Cognitive-behavioral therapy for panic disorder with agoraphobia in older people: a comparison with younger patients.

BACKGROUND: Older adults with panic disorder and agoraphobia (PDA) are underdiagnosed and undertreated, while studies of cognitive-behavioral therapy (CBT) are lacking. This study compares the effectiveness of CBT for PDA in younger and older adults. METHODS: A total of 172 patients with PDA (DSM-IV) received manualized CBT. Primary outcome measures were avoidance behavior (Mobility Inventory Avoidance scale) and agoraphobic cognitions (Agoraphobic Cognitions Questionnaire), with values of the younger (18-60 years) and older (≥ 60 years) patients being compared using mixed linear models adjusted for baseline inequalities, and predictive effects of chronological age, age at PDA onset and duration of illness (DOI) being examined using multiple linear regressions. RESULTS: Attrition rates were 2/31 (6%) for the over-60s and 31/141 (22%) for the under-60s group (χ(2) = 3.43, df = 1, P = .06). Patients in both age groups improved on all outcome measures with moderate-to-large effect sizes. Avoidance behavior had improved significantly more in the 60+ group (F = 4.52, df = 1,134, P = .035), with agoraphobic cognitions showing no age-related differences. Baseline severity of agoraphobic avoidance and agoraphobic cognitions were the most salient predictors of outcome (range standardized betas 0.59 through 0.76, all P-values < .001). Apart from a superior reduction of agoraphobic avoidance in the 60+ participants (ß = -0.30, P = .037), chronological age was not related to outcome, while in the older patients higher chronological age, late-onset type and short DOI were linked to superior improvement of agoraphobic avoidance. CONCLUSIONS: CBT appears feasible for 60+ PDA-patients, yielding outcomes that are similar and sometimes even superior to those obtained in younger patients.

Predictors of outcome of pharmacological and psychological treatment of late-life panic disorder with agoraphobia.

OBJECTIVE: This study aims to evaluate the differential predictive values of age, age of onset and duration of illness on paroxetine and cognitive-behavioural therapy (CBT) outcome in late-life panic disorder with agoraphobia. METHOD: Patients 60 years and older with a confirmed diagnosis of panic disorder with agoraphobia (n = 49) were randomly assigned to paroxetine (40 mg/day) treatment, individual CBT or a waiting-list control condition. Multiple regression analyses were conducted per treatment arm with post-treatment avoidance behaviour and agoraphobic cognitions as the dependent variables. RESULTS: Higher age at onset and shorter duration of illness were predictors of superior outcomes following CBT, although these variables did not influence the treatment effects of paroxetine. CONCLUSIONS: In late-life agoraphobic panic disorder, chronological age has no impact on treatment modality outcome. In older patients with a late disease onset or shorter duration of illness, CBT is to be preferred over paroxetine, whereas paroxetine might be the treatment of choice for older people with an early onset and short duration of illness.

Agoraphobic cognitions in old and young patients with panic disorder.

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 agerelated cognitions are missed in the current questionnaires.

A transdiagnostic comparison of trauma and panic memories in PTSD, panic disorder, and healthy controls.

Inadequate processing of trauma information is considered to lead to particularly vivid recollections and disorganized memories of the trauma. Although trauma memories have mainly been investigated in PTSD, memories in other psychiatric disorders may actually share some characteristics. This may particularly be true for patients with panic disorder with agoraphobia (PDA) as a first panic attack resembles trauma. To test this hypothesis, PTSD trauma memories (n=59) were compared with PDA panic memories (n=58), and trauma memories of healthy trauma victims (n=135) on self-reported re-experiencing and disorganization. PTSD trauma memories had more re-experiencing elements than memories of the other two groups, although PDA memories had more re-experiencing elements than the controls' trauma memories. Relative to the controls, PTSD and PDA memories were disorganized. Peritraumatic dissociation and current memory-associated dissociation were also high in PTSD and PDA patients compared to the controls. Implications of these results are discussed.

Habituation of premonitory sensations during exposure and response prevention treatment in Tourette's syndrome.

Exposure to premonitory sensations and response prevention of tics (ER) has been shown to be a promising new treatment for Tourette's syndrome (TS). The present study tested the hypothesis that habituation to unpleasant premonitory sensations associated with the tic is an underlying mechanism of change in ER. Patients rated the severity of sensations and urges at 15-minute intervals during ten 2-hour ER sessions. Multilevel models using multiple time trend analyses showed significant reductions of the sensory severity ratings both within and between sessions. The decrease of these severity ratings was related to the frequency of tics exhibited during sessions, regardless of tic severity at baseline. These results support the hypothesis that habituation may be at least part of the underlying working mechanism of exposure in the treatment of tics in TS and that effective tic suppression during sessions is an important factor in this habituation process.

