The Effectiveness of a Digital App for Reduction of Clinical Symptoms in Individuals With Panic Disorder: Randomized Controlled Trial.

BACKGROUND: Panic disorder is a common and important disease in clinical practice that decreases individual productivity and increases health care use. Treatments comprise medication and cognitive behavioral therapy. However, adverse medication effects and poor treatment compliance mean new therapeutic models are needed. OBJECTIVE: We hypothesized that digital therapy for panic disorder may improve panic disorder symptoms and that treatment response would be associated with brain activity changes assessed with functional near-infrared spectroscopy (fNIRS). METHODS: Individuals (n=50) with a history of panic attacks were recruited. Symptoms were assessed before and after the use of an app for panic disorder, which in this study was a smartphone-based app for treating the clinical symptoms of panic disorder, panic symptoms, depressive symptoms, and anxiety. The hemodynamics in the frontal cortex during the resting state were measured via fNIRS. The app had 4 parts: diary, education, quest, and serious games. The study trial was approved by the institutional review board of Chung-Ang University Hospital (1041078-202112-HR-349-01) and written informed consent was obtained from all participants. RESULTS: The number of participants with improved panic symptoms in the app use group (20/25, 80%) was greater than that in the control group (6/21, 29%; χ21=12.3; P=.005). During treatment, the improvement in the Panic Disorder Severity Scale (PDSS) score in the app use group was greater than that in the control group (F1,44=7.03; P=.01). In the app use group, the total PDSS score declined by 42.5% (mean score 14.3, SD 6.5 at baseline and mean score 7.2, SD 3.6 after the intervention), whereas the PDSS score declined by 14.6% in the control group (mean score 12.4, SD 5.2 at baseline and mean score 9.8, SD 7.9 after the intervention). There were no significant differences in accumulated oxygenated hemoglobin (accHbO2) at baseline between the app use and control groups. During treatment, the reduction in accHbO2 in the right ventrolateral prefrontal cortex (VLPFC; F1,44=8.22; P=.006) and the right orbitofrontal cortex (OFC; F1,44=8.88; P=.005) was greater in the app use than the control group. CONCLUSIONS: Apps for panic disorder should effectively reduce symptoms and VLPFC and OFC brain activity in patients with panic disorder. The improvement of panic disorder symptoms was positively correlated with decreased VLPFC and OFC brain activity in the resting state. TRIAL REGISTRATION: Clinical Research Information Service KCT0007280; https://cris.nih.go.kr/cris/search/detailSearch.do?seq=21448.

Evaluation of effect of brief-intensive cognitive behavior therapy on symptoms severity in relation with catastrophic cognition in patients with panic disorder: a randomized controlled trial.

INTRODUCTION: Due to a dearth of evidence, we examined the effectiveness of brief-intensive CBT on symptom severity and catastrophic cognition in patients with panic disorder (PD). MATERIALS AND METHODS: In this randomized controlled trial, 155 patients were assigned to either the experimental group (2 successive days of brief-intensive CBT-3 h per day) or the control group (regular pharmacotherapy only). After excluding ineligible participants, 20 patients in the brief intensive CBT group and 18 patients in the control group completed the study and were included in the final analysis. The primary outcome was symptom severity, and the secondary outcome was catastrophic cognition, assessed by the Panic Disorder Severity Scale (PDSS) for symptoms severity and the Agoraphobic Cognition Scale (ACS) for cognitive assessment, respectively. RESULTS: The study showed that after one month of treatment, the PDSS (1.70 vs. 4.78; p = 0.0172) in the brief-intensive CBT group was significantly lower compared to the control group in contrast with the ACS (5.10 vs. 5.44; p = 0.8533). The mean score of PDSS and ACS significantly decreased from 21.60 to 1.7 (p < 0.0001) and from 22.55 to 5.10 (p < 0.0001) in the brief CBT group and from 19.44 to 4.78 (p < 0.0001) and 20.00 to 5.44 (p < 0.0001) in the control group, respectively. After treatment, the mean scores of PDSS and ACS significantly decreased in the brief intensive CBT and control groups. Both higher ACS and lower education levels contributed to higher PDSS in the brief intensive CBT group. However, only the PDSS correlated to the ACS in the control group. CONCLUSIONS: The study showed that brief-intensive CBT is an effective technique for reducing the severity of symptoms among PD patients. But, it was not effective to improve the cognitive level in PD patients at one month.

