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Anxiety-related disorders constitute the leading prevalent mental disorders, with major burden on patients, their relatives, and society. Moreover, there is considerable treatment nonadherence/nonresponse. We used routine outcome monitoring (ROM) data from outpatients covering four anxiety-related disorders (DSM-IV-R , N = 470) to examine their 6-month treatment course and its predictors: generalized anxiety disorder, panic disorder with agoraphobia, obsessive-compulsive disorder, and posttraumatic stress disorder. Measures included Mini-International Neuropsychiatric Interview Plus, Brief Symptom Inventory (BSI), Montgomery-Åsberg Depression Rating Scale (MADRS), Brief Anxiety Scale (BAS), and Short Form Health Survey 36 (SF-36). On the clinician-rated instruments (MADRS/BAS), all anxiety-related disorder groups showed a significant albeit modest improvement after treatment. On the BSI self-rating, only generalized anxiety disorder and posttraumatic stress disorder showed a significant modest improvement. No anxiety-related disorder groups improved significantly regarding SF-36 physical functioning. For BSI symptom course, significant predictors were comorbid somatoform/total disorders, SF-36 physical functioning/general health, and MADRS score. Clinical implications and future research recommendations are discussed. [ABSTRACT FROM AUTHOR]

Abstract Background Phobic anxiety disorders are among the most prevalent psychiatric disorders and are burdensome in terms of loss of quality of life and work productivity. Evidence-based treatments are relatively successful in the majority of patients, especially exposure therapy. However, a substantial subset of patients fails to achieve or stay in remission. Preclinical and genetic research have yielded evidence that the cannabinoid system is involved in the extinction of fear, presumed to underlie the beneficial effects of exposure therapy in phobic disorders. A cannabinoid constituent that may enhance endocannabinoid signaling is cannabidiol (CBD), a non-psychoactive component of cannabis. Hence, the addition of CBD to exposure therapy is expected to strengthen effects of treatment. To determine the added benefit of CBD on exposure therapy, we conduct a randomized controlled trial, in which patients in whom previous treatment as usual has not yielded sufficient response receive either CBD or placebo preceding 8 exposure sessions in a double-blind fashion. A subsidiary aim is to explore which (combination of) clinical, behavioral and genetic profiles of patients are related to treatment response. Methods/design This is an 8-week multicenter, randomized, double-blind, placebo-controlled trial. Seventy-two patients with social phobia or panic disorder with agoraphobia with incomplete response to earlier treatment will be included from outpatient clinics in the Netherlands. Patients are randomized to augmentation of exposure therapy with 300 mg CBD or placebo. The study medication is administered orally, 2 h preceding each of the eight 90 min exposure sessions. Measurements will take place at baseline, first administration of medication, every session, mid-treatment, last administration of medication, post-treatment and at 3 and 6 months’ follow-up. The primary outcome measure is the score on the Fear Questionnaire (FQ). In addition, determinants of the expected treatment enhancing effect of CBD will be explored. Discussion This is the first trial to investigate whether the addition of CBD to exposure therapy is effective in reducing phobic symptoms in treatment refractory patients with social phobia or panic disorder with agoraphobia. Trial registration Netherlands Trial Register NTR5100. Registered 13 March 2015. Protocol version: issue date 17 Jan 2018, protocol amendment number 7.

Objective: There is a very limited amount of research on the relationship between therapist and patient in‐session behavior and treatment outcome in cognitive behavioral therapy (CBT) for panic disorder with agoraphobia (PD/AG). Additionally, the findings tend to be inconclusive. This study investigates the association between therapist competence, adherence, patient interpersonal behavior, and therapeutic alliance and outcome in a low‐control CBT setting by using comprehensive measures. Methods: Twenty‐six patients with PD/AG received 12 sessions of exposure‐based CBT. With regard to the outcome, treatments were classified either as problematic or nonproblematic by means of distinct criteria. Two raters evaluated the in‐session behavior. Results: Patient interpersonal behavior was significantly associated with outcome at follow‐up (r = 0.49). At posttreatment, the correlation did not reach significance (r = 0.34). Competence, adherence, and alliance were not outcome associated. Conclusion: The findings emphasize the need for therapists to pay particular attention to patients' interpersonal behavior during treatment. [ABSTRACT FROM AUTHOR]