Tic suppression in the treatment of Tourette's syndrome with exposure therapy: the rebound phenomenon reconsidered.

Exposure and response prevention (ER), a behavioral treatment program consisting of exposure to premonitory sensory experiences during prolonged tic suppression, was shown to be a promising new treatment for tics in Tourette's syndrome (TS). In this study, the commonly reported paradoxical increase in tic frequency following voluntary tic suppression, i.e., rebound phenomenon, was examined. Tic frequency was rated in 20 TS patients during 15-minute videotaped conversations taken both before and following 10 ER sessions. In addition, tic frequency was obtained at home by family members of the patients during 15-minute daily tic frequency registrations. Ratings following ER sessions were compared with ratings obtained before the sessions. Neither the ratings at the institute nor the ratings at home supported a rebound effect following ER tic suppression.

Behavioural treatment of trichotillomania: two-year follow-up results.

Post-treatment evaluation studies of behaviour therapy (BT) for trichotillomania (TTM) have shown that BT is successful in reducing symptoms in this impulse-control disorder. The present study was aimed at investigating gain maintenance at long-term follow-up. TTM-related symptoms and other symptom characteristics were evaluated in 28 patients suffering from TTM before and after brief BT and at a 3-month and 2-year follow-up. The manual-based BT consisted of self-control procedures offered in six sessions. Pre-post effect sizes for TTM symptoms at post-treatment evaluation and at the two follow-ups were 2.91, 1.47, and .87. Compared to the post-treatment effects, the 3-month and 2-year follow-up effect sizes had decreased by 49% and 70%, respectively. Better 2-year follow-up results were associated with lower pre-treatment levels of depressive symptoms and with complete abstinence from hair pulling immediately after treatment.

Exposure with response prevention versus habit reversal in Tourettes's syndrome: a controlled study.

The intentional nature of tics provides the opportunity to apply behavioural interventions aimed at tic reduction through interruption of stimulus-response sequences. The aim of this study has been to evaluate the effect of exposure and response prevention (ER) versus habit reversal (HR) in 43 Tourette's syndrome (TS) patients. The three outcome measures were: the Yale Global Tic Severity Scale (YGTSS), 15-min tic frequency registrations monitored at the institute and 15-min home tic frequency registrations. Both treatment conditions resulted in statistically significant improvements on all outcome measures (p < 0.001). No significant differences were found between the treatment conditions on any of the outcome measures, although there was a tendency in favour of ER on the YGTSS (p = 0.05). These results suggest that, at least in the short term, TS tic symptoms can be treated effectively with both types of treatment.

Prophylactic efficacy of lithium versus carbamazepine in treatment-naive bipolar patients.

BACKGROUND: Alternatives to lithium for prophylactic treatment of patients with bipolar affective disorders are increasingly being advocated. However, trials comparing lithium with alternatives are scarce and often biased. METHOD: We studied 94 patients with at least 2 episodes of bipolar disorder (DSM-III-R) during the previous 3 years who were in remission at entry into the study. Treatment with lithium or carbamazepine had not exceeded a total of 6 months during their lifetime. Patients were randomly assigned to carbamazepine or lithium at entry into the 2-year double-blind study or during the acute index episode previous to entry into the study. No concurrent antipsychotics or antidepressants were allowed. RESULTS: On lithium treatment, 12/44 patients developed an episode, compared with 21/50 on carbamazepine treatment. Episodes on lithium treatment occurred almost exclusively during the first 3 months of the trial. Carbamazepine carried a constant risk of an episode of about 40% per year. Efficacy of lithium was superior to that of carbamazepine in patients with a (hypo)manic index episode that had not been treated with study drug during the index episode (p <.01) and also in patients with prior hypomanic but no manic episodes (p <.05). The proportion of patients who dropped out was slightly higher among those taking lithium (16/44) compared with those taking carbamazepine (13/50), resulting in 16/44 patients (36%) on lithium treatment completing the 2 years with no episode, compared with 16/50 (32%) on carbamazepine treatment. CONCLUSION: Lithium appears to be superior in prophylactic efficacy to carbamazepine in bipolar patients not previously treated with mood stabilizers. Our results should reinforce efforts to put and maintain such patients on treatment with lithium.