Terapia Cognitivo Conductual presencial y remota para adultos con pánico en Servicios de Emergencias: tres estudios de caso / Face-to-face and remote Cognitive Behavioral Therapy for adults with panic in Emergency Services: study of three cases

Most patients with panic attacks or panic disorder who seek emergency department care go unnoticed and do not receive appropriate treatment. Although first-line psychological treatments exist for these patients, they may be insensitive and inaccessible to their characteristics. The aim of this study was to describe three different brief protocols based on Cognitive Behavioral Therapy that were adapted for face-to-face or videoconferencing application for patients with panic attacks or panic disorder seeking care in emergency department. Three cases of adult patients, two diagnosed with panic disorder and one with panic attacks, are presented to show the implementation and outcomes of the protocols on diagnostic severity, anxiety sensitivity, quality of life, health services utilization, and patient satisfaction with the protocols. As well as the use of a panic screening diagram designed for the initial evaluation of these patients. After one to seven sessions, a decrease in panic disorder severity or frequency of panic attacks, and anxiety sensitivity was observed. Quality of life improved, patients stopped using emergency department and showed satisfaction with the intervention they received. Brief interventions based on Cognitive Behavioral Therapy, both face-to-face and remote, can be implemented in emergency department to overcome some barriers to mental health access and fit the diverse care possibilities of panic patients. (AU)

Clinical and cognitive insight in panic disorder: phenomenology and treatment effects in internet cognitive behavior therapy.

Clinical observations suggest that individuals with panic disorder (PD) vary in their beliefs about the causes of their panic attacks. Some attribute these attacks to psychological factors, while others to physiological or medical factors. These beliefs also extend to whether individuals perceive panic attacks as dangerous. In other areas of psychiatric nosology, these phenomena are commonly called clinical insight (recognition of disorder and the need for treatment) and cognitive insight (the ability to reflect on one's beliefs). Despite its importance, limited research exists on insight in PD and its relation to symptoms and treatment outcomes. This study examines clinical and cognitive insight in 83 patients with PD who received internet-based cognitive behavioral therapy, investigating their relationship with symptoms, treatment outcomes, and changes in insight. We assessed patients using interview and self-report measures of insight and symptoms. Clinical and cognitive insight were correlated and both constructs improved significantly during treatment. Good clinical insight pretreatment was positively correlated with more severe pretreatment symptoms. Pretreatment clinical and cognitive insight were not correlated with symptom change or attrition. Greater change in clinical and cognitive insight was related to greater change in symptoms. The findings highlight the significance of clinical and cognitive insight in PD, and the importance of distinguishing between them. This suggests the need to develop interventions according to patients' level of insight, particularly focusing on those lacking insight. Further research is essential to advance our understanding of the relationship between insight and the phenomenology and treatment of PD.

Effects of panic-specific cognitive behavioural and psychodynamic psychotherapies on work ability in a doubly randomised clinical trial.

Objective: The effects of panic-specific psychotherapy on occupational functioning remain under-researched. This study tests whether two brief psychotherapies for Panic Disorder with or without Agoraphobia (PD/A) may generate improvement in work ability. Methods: Adults (N = 221) with a primary diagnosis of PD/A were randomised to wait-list, panic-focused psychodynamic psychotherapy (PFPP), panic control treatment (PCT), or to the choice between the two treatments. Participants completed the Work Ability Inventory (WAI) at baseline, post-treatment, and during 24-month follow-ups. Change in WAI scores were assessed using segmented multilevel linear growth models, and mediation was explored through path analysis. Results: WAI scores changed from the moderate to good range between baseline and post-treatment (SMD = 0.45; 95% CI [0.33, 0.57]) and continued to increase throughout the follow-up (SMD = 0.16; 95% CI [0.03, 0.28]) with no differences between treatments or allocation forms. In PFPP (but not in PCT) pre- to post-treatment change in WAI was mediated by reduction in panic symptoms and WAI predicted employment status and absences. Conclusions: Two brief panic specific psychotherapies, one cognitive behavioural and one psychodynamic, produced short and long-term increases in work ability.