Panic disorder and agoraphobia are both characterized by avoidance behaviors, which are known correlates of treatment discontinuation. The aim of this exploratory study is to distinguish the profile of participants suffering from panic disorder with agoraphobia that complete treatment from those who discontinue therapy by assessing four categories of predictor variables: the severity of the disorder, sociodemographic variables, participants' expectations, and dyadic adjustment. The sample included 77 individuals diagnosed with panic disorder with agoraphobia who completed a series of questionnaires and participated in a cognitive-behavioral group therapy consisting of 14 weekly sessions. Hierarchical linear regression analyses revealed the importance of anxiety, prognosis, and role expectations as well as some individual variables as predictors of therapeutic dropout, either before or during treatment. Among the most common reasons given by the 29 participants who discontinued therapy were scheduling conflicts, dissatisfaction with treatment, and conflicts with their marital partner. These results suggest that expectations and dyadic relationships have an impact on therapeutic discontinuation. The clinical implications of these findings are discussed. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to test 2 cognitive models of panic disorder with agoraphobia (PDA)--a catastrophic cognitions model and a low self-efficacy model--by examining the within- person effects of model-derived cognitive variables on subsequent anxiety symptoms. Method: Participants were 46 PDA patients with agoraphobic avoidance of moderate to severe degree who were randomly allocated to 6 weeks of either cognitive therapy, based on the catastrophic cognitions model of PDA, or guided mastery (guided exposure) therapy, based on the self-efficacy model of PDA. Cognitions and anxiety were measured weekly over the course of treatment. The data were analyzed with mixed models, using person-mean centering to disaggregate within- and between-person effects. Results: All of the studied variables changed in the expected way over the course of therapy. There was a within-person effect of physical fears, loss of control fears, social fears, and self-efficacy when alone on subsequent state anxiety. On the other hand, within-person changes in anxiety did not predict subsequent cognitions. Loss of control and social fears both predicted subsequent self-efficacy, whereas self-efficacy did not predict catastrophic cognitions. In a multipredictor analysis, within-person catastrophic cognitions still predicted subsequent anxiety, but self-efficacy when alone did not. Conclusions: Overall, the findings indicate that anxiety in PDA, at least in severe and long-standing cases, is driven by catastrophic cognitions. Thus, these cognitions seem to be useful therapeutic targets. [ABSTRACT FROM AUTHOR]

Treatment delivery factors (i.e., therapist adherence, therapist competence, and therapeutic alliance) are considered to be important for cognitive behavioral therapy (CBT) for panic disorder and agoraphobia (PD/AG). In the current study, four independent raters conducted process evaluations based on 168 two-hour videotapes of 84 patients with PD/AG treated with exposure-based CBT. Two raters evaluated patients’ interpersonal behavior in Session 1. Two raters evaluated treatment delivery factors in Session 6, in which therapists provided the rationale for conducting exposure exercises. At the 6-month follow-up, therapists’ adherence ( r = 0.54) and therapeutic alliance ( r = 0.31) were significant predictors of changes in agoraphobic avoidance behavior; therapist competence was not associated with treatment outcomes. Patients’ interpersonal behavior in Session 1 was a significant predictor of the therapeutic alliance in Session 6 ( r = 0.17). The findings demonstrate that treatment delivery factors, particularly therapist adherence, are relevant to the long-term success of CBT for PD/AG. [ABSTRACT FROM AUTHOR]

Patients with panic disorder with agoraphobia (PDA) or generalized anxiety disorder (GAD) frequently also suffer from insomnia. However, the impact of cognitive-behavioral therapy (CBT) for anxiety disorders on insomnia has been understudied. Furthermore, comorbidity between anxiety disorders is common. Our main objective was to assess the impact of CBT for PDA or GAD on insomnia. In a quasi-experimental design, 86 participants with PDA and GAD received conventional CBT for their primary disorder or combined CBT for both disorders. Overall, CBTs had a significant impact on reducing insomnia symptoms (η = 0.58). However, among people with insomnia at pretest (67%), 33% still had an insomnia diagnosis, and the majority (63%) had clinically significant residual insomnia following treatment. In conclusion, the CBTs had a positive effect on the reduction of insomnia, but a significant proportion of participants still had insomnia problems following treatment. Clinicians should address insomnia during CBT for PDA and GAD. [ABSTRACT FROM AUTHOR]

Objective The objective of this paper was to examine the relationships between perceived parental bonding, Early Maladaptive Schemas (Young et al., 2003), and outcome of schema therapy of Cluster C personality problems and whether the perceptions of parental bonding could be influenced by schema therapy. Method The sample consisted of 45 patients with panic disorder and/or agoraphobia and Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Cluster C personality traits who participated in an 11-week inpatient programme consisting of two phases; the first was a 5-week panic/agoraphobia-focused cognitive therapy, whereas the second phase was a personality-focused schema therapy. The patients were assessed at pre-treatment, mid-treatment and post-treatment and at 1-year follow-up. Results Opposite to our hypothesis, lower paternal care at pre-treatment was related to more reduction in Cluster C personality traits from pre-treatment to 1-year follow-up. Maternal protection was related to the schema domains of impaired autonomy and exaggerated standards. Overall schema severity and the schema emotional inhibition at pre-treatment were associated with less change in Cluster C traits. Perceived maternal care was reduced from pre-treatment to 1-year follow-up, and more reduction in maternal care was related to less reduction in Cluster C traits. Discussion Parental bonding failed to predict treatment outcome in the expected direction, but maternal protection was related to two of the schema domains. Overall schema severity and the particular schema emotional inhibition predicted outcome. Furthermore, perceived maternal care was reduced from before to after treatment. Future studies should examine these questions in larger samples of Cluster C patients receiving schema therapy of a longer duration. Copyright © 2014 John Wiley & Sons, Ltd. Key Practitioner Message Most schemas within the impaired autonomy domain and the schema self-sacrifice seem to be related to low perceived maternal protection., Overall schema severity and the schema emotional inhibition predict a poorer outcome of schema therapy of Cluster C personality problems, and therapy should give priority to emotional inhibition when this schema is endorsed., Therapists should be aware that schema therapy carries the risk to lead to a more negative view of mother's care during upbringing and this risk is accentuated with less benefit of therapy. [ABSTRACT FROM AUTHOR]

