The role of trauma and dissociation in cognitive-behavioral psychotherapy outcome and maintenance for panic disorder with agoraphobia.

The relationship between traumatic experiences and dissociation with pretreatment psychopathology and rates of recovery, relapse and maintenance for patients receiving cognitive-behavioral treatments for panic disorder with agoraphobia (PDA) were investigated. One-hundred and forty-seven subjects who met DSM-III criteria for agoraphobia with panic attacks and who completed participation in one of two previously conducted treatment outcome studies were mailed packets containing measures to assess history of trauma, victimization and dissociation. Eighty-nine of these were returned and completed sufficiently to be included in the present study. It was hypothesized that a variety of trauma-related variables (e.g. history of traumatic experience, type of trauma, age at which the trauma first occurred, perceived responsibility, social supports available, self-perceived severity, level of violence, and whether or not the traumatic event was followed by self-injurious or suicidal thoughts and/or behaviors) and dissociative symptomatology would be predictive of (1) greater psychopathology at pretreatment, (2) poorer treatment response and (3) higher relapse rates and poorer maintenance over a 1 year longitudinal follow-up. These hypotheses were supported by the findings and the theoretical, empirical and clinical implications are discussed.

The role of self-directed in vivo exposure in combination with cognitive therapy, relaxation training, or therapist-assisted exposure in the treatment of panic disorder with agoraphobia.

The effects of self-directed in vivo exposure in the treatment of panic disorder with agoraphobia were examined. Seventy-four chronic and severe agoraphobic subjects were randomly assigned to Cognitive Therapy plus graded exposure. Relaxation Training plus graded exposure, or therapist-assisted graded exposure alone. Treatment consisted of 16 weekly 2.5-hour sessions. All subjects received programmed practice instructions for engaging in self-directed exposure as a concomitant strategy to their primary treatment. All subjects were instructed to keep systematic behavioral diary recordings of all self-directed exposure practice. The diary data were analyzed across and within treatments and assessment phases. Statistically significant findings were obtained across all diary measure domains with powerful repeated measures effects observed across all treatments. Significant between group effects and treatment x repeated measures interactions were obtained across the diary measure domains. Multiple linear regressions of in vivo anxiety levels and, to a lesser extent, frequency of self-directed exposure practice were found to be significantly associated with global assessment of severity at posttreatment and 3-month follow-up assessments. Furthermore, depression and marital satisfaction were significantly associated with in vivo anxiety. These and other findings are discussed with regard to their conceptual and clinical implications.

The relationship of attributional style to agoraphobia severity, depression, and treatment outcome.

The present study examined the relationship of attributional style, as measured with a revised version of the Attributional Style Questionnaire (ASQ) and measures of agoraphobia severity, depression, and treatment outcome in 73 Ss who met DSM-III criteria for agoraphobia with panic attacks and participated in one of three 13-week treatment conditions: paradoxical intention, graduated exposure, or progressive deep muscle relaxation training. Subjects completed assessments at four periods: pretreatment, midtreatment, posttreatment, and at 3 month follow-up. In addition to the three dimensions typically examined on the ASQ, this revised version also measured Ss' estimates of the perceived importance, and future likelihood for both positive and negative events. Congruent with previous research, moderate but somewhat inconsistent associations were observed between attributional style and depression both within and across assessment periods. Predictions about associations between attributional style and agoraphobic severity were not supported; however, an interaction was observed between depression and attributional style with respect to severity of agoraphobia. There was no evidence of group differences across treatment types, although there were several significant changes in attributional style across time. Attributions for health related events were also examined. Conceptual, clinical, and research issues related to the findings are discussed.

Panic disorder: cognitive-behavioral treatment.

The effectiveness of an integrated treatment program utilizing cognitive-behavioral therapies for Panic Disorder was examined. Treatment was comprised of Cognitive Model of Panic-derived procedures, Cognitive Therapy and Applied Relaxation Training. Subjects meeting DSM-III-R criteria for Panic Disorder received thirteen 2.5-hr sessions of outpatient therapy in small groups, over a 12-week period. Subjects were given an extensive rationale of the etiology, development and maintenance of Panic Disorder, within the framework of the Cognitive Model of Panic, and controlled behavioral experiments in panic evocation to internal panicogenic cues, cognitive reappraisal of somatic and ideational cues, breathing retraining, Applied Relaxation Training and Cognitive Therapy to identify and remediate maladaptive beliefs and dysfunctional cognitive schemas. A comprehensive assessment battery was given at pre-mid-post-treatment which included measures of tripartite functioning, global severity, panic, fear, anxiety, depression and psychiatric symptomatology. Analyses indicated statistically significant improvements across all outcome domains. All subjects were free of spontaneous (uncued) panic attacks at post-treatment, and all met operationalized criteria for high endstate functioning. These findings are discussed, with recommendations for future research.

Psychophysiological outcome of cognitive, behavioral and psychophysiologically-based treatments of agoraphobia.

Psychophysiological process and outcome phenomena were analyzed to examine differential temporal patterns within and across cognitive, behavioral and physiologically-based treatments of agoraphobia. Eighty-eight severe and chronic agoraphobics with panic attacks (DSM-III) were randomly assigned to one of three treatments: Paradoxical Intention, Graduated Exposure or Progressive Deep Muscle Relaxation Training. Protocol therapists, whose treatment integrity was objectively monitored, conducted 12 two-hour weekly sessions. All subjects received programmed practice instructions concurrent with their primary treatment. Analyses revealed numerous significant reductions on in vivo psychophysiological measures for the relaxation condition, a few improvements for the exposure treatment and no effects for the paradoxical intention modality. The mediating role of pretreatment physiological reactivity in treatment outcome and follow-up status was examined and revealed no significant associations. Synchrony-desynchrony patterns were found to vary widely according to both treatment phase and the time interval between assessments. No between-group differences were observed on the proportion of synchronizers. However, synchronizers exhibited superior outcome and follow-up compared to desynchronizers on all domains except the physiological measures. Conceptual, methodological and clinical implications of these findings are discussed with recommendations for future research.