Exposure traced in daily life: improvements in ecologically assessed social and physical activity following exposure-based psychotherapy for anxiety disorders.

BACKGROUND: Although exposure-based cognitive-behavioral therapy for anxiety disorders has frequently been proven effective, only few studies examined whether it improves everyday behavioral outcomes such as social and physical activity. METHODS: 126 participants (85 patients with panic disorder, agoraphobia, social anxiety disorder, or specific phobias, and 41 controls without mental disorders) completed smartphone-based ambulatory ratings (activities, social interactions, mood, physical symptoms) and motion sensor-based indices of physical activity (steps, time spent moving, metabolic activity) at baseline, during, and after exposure-based treatment. RESULTS: Prior to treatment, patients showed reduced mood and physical activity relative to healthy controls. Over the course of therapy, mood ratings, interactions with strangers and indices of physical activity improved, while reported physical symptoms decreased. Overall results did not differ between patients with primary panic disorder/agoraphobia and social anxiety disorder. Higher depression scores at baseline were associated with larger changes in reported symptoms and mood ratings, but smaller changes in physical activity CONCLUSIONS: Exposure-based treatment initiates increased physical activity, more frequent interaction with strangers, and improvements in everyday mood. The current approach provides objective and fine-graded process and outcome measures that may help to further improve treatments and possibly reduce relapse.

Cognitive change before sudden gains in cognitive behavioural therapy for panic disorder.

BACKGROUND: Sudden gains occur in a range of disorders and treatments and are of clinical and theoretical significance if they can shed light on therapeutic change processes. This study investigated the relationship between sudden gains in panic symptoms and preceding cognitive change during cognitive behavioural therapy (CBT) for panic disorder. METHOD: Participants with panic disorder completed in session measures of panic symptoms and catastrophic cognitions. Independent samples t-tests were used to compare the post-treatment score of those who met criteria for one or more sudden gain during treatment with those who did not, and to compare within-session cognitive change between pre-sudden gain sessions and the previous (control) session. RESULTS: Twenty-two (42%) of 53 participants experienced a sudden gain during treatment. Participants demonstrating a sudden gain showed more improvement in panic symptoms from pre- to post-treatment than those without a sudden gain. The within-session cognitive change score in the pre-gain session was significantly greater than in the control session. CONCLUSIONS: Sudden gains occurred in individual CBT for panic disorder and within-session cognitive change was associated with sudden gains. This is consistent with the cognitive model of panic disorder and highlights how sudden gains can help to identify key change processes.

Personalized virtual reality exposure for panic disorder and agoraphobia: A preliminary neurophysiological study.

BACKGROUND: Personalization is considered an important principle in virtual reality (VR) exposure therapy. We aimed to identify whether personalized VR exposure could provoke increased anxiety in patients with panic disorder and agoraphobia as it is considered the first step in successful treatment for anxiety. METHODS: We performed a double-arm, one-day preliminary study among 28 patients with panic disorder and agoraphobia. Three sessions of VR exposure, including a theater, train, and elevator scenario, were conducted in two groups. In the personalized group (n = 14), the brightness and crowd density were customized based on a pre-assessment. In the control group (n = 14), these conditions were fully randomized. Self-reported anxiety, heart rate, skin conductance, and electroencephalography were measured before, during, and after the VR sessions. RESULTS: In the later VR sessions, higher self-reported anxiety levels measured by the Visual Analogue Scale were observed in the personalized exposure group. Increased heart rates during and after the VR sessions were observed in the personalized group. The changes in skin conductance peaks were not significantly different between the groups, but the increase in skin conductance was associated with the participants' perception of presence. The electroencephalogram showed widespread increases in alpha waves in the frontal and temporal areas of the brain in the personalized group than in the control group. CONCLUSION: Personalized VR exposure elicits stronger anxiogenic effects in patients with panic disorder and agoraphobia as suggested by self-report and neurophysiological data. Personalization of VR exposure has the potential for effective behavioral therapy.