The aim of the current study was to compare the 20-year outcome in panic disorder with agoraphobia (PD with AG) and agoraphobia without panic disorder (AG without PD) patients after inpatient psychological treatment. Of 53 eligible patients having completed a medication-free integrated exposure and psychodynamic treatment, 38 (71.7%)-25 PD with AG and 13 AG without PD patients-attended 20-year follow-up. AG without PD patients improved less than PD with AG patients did on primary outcome measures. In the PD with AG group, there were large uncontrolled effect sizes (<-2.30). More of the AG without PD patients had avoidant personality disorder at pretreatment, but the presence of this disorder did not predict outcome. The follow-up results support that PD with AG and AG without PD are two different disorders. The results also suggest that the very long-term outcome in PD with AG patients is excellent for this integrated treatment. [ABSTRACT FROM AUTHOR]

In this study, we wished to compare the long-term outcome of (medication-free) panic disorder with agoraphobia patients randomized to cognitive or guided mastery therapy. Thirty-one (67.4%) of 46 patients who had completed treatment were followed up about 18 years after end of treatment. In the combined sample and using intent-to-follow-up analyses, there were large within-group effect sizes of −1.79 and −1.63 on the primary interview-based and self-report outcome measures of avoidance of situations when alone, and 56.5% no longer had a panic disorder and/or agoraphobia diagnosis. No outcome differences between the two treatments emerged. Guided mastery was associated with greater beneficial changes in catastrophic beliefs and self-efficacy. For two of five outcome measures, more reduction in panic-related beliefs about physical and mental catastrophes from pre- to post-treatment predicted lower level of anxiety from post-treatment to 18-year follow-up when the effect of treatment changes in (a) self-efficacy and (b) anxiety was controlled. However, for one of the outcome measures, this effect attenuated with time. Copyright © 2014 John Wiley & Sons, Ltd. Key Practitioner Message The results suggest that the very-long-term outcome of both cognitive therapy and guided mastery therapy for agoraphobia is positive., The results support the role of catastrophic beliefs as mediator of change., The pattern of results suggests that learning processes other than catastrophic beliefs may be important for long-term outcome as well. [ABSTRACT FROM AUTHOR]

Background: Increased heartbeat perception accuracy (HBP-accuracy) may contribute to the pathogenesis of Panic Disorder (PD) without or with Agoraphobia (PDA). Extant research suggests that HBP-accuracy is a rather stable individual characteristic, moreover predictive of worse long-term outcome in PD/PDA patients. However, it remains still unexplored whether HBP-accuracy adversely affects patients’ short-term outcome after structured cognitive behaviour therapy (CBT) for PD/PDA. Aim: To explore the potential association between HBP-accuracy and the short-term outcome of a structured brief-CBT for the acute treatment of PDA. Method: We assessed baseline HBP-accuracy using the “mental tracking” paradigm in 25 consecutive medication-free, CBT-naive PDA patients. Patients then underwent a structured, protocol-based, 8-session CBT by the same therapist. Outcome measures included the number of panic attacks during the past week, the Agoraphobic Cognitions Questionnaire (ACQ), and the Mobility Inventory-Alone subscale (MI-alone). Results: No association emerged between baseline HBP-accuracy and posttreatment changes concerning number of panic attacks. Moreover, higher baseline HBP-accuracy was associated with significantly larger reductions in the scores of the ACQ and the MI-alone scales. Conclusion: Our results suggest that in PDA patients undergoing structured brief-CBT for the acute treatment of their symptoms, higher baseline HBP-accuracy is not associated with worse short-term outcome concerning panic attacks. Furthermore, higher baseline HBP-accuracy may be associated with enhanced therapeutic gains in agoraphobic cognitions and behaviours. [ABSTRACT FROM AUTHOR]

