © 2012 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Purpose: Panic Disorder (PD) is a classic example of a disease where symptom remission may be achieved, yet patient quality of life (QOL) remains low, providing further support for the need to measure QOL as an additional outcome in patient care. The objectives of this review are to examine the substantial QOL impairments in PD and to determine whether modern treatments for PD, which have been proven to achieve symptom remission, have been shown to restore QOL. Methods: We identified studies on QOL in PD from 1980 to 2010 by searching MEDLINE, PsycINFO, and PubMed databases. Results: The literature reveals substantial QOL impairments in PD, often resulting in poor sense of health, frequent utilization of medical services, occupational deficiency, financial dependency, and marital strife. Modern therapies have been demonstrated to achieve symptom remission and improve QOL in PD; however, post-treatment QOL is still significantly lower than community averages. Conclusions: QOL needs to be added as an essential outcome measure in patient care. Further research should be conducted to better understand the nature of comorbidities in PD as well as to determine whether additional interventions that have been studied in other psychiatric disorders, such as exercise, meditation, yoga, humor, massage, and nutritional supplements, can be utilized to improve QOL in PD to normal community levels. [ABSTRACT FROM AUTHOR]

The article presents a study which looks into the effectiveness of two breathing therapies such as lowering end-tidal partial pressure of carbon dioxide (PCO2) for patients with panic disorder. The study has found out a reduction in the severity of panic disorder with the use of the Panic Disorder Severity Scale. It has suggested that clinical improvement should be relied on elements including varied beliefs and expectancies and bodily sensations exposure.