[Intensive cognitive behavioral group therapy for the treatment of panic disorder]. / Intenzív kognitív viselkedésterápiás csoport pánikbetegség kezelésére.

INTRODUCTION: Panic disorder is one of the most commonly occurring emotional disorder, showing increased prevalence rates since the COVID-19 pandemic. The ever-growing number of patients in need of treatment is a heavy burden on the healthcare system, which draws attention to the importance of low-intensity, short and effective psychological interventions in the treatment of mental disorders, especially in the field of primary care. According to international guidelines, the recommended evidence-based treatment of panic disorder is cognitive behavioral therapy, which is based on the cognitive model of panic disorder. According to the model, a panic attack develops in those who catastrophize the symptoms of the normal stress reaction, i.e., consider them a sign of a serious physical illness such as heart-attack and react to this with intense anxiety. OBJECTIVE: Based on Salkovskis and Clark (1986), we developed a 5 session, intensive cognitive behavioral group therapy protocol for panic patients. METHOD: Effectiveness of the short group therapy was assessed with questionnaires (Spielberger's State-Trait Anxiety Inventory, Beck Depression Inventory) and an additional subjective scale. Paired sample t-tests were conducted. RESULTS: Our results suggest that the intensity of anxiety and depressive symptoms (t(36) = 5.497, p<0.0001; Z = -4.871, p<0.0001) as well as the frequency of panic attacks (Z= -5.190, p<0.0001) decreased significantly after the 5 session group therapy. DISCUSSION AND CONCLUSION: Our clinical study provides further evidence by the effectiveness of low-intensity psychological interventions, offering an evidence-based protocol for professionals working in primary as well as mental health care. Orv Hetil. 2023; 164(42): 1665-1672.

Efficacy of an Internet-based intervention with self-applied exposure therapy in virtual reality for people with panic disorder: study protocol for a randomized controlled trial.

BACKGROUND: Due to several treatment barriers, many individuals with panic disorder do not receive evidence-based treatment. One promising option to narrow this treatment gap is Internet-based psychotherapy, which has been shown particularly effective in guided formats. Still, there remains room for improvement to make these digital therapies more accessible, cost-efficient, and aligned with best practices for in-person interventions (e.g., exposure). The smartphone app "Invirto - Treatment for Anxiety" offers digitally guided, evidence-based treatment of panic disorders including virtual reality (VR) for exposure therapy. The aim present study is to investigate the efficacy, safety, and acceptance of Invirto in comparison to a care-as-usual (CAU) control group. METHODS: We plan to conduct a randomized controlled trial with two conditions (intervention vs. CAU), three assessment times via online surveys (t0: baseline; t1: 3 months after baseline; t2: follow-up assessment 6 months after baseline), and a total of 128 participants with a clinical diagnosis of panic disorder (symptoms must be experienced ≥ 1 year). Recruitment will take place via email, phone, and the study website. The primary outcome will be the change in anxiety symptoms as measured by Beck's Anxiety Inventory from t0 to t1. Secondary outcomes will be the change in anxiety symptoms (measured by the Panic and Agoraphobia Scale, PAS; Questionnaire on panic-related Anxieties, Cognitions and Avoidance, ACA), depressive symptoms (measured by the Beck-Depression-Inventory, BDI-II), treatment satisfaction (measured by the Client Satisfaction Questionnaire, CSQ-8; Treatment Adherence Perception Questionnaire, TAPQ-adapt; Positive and Negative Effects of Psychotherapy Scale, PANEPS-I), psychological flexibility (measured by the Acceptance and Action Questionnaire-II, AAQ-II), and dissociation during VR exposure (measured by an adapted version of the Peritraumatic Dissociative Experiences Questionnaire, PDEQ-adapt). Participants in the intervention group will receive access to the intervention (Invirto) right after t0, while the CAU group will receive access to Invirto after t1. We expect a larger change in both the primary and secondary outcomes from t0 to t1 in the intervention group in comparison to the CAU group. DISCUSSION: This study is one of the first to evaluate an Internet-based intervention for people with panic disorder that includes self-application of VR exposure therapy. The findings are expected to extend the body of knowledge about effective Internet-based treatment options for people with panic disorder. The empirical and clinical implications and the limitations of the study are discussed. TRIAL REGISTRATION: DRKS00027585 ( www.drks.de/drks_web/ ), date of registration: 13 January 2022.