Der Veränderung von psychischen Prozessen durch Psychotherapie muss eine Veränderung neuronaler Vorgänge im Gehirn zugrunde liegen. Einfache neurobiologische Modelle über die Wirkmechanismen der Kognitiven Verhaltenstherapie (KVT) postulierten, dass eine unmittelbare Hemmung von neuronalen bottom-up Prozessen und/oder eine Verstärkung von kognitiven top-down Regulationsmechanismen in Gehirn zur Symptomreduktion führen können. Der vorliegende Übersichtsartikel fasst die neusten Befunde zu den neuralen Korrelaten von KVT, gemessen mit funktioneller Magnetresonanztomographie, bei Patienten mit Panikstörungen zusammen, die einerseits diese Modelle zum Teil bestätigen, andererseits aber auch deutlich weiterentwickeln. Des Weiteren widmet sich diese Arbeit den neuronalen Biomarkern der Therapieresponse und den neuralen Korrelaten der genetischen Moderatoren des Therapieeffektes. Diese Befunde könnten zukünftig in der personalisierten und individualisierten Psychotherapie von Nutzen sein und werden hier abschließend bezüglich der generellen Perspektiven der Neurowissenschaften für die Psychotherapieforschung diskutiert. [ABSTRACT FROM AUTHOR]

Background: People with anxiety disorders occasionally report fears about losing control of basic bodily functions in public. These anxieties often occur in the absence of physical disorder and have previously been recognized as “obsessive” anxieties reflecting a preoccupation with loss of bowel/bladder control. Motivated by our observations of the non-trivial occurrence of such anxieties in our clinical practice we sought to fill a gap in the current understanding of “bowel/bladder-control anxieties”. Method: Eligible participants completed an internet survey. Results: Bowel/bladder-control anxieties (n = 140) tended to emerge in the mid to late 20s and were associated with high levels of avoidance and functional impairment. There was a high prevalence of panic attacks (78%); these were especially prevalent among those with bowel-control anxiety. Of those with panic attacks, 62% indicated that their main concern was being incontinent during a panic attack. Significantly, a proportion of respondents (~16%) reported actually being incontinent during a panic attack. Seventy percent of participants reported intrusive imagery related to loss of bowel/bladder control. Intrusion-related distress was correlated with agoraphobic avoidance and general role impairment. Some differences were noted between those with predominantly bowel-, predominantly bladder- and those with both bowel and bladder-control anxieties. Conclusion: This preliminary characterization indicates that even in a non-treatment seeking community sample, bowel/bladder-control anxieties are associated with high levels of distress and impairment. Further careful characterization of these anxieties will clarify their phenomenology and help us develop or modify treatment protocols in a way that takes account of any special characteristics of such viscerally-centred phobic syndromes. [ABSTRACT FROM PUBLISHER]

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]

Personality and psychopathology differences were explored among a clinical sample of 52 patients with Panic Disorder (PD), with Agoraphobia (PDA) or without Agoraphobia, and two nonclinical samples, one with 45 participants with high anxiety sensitivity (AS) scores, and 55 with low AS scores. The clinical sample was evaluated according to DSM-IV-TR (APA, 2000) criteria. The participants in nonclinical samples were assigned depending on the ''Anxiety sensitivity index'' (ASI; Reiss, Peterson, Gursky, & McNally, 1986) scores. The ''Brief symptom inventory'' (BSI; Derogatis & Melisaratos, 1983) was used to assess general psychopathology and the ''NEO personality inventory- revised'' (NEO-PI-R; Costa & McCrae, 1992) was used to measure personality, both in the three samples. The results show that the only statistically significant differences between the participants with high AS scores and PD/PDA patients were in the psychopathological scales, phobic anxiety and paranoid ideation, and in the personality facet, social anxiety. [ABSTRACT FROM AUTHOR]

To examine the relationship between preference for group psychotherapy and adherence to group cognitive-behavioral therapy (CBT) for clients with panic disorder with agoraphobia (PDA), 109 participants experiencing PDA completed a questionnaire measuring preference for group treatment (PGTQ) before beginning CBT groups. A t test was used to compare preference scores for group treatment to investigate whether participants who completed treatment differed from those who abandoned treatment. Participants who completed group therapy expressed higher preference for group treatment than participants who dropped out of treatment ( t[107] = 1.99; p < 0.05). The PGTQ-4 presented adequate psychometric properties. Reliability analyses of the items retained after factorization demonstrated an acceptable level of internal consistency (Cronbach's alpha of 0.76). Preference for individual or group therapy appears to impact treatment retention for patients with PDA. Matching patients' preferences to the type of treatment modality used appears to be pertinent, especially for the treatment of anxiety disorders. In terms of practical implications, the rationale and benefits of group therapy should be explained to participants reluctant to engage in group therapy. Individual intervention or a combination of group and individual treatment could be considered for clients who are likely to drop out of group therapy. [ABSTRACT FROM AUTHOR]