Endogenous and exogenous attention in patients with conversion paresis.

Endogenous and exogenous attention of patients with conversion paresis was investigated using Posner's 'covert orienting of visual attention' task. In the light of previous evidence showing that inhibition of higher-level control functions plays a role in conversion paralysis (e.g., Marshall, Halligan, Fink, Wade, & Frackowiak, 1997), patients were expected to display weaker cue effects in the endogenous condition and weaker inhibition of return (IOR) in the exogenous condition. Eight patients with conversion paresis in one or more limbs and eight healthy controls were administered the attention task in a verbal response condition and in a limb response condition in which subjects responded with each limb separately. When responding verbally, patients showed relatively weakened endogenous cue effects on a 150-ms stimulus onset asynchronicity (SOA) and no IOR in the exogenous condition. Comparable effects emerged when patients responded with affected limbs but not when they responded with unaffected limbs. The findings suggest impairment in voluntary attention. High-level inhibition is suggested to interfere with the orientation to stimuli that prime responses with affected limbs. The fact that similar results were found for verbal responses is interpreted as supporting the view that attention deficits are manifested on a high, abstract level of cognitive processing.

A randomized, double-blind, placebo-controlled study of the effects of adjunctive paroxetine in panic disorder patients unsuccessfully treated with cognitive-behavioral therapy alone.

BACKGROUND: Both cognitive-behavioral therapy and treatment with selective serotonin reuptake inhibitors (SSRIs) have proved to be effective in the treatment of panic disorder. The present study examined the effects of paroxetine added to continued cognitive-behavioral therapy in patients who were unsuccessfully treated with initial cognitive-behavioral therapy alone. METHOD: 161 patients with panic disorder with or without agoraphobia (DSM-IV criteria) underwent a manual-guided cognitive-behavioral therapy of 15 sessions. Forty-three unsuccessfully treated patients from this group were included in a double-blind, placebo-controlled, next-step treatment study consisting of continued cognitive-behavioral therapy plus adjunctive paroxetine at a dose of 40 mg/day or continued cognitive-behavioral therapy plus placebo. RESULTS: Overall, patients in the cognitive-behavioral therapy plus paroxetine condition improved significantly on agoraphobic behavior (p < .05) and anxiety discomfort (p < .01), whereas patients in the cognitive-behavioral therapy plus placebo condition did not. Effect sizes in the cognitive-behavioral therapy plus paroxetine condition ranged from 1.0 to 1.8 and in the cognitive-behavioral therapy plus placebo condition, from 0.4 to 1.0. CONCLUSION: Patients with panic disorder who are unsuccessfully treated with initial cognitive-behavioral therapy may benefit from the addition of an SSRI as a second treatment modality. The importance of timely evaluation of treatment results is emphasized.

The emotional Stroop: a comparison of panic disorder patients, obsessive-compulsive patients, and normal controls, in two experiments.

An emotional Stroop task with four word types (panic threat, obsessive-compulsive threat, general threat, and neutral) and two presentation conditions (supraliminal, subliminal) was used in two experiments. The first experiment involved 21 panic disorder (PD) patients and 20 normal controls; the second experiment 20 PD patients and 20 obsessive-compulsive patients. PD patients, obsessive-compulsive patients, and normal controls did not differ in Stroop interferences. In addition, there were no significant correlations between reduction of PD symptoms and differences between pre- and post-treatment Stroop response latencies.

Motor initiation and execution in patients with conversion paralysis.

Motor initiation and motor execution in four patients with conversion paralysis were investigated in a non-affected motor modality (speech). In line with the hypothesis of dissociated control in conversion disorder [Cognit. Neuropsychiatry 8 (1) (2001) 21] motor initiation, but not response duration, was expected to be impaired. The motor initiation times (reaction time: RT) and motor execution times (response duration: RD) were compared on four RT-tasks that required the production of a verbal response: a simple choice RT-task, a mental letter rotation task, and an implicit and an explicit mental hand rotation task. Because conversion disorder is expected to primarily involve an impairment in the initiation of movement, we expected the following task characteristics to uniquely affect RT and not RD: type of instruction (implicit versus explicit instructed imagery), angle of rotation, and target arm (affected versus non-affected arm). The results indeed showed the task characteristics to significantly affect the participants' RT and not their RD. It was concluded that conversion paralysis is associated with a specific impairment in the explicit initiation of processes with a spatial and motor component.