CBT-Intervention for panic disorder in primary care: 5 years follow-up of a cRCT during the Covid-19 pandemic.

A practice team-based exercise programme with elements of cognitive behavioural therapy (CBT) and case management for patients with panic disorder with or without agoraphobia in primary care showed significant positive effects. Here, we analyse the long-term effects (>5 years) of this intervention in the stressful context of the Covid-19 pandemic. All participants of the original PARADIES cluster randomized controlled trial (cRCT; 2012-2016) were invited to participate in a follow-up during the Covid-19 pandemic. Clinical outcomes were anxiety symptoms, number and severity of panic attacks, agoraphobic avoidance behaviour, Covid-specific anxiety symptom severity, depression, and patient assessment of chronic illness care. Data were analysed cross-sectionally for group differences (intervention, control) and longitudinally (T0: baseline, T1: 6 months and TCorona: >60 months). Of the original 419 participants, 100 participated in the 60 months follow-up (October 2020-May 2021). In the cross-sectional analysis, the anxiety symptom severity in the intervention group was lower than in the control group (p = .011, Cohen's d = .517). In the longitudinal analysis, both groups showed an increase of anxiety and depression symptoms compared to pre-pandemic level. The intervention may have had a lasting impact regarding anxiety severity despite the challenging context of the Covid-19 pandemic. However, we cannot say to what extend the intervention still played a role in participants' lives; other factors may also have helped with coping. The increase of anxiety and depression symptoms in both groups over time could be attributed to external circumstances.

Treatment Course Comparison Between Anxiety-Related Disorders in Adult Outpatients: A Leiden Routine Outcome Monitoring Study.

ABSTRACT: 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.

CBT treatment delivery formats for panic disorder: a systematic review and network meta-analysis of randomised controlled trials.

Several in-person and remote delivery formats of cognitive-behavioural therapy (CBT) for panic disorder are available, but up-to-date and comprehensive evidence on their comparative efficacy and acceptability is lacking. Our aim was to evaluate the comparative efficacy and acceptability of all CBT delivery formats to treat panic disorder. To answer our question we performed a systematic review and network meta-analysis of randomised controlled trials. We searched MEDLINE, Embase, PsycINFO, and CENTRAL, from inception to 1st January 2022. Pairwise and network meta-analyses were conducted using a random-effects model. Confidence in the evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). The protocol was published in a peer-reviewed journal and in PROSPERO. We found a total of 74 trials with 6699 participants. Evidence suggests that face-to-face group [standardised mean differences (s.m.d.) -0.47, 95% confidence interval (CI) -0.87 to -0.07; CINeMA = moderate], face-to-face individual (s.m.d. -0.43, 95% CI -0.70 to -0.15; CINeMA = Moderate), and guided self-help (SMD -0.42, 95% CI -0.77 to -0.07; CINeMA = low), are superior to treatment as usual in terms of efficacy, whilst unguided self-help is not (SMD -0.21, 95% CI -0.58 to -0.16; CINeMA = low). In terms of acceptability (i.e. all-cause discontinuation from the trial) CBT delivery formats did not differ significantly from each other. Our findings are clear in that there are no efficacy differences between CBT delivered as guided self-help, or in the face-to-face individual or group format in the treatment of panic disorder. No CBT delivery format provided high confidence in the evidence at the CINeMA evaluation.

Obstruction sleep apnoea and panic disorder.