Therapists typically have limited information about how unaccompanied situational exposure is undertaken. To address this issue, we present a method of assessing movement patterns and concurrent arousal collected during situational exposure. We illustrate how this provides both objective and useful accounts of this important treatment component. In this case study, recordings of global positioning system-derived position and heart rate were obtained from a 47-year-old female patient suffering from panic disorder with agoraphobia who received treatment through an outpatient clinic. Ambulatory assessment of movement and accompanying physiology (heart rate) during situational exposure is described. Visualizations of positional and physiological data recorded during exposure sessions revealed (a) that the patient actually confronted feared environmental cues, (b) that she experienced elevated physiological arousal, and (c) good therapeutic compliance. These depictions were used to plan subsequent exposure sessions and we discuss how this information provided unique insights into the process of exposure. Assessment of movement patterns using commercially available technology can yield clinically relevant information about treatment progress. We conclude that this method could extend traditional self-report measures of agoraphobic avoidance. Future directions, such as the possibility of using movement information to refine follow-up assessment, and the limitations of this approach are discussed. [ABSTRACT FROM AUTHOR]

Background: No studies have been found that compared the psychopathology features, including personality disorders, of Panic Disorder (PD) and Panic Disorder with Agoraphobia (PDA), and a nonclinical sample with anxiety vulnerability. Method: The total sample included 152 participants, 52 in the PD/PDA, 45 in the high anxiety sensitivity (AS) sample, and 55 in the nonclinical sample. The participants in PD/PDA sample were evaluated with the structured interview ADISIV. The Brief Symptom Inventory and the MCMI-III were used in all three samples. Results: Statistically significant differences were found between the PD/PDA and the nonclinical sample in all MCMI-III scales except for antisocial and compulsive. No significant differences were found between PD/PDA and the sample with high scores in AS. Phobic Anxiety and Paranoid Ideation were the only scales where there were significant differences between the PD/PDA sample and the high AS sample. Conclusions: Our findings showed that people who scored high on AS, despite not having a diagnosis of PD/PDA, were similar in regard to psychopathology features and personality to individuals with PD/PDA. [ABSTRACT FROM AUTHOR]

Concurrent panic disorder with agoraphobia (PDA) and generalized anxiety disorder (GAD) are the most common diagnostic occurrences among anxiety disorders. This particular comorbidity is associated with significant impairments in quality of life (QOL). The current study sought to investigate the efficacy of a combined cognitive-behavioral psychotherapy that addressed both conditions compared with a conventional psychotherapy, which attends solely to the primary disorder. The hypotheses postulated firstly, that both treatment conditions would lead to improvements in participants’ QOL and secondly, that the combined therapy would lead to greater QOL ameliorations. Twenty-five participants with comorbid PDA/GAD diagnoses were evaluated with a number of clinical interviews and self-report questionnaires, and were provided with either conventional or combined cognitive-behavioral psychotherapy, which consisted of 14 one-hour weekly sessions. Participants were once again evaluated in the same fashion 2-weeks after the completion of the psychotherapy. The results revealed that both conditions led to significant improvements in participants’ QOL, but that the two groups did not significantly differ in terms of the effect on QOL. The results also reveal that the two conditions did not significantly differ in terms of their effect on PDA and GAD symptomatology or psychiatric comorbidity. The results demonstrate that the combined psychotherapy, which addresses both conditions simultaneously, is similar to the conventional psychotherapy employed for the primary disorder in terms of QOL enhancement, symptom severity, and comorbidity reduction. [ABSTRACT FROM PUBLISHER]

Abstract: Background: Panic disorder with agoraphobia (PD-A) has been associated with abnormal neural activity for threat-related stimuli (faces, places). Recent findings suggest a disturbed neural processing of emotionally neutral stimuli at a more general level. Methods: Using functional magnetic resonance imaging (fMRI) we investigated the neural processing of emotionally neutral faces and places in PD-A. Fifteen patients with PD-A and fifteen healthy subjects participated in the study. Results: When they perceived neutral faces and places, the patients with PD-A showed significantly less brain activity in the fusiform gyrus, the inferior occipital gyrus, the calcarine gyrus, the cerebellum, and the cuneus compared with the healthy controls. However, the patients with PD-A showed significantly more brain activity in the precuneus compared with controls subjects. Limitations: It was not possible to distinguish the agoraphobia-associated effects from possible contributions due to general anxiety induced by fMRI. For future investigations, an additional clinical control group with patients suffering from panic disorder without agoraphobia would be of interest. In addition, the psychopathology concerning the agoraphobic symptoms needs to be investigated in more detail. Conclusions: The findings suggest altered neural processing of emotionally neutral faces and places in patients with PD-A. Reduced neural activity in different brain regions may indicate difficulties in recognizing the emotional content in face and place stimuli due to anxiety-related hyper-arousal. [Copyright &y& Elsevier]