OBJECTIVE: Both panic disorder (PD) and obstructive sleep apnea (OSA) are frequent conditions that can be comorbid. This article reviews the current state of knowledge about the comorbidity of PD and OSA and the effectiveness of therapy in patients with this comorbidity. METHOD: Articles obtained via PubMed and Web of Science search were selected; the publishing date was between January 1990 and December 2022. The applied search terms were: obstructive sleep apnea; panic disorder; CPAP; antidepressants; anxiolytics; antipsychotics. Eighty-one articles were chosen by primary search via keywords. After a complete assessment of the full texts, 60 papers were chosen. Secondary papers from the references of the primary documents were investigated, evaluated for suitability, and included in the list of documents (n = 18). Thus, seventy-eight papers were incorporated into the review article. RESULTS: Studies describe a greater prevalence of panic disorder in OSA patients. So far, there is no data on the prevalence of OSA in PD patients. Limited evidence is found regarding the influence of CPAP treatment on PD, and this evidence suggests that CPAP can partially alleviate PD symptoms. Medication used in PD treatment can significantly impact comorbid OSA, as explored in several studies. CONCLUSIONS: The relationship between the two conditions seems bidirectional, and it is necessary to assess OSA patients for comorbid panic disorder and vice versa. Both disorders can worsen the other and must be treated with a complex approach to ensure improvement in patients' physical health and psychological well-being.

La Influencia de la Evitación Experiencial y la Fusión Cognitiva en Personas con Diagnóstico de Trastorno de Pánico y Agorafobia y TOC / The Influence of Experiential Avoidance and Cognitive Fusion in People Diagnosed with Panic Disorder and Agoraphobia and OCD

La terapia de aceptación y compromiso (ACT) pone de manifiesto la importancia de la evitación experiencial y la fusión cognitiva en un amplio espectro de problemas psicológicos. El propósito de este estudio es conocer cómo influyen la gravedad del trastorno de pánico y agorafobia (TPA) y la gravedad del trastorno obsesivo-compulsivo (TOC) en los niveles de evitación experiencial y fusión cognitiva. Se pretende examinar, además, si existen diferencias entre ambos grupos diagnósticos. La muestra estaba constituida por 67 personas diagnosticadas de TPA y TOC. Se utilizaron los siguientes instrumentos de evaluación: Acceptance and Action Questionnaire (AAQ), Cognitive Fusion Questionnaire (CFQ), Yale-Brown Obsessive Compulsive Scale (Y-BOCS) y Beck Anxiety Inventory (BAI). Los resultados mostraron que los pacientes con TPA presentan mayores niveles de fusión cognitiva frente a los pacientes con TOC, que elevados niveles de ansiedad se asocian a mayor grado de evitación experiencial y que una mayor gravedad del TOC correlacionaba con elevados niveles de evitación experiencial y fusión cognitiva. Se propone una intervención temprana en pacientes con TOC para prevenir la cronicidad del trastorno y se recalca la importancia de los aspectos de aceptación en el trascurso de la terapia de estos pacientes (AU)

Acceptance and Commitment Therapy (ACT) highlights the importance of experiential avoidance and cognitive fusion in a wide spectrum of psychological problems. The purpose of this study is to know how the severity of panic disorder and agoraphobia (APT) and the severity of obsessive-compulsive disorder (OCD) influence levels of experiential avoidance and cognitive fusion. It is also intended to examine whether there are differences between the two diagnostic groups. The sample consisted of 67 people diagnosed with APT and OCD. The following assessment instruments were used: Acceptance and Action Questionnaire (AAQ), Cognitive Fusion Questionnaire (CFQ), Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and Beck Anxiety Inventory (BAI). The results showed that patients with APT present higher levels of cognitive fusion compared to patients with OCD, that high levels of anxiety are associated with a higher degree of experiential avoidance, and that greater severity of OCD correlated with high levels of experiential avoidance and fusion cognitive. Early intervention in OCD patients is proposed to prevent the chronicity of the disorder and the importance of the acceptance aspects is emphasized in the course of therapy of these patients (AU)

Mood and Anxiety Disorders: Generalized Anxiety and Panic Disorders.

Anxiety disorders are characterized by excessive fear and worry. Generalized anxiety disorder (GAD) and panic disorder (PD) are two of the most common anxiety disorders in the United States. GAD is defined as excessive worry and anxiety that occur on most days for at least 6 months that affect daily functioning. PD is defined by recurrent unexpected panic attacks. Patients with symptoms of GAD or PD should be assessed for conditions such as hyperthyroidism, hyperparathyroidism, and cardiac arrhythmia before confirmation of an anxiety disorder diagnosis. A U.S. Preventive Services Task Force (USPSTF) draft statement recommends screening for anxiety in adults 64 years and younger, including pregnant and postpartum women. A final statement recommends screening for anxiety in children and adolescents ages 8 to 18 years. Multiple self-report tools have been validated for GAD and PD screening. The 7-item Generalized Anxiety Disorder (GAD-7) scale is an option for screening for GAD. The Panic Disorder Severity Scale (PDSS) is a 7-item tool with excellent sensitivity and specificity in screening for PD. Management with selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors in combination with psychotherapy has been shown to be effective for GAD and PD. Research on alternative treatments, such as psychedelic-assisted psychotherapy, is ongoing.

Effective-and Tolerable: Acceptance and Side Effects of Intensified Exposure for Anxiety Disorders.

Despite striking empirical support, exposure-based treatments for anxiety disorders are underutilized. This is partially due to clinicians' concerns that patients may reject exposure or experience severe side effects, particularly in intensive forms of exposure. We examined acceptance and side effects of two randomly assigned variants of prediction error-based exposure treatment differing in temporal density (1 vs. 3 sessions/week) in 681 patients with panic disorder, agoraphobia, social anxiety disorder, and multiple specific phobias. Treatment acceptance included treatment satisfaction and credibility, engagement (i.e., homework completion), and tolerability (i.e., side effects, dropout, and perceived treatment burden). Side effects were measured with the Inventory for the Balanced Assessment of Negative Effects of Psychotherapy (INEP). We found treatment satisfaction, credibility, and engagement to be equally high in both variants of exposure-based treatment, despite higher treatment burden (ß = 0.25) and stronger side effects (ß = 0.15) in intensified treatment. 94.1% of patients reported positive effects in the INEP. 42.2% reported side effects, with treatment stigma (16.6%), low mood (14.8%) and the experience to depend on the therapist (10.9%) being the most frequently reported. The mean intensity of side effects was low. We conclude that prediction error-based exposure treatment is well accepted by patients with different anxiety disorders and that patients also tolerate temporally intensified treatment, despite higher perceived treatment burden and stronger side effects. Clinicians should be aware of the most frequent side effects to take appropriate countermeasures. In sum, temporal intensification appears to be an acceptable strategy to achieve faster symptom reduction, given patients' well-informed consent.

Virtual reality interventions for the treatment of anxiety disorders: A scoping review.

BACKGROUND: & Objectives: Virtual Reality (VR) refers to an artificial, immersive three-dimensional environment with interactive sensory stimuli. VR is typically incorporated into the psychotherapeutic process as a means of providing exposure therapy. The objectives of this scoping review were to synthesize the most up-to-date evidence on the outcomes, acceptability, and side effects of VR interventions for treating anxiety disorders in adults. METHODS: This scoping review is grounded in the methodological framework of Arksey and O'Malley (2005). The databases searched were PubMed, EMBASE, Web of Science, PsycINFO, and ProQuest Dissertations and Theses. RESULTS: The search process identified 112 unique citations. 52 (46%) of the eligible articles examined participants with specific phobias, 25 (22%) with PTSD, 21 (19%) with social anxiety disorder, 12 (10%) with panic disorder with or without agoraphobia, and 3 (3%) with generalized anxiety disorder. VR interventions often led to statistically significant and meaningful reductions in symptoms for people with anxiety disorders. Additionally, they were acceptable to clients and associated with minimal side effects for all types of anxiety disorders, except for Combat-Related PTSD in Vietnam veterans. LIMITATIONS: Limitations included the fact that the studies in this review were of varying quality, and that articles in languages other than English and French were excluded. CONCLUSION: VR interventions appeared to be a viable alternative to conventional exposure therapy. Future research should include more male participants and have a stronger emphasis on acceptability and side effects. Increased traction for VR interventions for generalized anxiety disorder and panic disorder is also important.