Background: The present study evaluated attentional bias in adolescents diagnosed with panic disorder. Although a large body of research exists in the area of attentional bias in adults, this feature of panic disorder is not well understood in adolescents. Method: Twenty-five adolescents, aged 12–17, with a panic disorder diagnosis were included in the study. An emotional Stroop task was utilized to assess whether: (1) adolescents with panic disorder exhibit an attentional bias to panic-relevant stimuli; (2) this bias diminishes after completing a course of CBT; and (3) a specific attentional bias towards disorder-relevant stimuli exists. Results: An attentional bias to panic-relevant stimuli was found at pre-treatment but was no longer present following an intensive CBT intervention. Contrary to some findings in the adult literature, no significant differences were found between panic-relevant versus other threatening stimuli. Conclusions: These results suggest that adolescents with panic disorder, similar to adults, do exhibit an attentional bias towards panic-relevant stimuli, and treatment seems to normalize this cognitive process. [ABSTRACT FROM PUBLISHER]

Abstract: Background: Panic disorder with/without agoraphobia (PD/PDA) is a prevalent anxiety disorder, associated with impairment in quality of life and functionality, as well as increased healthcare utilization. Extant research shows a relationship between stressful life events (SLEs) and the onset of panic attacks in adults who ultimately develop PD/PDA. However, limited attention has been paid to how SLEs might affect the severity of panic symptoms in individuals with PD/PDA. In this study, we examined the relationship between SLEs and panic symptom severity in adults with PD/PDA. Methods: Four hundred-eighteen adults with PD/PDA from the Harvard/Brown Anxiety Research Program (HARP), a long-term prospective longitudinal observational multicenter study of adults with a current or past history of anxiety disorders were included in this study. We examined occurrence of SLEs and their impact on panic symptom severity 12-weeks pre- and post-SLE. Results: A time-slope effect showed that participants had worsened panic symptoms over the course of the 12-weeks after family/friends/household and work SLEs. That is, their symptoms worsened progressively after the event, rather than immediately thereafter (i.e., significant symptom change within the same week of the event). Limitations: The sample may not be representative of the general population. Conclusions: These findings provide new insights into how SLEs affect panic symptoms in adults with PD/PDA in that household-related SLEs, such as serious family arguments, and work-related SLEs, such as being fired, put some adults at risk for worsened panic symptoms within 12-weeks of the event. [Copyright &y& Elsevier]

Background: Panic disorder with agoraphobia (PDA) co-occurs highly with depression. Greater panic symptoms, agoraphobic avoidance, comorbidity and anxiety sensitivity have all been linked to depressive symptoms in PDA. Psychotherapy research has historically linked prognostic and process expectations to symptom severity. However, no study has explored the relationship of expectancies and depressive symptoms in PDA. The purpose of the present study was to determine the extent to which expectations and panic symptomatology have a differential impact on depressive symptoms in PDA above and beyond the influence of anxiety sensitivity and secondary Axis I comorbid disorders (e.g., generalized anxiety disorder, social anxiety disorder) just prior to entering therapy. Method: The relationship between depressive symptoms, panic symptomatology and expectancies (i.e., prognostic and process expectations) was investigated in 74 patients with a primary diagnosis of panic disorder with agoraphobia. It was hypothesized that expectancy measures rather that panic symptomatology would add to the prediction of depressive symptoms beyond the effects of secondary comorbid disorders and anxiety sensitivity. Results: The findings showed that prognostic and process expectations accounted for significant variance in depressive symptoms beyond that predicted by anxiety sensitivity and secondary Axis I comorbid disorders. In addition, PDA symptomatology failed to significantly enter into our prediction model. Conclusions: These results suggest that expectancies have a greater impact on depressive symptoms in PDA regardless of the secondary comorbid disorders and severity of symptoms in PDA. Implications of these findings on the treatment of PDA are discussed. [ABSTRACT FROM AUTHOR]

Objectives: To compare the agoraphobic cognitions of younger and older patients suffering from panic disorder with agoraphobia by means of existing questionnaires. Method: Agoraphobic cognitions were assessed using the Agoraphobic Cognitions Questionnaire (ACQ) in 205 patients confirmed with confirmed panic disorder with agoraphobia (Diagnostic and Statistical Manual, Fourth Edition, Text Revision) and analyzed at the item level applying a Bonferroni correction. Results: The 48 patients who were older than 60 years had a significantly lower mean (SD) ACQ total score than their younger counterparts (1.6[0.5)'versus 2.1 [0.6]; t = 5.7, df =203,p < 0.001), with their scores on the items fear of going crazy, acting foolishly, losing control, passing out, and brain tumors (p < 0.004) being significantly lower. Conclusion: The differential effect at the ACQ item level suggests that some cognitions seem less relevant for agoraphobic panic disorder in later life. Future research should explore whether and which age related cognitions are missed in the current questionnaires. [ABSTRACT FROM AUTHOR]

The objectives of this study were to evaluate perceived unmet need for mental healthcare, determinants of unmet need, and barriers to care in individuals with social anxiety (SA) or panic disorder with agoraphobia (PDA) in Quebec. Data from 206 participants diagnosed with SA or PDA were collected using an online questionnaire. Correlational analyses and binary stepwise logistic regressions were conducted to explore determinants of perceived unmet need. Of the 206 participants, 144 (69.9%) reported instances of unmet need for treatment. Perceived unmet need was correlated with variables related to the severity of the disorder, such as comorbid depression, avoidance, duration of worry, interference with functioning, and time lapsed between the appearance of first symptoms and first consultation. Depression and avoidance emerged as predictors for perceived unmet need in the regression analysis. The most common barriers to treatment reported were concern about the cost of services (63.9%), not knowing where to go to get help (63.2%), lack of health insurance coverage (52.4%), and appointment wait times (52.1%). The results of this study demonstrate the need to overcome barriers to treatment engendered by avoidance behaviors associated with anxiety. Potential methods for achieving this objective include Internet outreach, support groups, and increased accessibility to public services. [ABSTRACT FROM AUTHOR]

This case study explores the treatment related issues of a 9 year old boy, who presented with symptoms of Panic Disorder with Agoraphobia, School Refusal and depressive symptoms, in a school counseling setting. To cope with anxiety and reintegrate the child within school. Initial three sessions focused on rapport building and exploring the problem using narrative therapy. Next three sessions included narrative therapy techniques and cognitive behaviour therapy including behaviour experiments and graded exposure was carried out to gain confidence over his anxieties and reintegrate him to school environment. Simultaneously family, teachers and peers were counselled to maintain the gains in therapy. At termination the child presented marked decrease in anxiety symptoms, willingness to attend school and engage with classmates, and improvements in self-confidence. The Narrative and Cognitive Behavioural Techniques were found to be effective in treatment of panic disorder with agoraphobia. Family and school support is essential and the treatment gains its effectiveness when all stakeholders come to support especially in a child case. [ABSTRACT FROM AUTHOR]

Response prevention exposure (RPE) has been considered the treatment of choice for obsessive- compulsive disorder (OCD). Its efficacy has been called into question given the clinical and empirical data showing that a great number of patients do not benefit from such treatment (Salkovskis, 1989; Salkovskis & Westbrook, 1989). In the present paper, given the most recent cognitive approaches, we have chosen an integrative model that highlights emotional and cognitive variables. Practical applications can be derived from Eysenck's Four Factor Theory (1997) in regards to cognitive treatment for OCD; special importance is given to the role played by attentional and interpretive biases for intrusive thoughts. Eliminating these biases constitutes a number one priority. Based on these theoretical models, a case study is presented, the application of a cognitive-behavioural treatment (CBT) is described; the cognitive techniques used and the results obtained are discussed. [ABSTRACT FROM AUTHOR]

Panic disorder, with and without agoraphobia, is the result of paying attention to and interpreting physiological sensations in an erroneous and catastrophic manner, up to the point that these sensations are believed to entail dangerous consequences. We present a case study of a 20 year old Psychology undergraduate student, who requests a psychological intervention due to a serious anxiety problem. He has suffered from agoraphobia for three years, without ever having experienced a single panic attack; three months ago he suffered his first and subsequent unexpected panic attacks. The drug treatment prescribed by his GP has not favoured any kind of symptom remission. Based on Clark's Cognitive Model of Panic (1986), we implemented a cognitive treatment (focusing on psychoeducation and the role played by cognitive biases, and catastrophic and irrational misinterpretations of bodily sensations), in 12 weekly, 60 minute sessions, plus three additional follow-up sessions. Successful results were obtained and maintained at follow-up: panic attacks were completely eradicated, anxiety and depression levels were reduced, feared situations were confronted without suffering anxiety (travelling by plane or public transport, going to movie theatres, etc.) and medication was discontinued without suffering a relapse. Lastly, pre and post-treatment results obtained through the use of several assessment instruments are discussed. [ABSTRACT FROM AUTHOR]

Abstract: The purpose of this study was to test the predictions of an integrated cognitive and behavioral model of agoraphobic avoidance in patients with chronic panic disorder and agoraphobia during the process of observed therapeutic change. Treatment was residential with the majority (n=165, 88%) receiving cognitive therapy, while the remaining 23 (12%) received guided mastery therapy. The results of latent variable path modeling of the changes occurring over the course of this treatment suggested that the anxiety elicited by bodily sensations influenced catastrophic beliefs, which, in turn, increased avoidance. Avoidance increased the anxiety elicited by bodily sensations. [Copyright &y& Elsevier]