Long-term benefits of mindfulness on white matter tracts underlying the cortical midline structures in panic disorder: A 2-year longitudinal study.

AIMS: We aimed to examine the long-term benefits of mindfulness-based cognitive therapy (MBCT) on white matter plasticity in the cortical midline structures (CMS) for a period of 2 years in patients with panic disorder and the relationships between white matter changes in the CMS and severity of state and trait symptoms. METHODS: Seventy-one participants were enrolled and underwent diffusion tensor imaging at baseline and after 2 years (26 who received MBCT as an adjunct to pharmacotherapy [MBCT+PT], 20 treated with pharmacotherapy alone [PT-alone], and 25 healthy controls [HCs]). The severity of symptoms and fractional anisotropy (FA) in white matter regions underlying the CMS were assessed at baseline and 2-year follow-up. RESULTS: The MBCT+PT group showed better outcomes after 2 years than the PT-alone group. The groups showed different FA changes: the MBCT+PT group showed decreased FA in the left anterior cingulate cortex (ACC); the PT-alone group showed increased FA in the bilateral dorsomedial prefrontal cortex, posterior cingulate cortex (PCC), and precuneus. Decreased white matter FA in the ACC, PCC, and precuneus was associated with improvements in the severity of state and trait symptoms in patients with panic disorder. CONCLUSION: Alleviation of excessive white matter connectivity in the CMS after MBCT leads to improvements in clinical symptoms and trait vulnerability in patients with panic disorder. Our study provides new evidence for the long-term benefits of MBCT on white matter plasticity and its clinical applicability as a robust treatment for panic disorder.

Eye movement desensitization and reprocessing (EMDR) therapy or supportive counseling prior to exposure therapy in patients with panic disorder: study protocol for a multicenter randomized controlled trial (IMPROVE).

BACKGROUND: Exposure-based therapy is the treatment of choice for anxiety disorders, but many patients do not benefit sufficiently from it. Distressing images of threat related to the future or past may maintain the anxiety symptomatology or impede exposure therapy. An intervention that targets threat-related imagery is eye movement desensitization and reprocessing (EMDR) therapy. The main goal of this multicenter randomized controlled trial is to investigate whether EMDR therapy plus exposure therapy, relative to supportive counseling plus exposure therapy, improves treatment efficacy, tolerability, and adherence in patients with panic disorder. In addition, we will examine potential predictors of optimal treatment allocation, mechanisms of change as well as the long term effects of treatment. Finally, we will assess cost-effectiveness. METHODS: A multicenter randomized controlled trial mixed design will be conducted. Participants will be 50 patients, aged ≥ 18, diagnosed with a panic disorder. They will be randomly assigned to one of two conditions: EMDR therapy (i.e., flashforward strategy) or supportive counseling (each consisting of four weekly sessions of 90 min each) prior to exposure therapy (consisting of eight weekly sessions of 90 min each). Assessments will be made pre-treatment (T1), between-treatments (T2), post-treatment (T3), one month post-treatment (FU1) and six months post-treatment (FU2) by an assessor blind to treatment condition. The primary outcome measure is severity of panic-related symptoms. Secondary outcome measures are: tolerability of exposure therapy (initial avoidance, willingness to start exposure therapy, considered drop-out; no-show and drop-out), related symptomatology (generalized anxiety, depression), and functional impairment. DISCUSSION: The primary goals of this research are to compare the efficacy, tolerability, and adherence of EMDR therapy plus exposure therapy and supportive counseling plus exposure therapy and to identify predictors, moderators, and mediators for treatment success. This multi-center research aims to make a significant contribution to our understanding as to how treatment for patients with anxiety disorders can be optimized, and elucidate who can benefit most from this novel approach. TRIAL REGISTRATION: ISRCTN-ISRCTN29668369: Improving anxiety treatment by modifying emotional memories before real-life exposure. Registered 27 June 2022-retrospectively registered. ISRCTN-ISRCTN29668369.