Abstract: Freezing defined as the complete absence of body movements is a normal response of animals to unavoidable fear stimuli. The present review presents a series of evidence relating different defensive patterns with specific anxiety disorders. There are at least four different kinds of freezing with specific neural substrates. The immobility induced by stimulation of the ventral column of the periaqueductal gray (vPAG) has been considered a quiescence characteristic of the recovery component of defense–recuperative processes. There is an isomorphism between freezing response to contextual stimuli paired with electrical shocks and generalized anxiety disorder. Besides, two types of freezing emerge with the electrical stimulation of the dorsal aspects of the periaqueductal gray (dPAG): the dPAG-evoked freezing and the dPAG post-stimulation freezing. Evidence is presented in support of the hypothesis that whereas dPAG-evoked freezing would serve as a model of panic attacks, the dPAG post-stimulation freezing appears to be a model of panic disorder. It is also proposed that conditioned freezing plus dPAG electrical stimulation might also mimic panic disorder with agoraphobia. A model of serotoninergic modulation through on- and off-cells of the defense reaction generated in the dPAG is also presented. The understanding of how the periaqueductal gray generates and elaborates different types of freezing is of relevance for our better knowledge of distinct types of anxiety such as panic disorder or generalized anxiety disorder. [Copyright &y& Elsevier]

Patients with panic disorder with agoraphobia (n = 40) or obsessive-compulsive disorder (n = 61) participated in a 10-mm problem-solving interaction with their primary relative. Relatives were categorized as hostile or nonhostile toward the patient on the basis of a measure of expressed emotion (EE). Observed interactions between patients and their hostile relatives, relative to those of dyads with a nonhostile relative, were marked by higher rates of relatives' criticism and of patients' negativity but not by higher rates of negative reciprocity. Analyses of sequences indicated that the dyads with a hostile relative had a higher rate of sequences in which the relative was first critical and the patient then negative than was the case for dyads with nonhostile relatives. Moreover, hostile relatives were more frequently critical than nonhostile relatives whether patients' preceding behavior was positive, negative, or neutral. The findings are consistent with the stress-vulnerability model of the effect of EE on mental health, in that patients living with a high EE relative appear to be exposed to higher levels of interpersonal stress. [ABSTRACT FROM AUTHOR]

The goal of this study was to evaluate the efficacy of cognitive-behavioral therapy for comorbid panic disorder with agoraphobia (PDA) and generalized anxiety disorder (GAD) by combining treatment strategies for both disorders. A single-case, multiple-baseline design across participants was used. Three participants with primary PDA and secondary GAD took part in the study. The efficacy of the treatment was assessed by means of a structured interview, self-administered questionnaires, and daily self-monitoring measures. After treatment, 2 of the 3 participants achieved high end-state functioning and maintained this level of functioning at 3-, 6-, and 12-month follow-ups. The third participant also improved but only reached high end-state functioning at 6-month follow-up. It therefore appears that the combined treatment is relatively effective for PDA-GAD comorbidity. Possible avenues for improving the treatment are suggested. [ABSTRACT FROM AUTHOR]

Abstract: The aim of this study is to assess if changes in dysfunctional beliefs and self-efficacy precede changes in panic apprehension in the treatment of panic disorder with agoraphobia. Subjects participated in a larger study comparing the effectiveness of cognitive restructuring and exposure. Four variables were measured: (a) the strength of each subject''s main belief toward the consequence of a panic attack; (b) perceived self-efficacy to control a panic attack in the presence of panicogenic body sensations; (c) perceived self-efficacy to control a panic attack in the presence of panicogenic thoughts; and (d) the level of panic apprehension of a panic attack. Variables were recorded daily on a “0” to “100” scale using category partitioning. Multivariate time series analysis and “causality testing” showed that, for all participants, cognitive changes preceded changes in the level of panic apprehension. Important individual differences were observed in the contribution of each variable to the prediction of change in panic apprehension. Changes in apprehension were preceded by changes in belief in three cases, by changes in self-efficacy in six cases, and by changes in both belief and self-efficacy in the remaining three cases. This pattern was observed in participants in the exposure condition as well as those in the cognitive restructuring condition. These results provide more empirical support to the hypothesis that cognitive changes precede improvement. They also underlie the importance of individual differences in the process of change. Finally, this study does not support the hypothesis that exposure and cognitive restructuring operate through different mechanisms, namely a behavioral one and a cognitive one. [Copyright &y& Elsevier]

The goal of this study was to evaluate the efficacy of a cognitive-behavioral treatment package for comorbid generalized anxiety disorder (GAD) and panic disorder with agoraphobia (PDA). A single-case, multiple-baseline, across-subjects design was used with 3 primary GAD patients with secondary PDA. The efficacy of the treatment was evaluated with a structured interview, a battery of self-report questionnaires, and daily self-monitoring booklets. Results are promising: At posttreatment, 2 Out of 3 participants achieved high endstate functioning and maintained this level at 3-, 6-, and 12-month follow-ups. The 3rd participant also improved but achieved moder- ate endstate functioning. The strengths and limitations of the treatment are discussed. [ABSTRACT FROM AUTHOR]