Coping Skills and Exposure Therapy in Panic Disorder and Agoraphobia: Latest Advances and Future Directions

Department of Psychology, Southern Methodist University, Dallas, TX 72505, USA.
Behavior therapy (Impact Factor: 3.69). 06/2012; 43(2):271-84. DOI: 10.1016/j.beth.2011.08.002
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Although cognitive-behavioral treatments for panic disorder have demonstrated efficacy, a considerable number of patients terminate treatment prematurely or remain symtpomatic. Cognitive and biobehavioral coping skills are taught to improve exposure therapy outcomes but evidence for an additive effect is largely lacking. Current methodologies used to study the augmenting effects of coping skills test the degree to which the delivery of coping skills enhances outcomes. However, they do not assess the degree to which acquisition of coping skills and their application during exposure therapy augment outcomes. We examine the extant evidence on the role of traditional coping skills in augmenting exposure for panic disorder, discuss the limitations of existing research, and offer recommendations for methodological advances.

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Available from: Kate B. Wolitzky-Taylor, Jan 09, 2014
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    • "Exposure therapy — the systematic confrontation with feared situations or sensations — facilitates fear extinction through acquisition of new, fear-discordant information (Bouton, 2002). However, a significant number of patients experience limited recovery or a return of fear following exposure, so detection of internal mediators and external agents that can facilitate corrective learning is extremely important (Craske et al., 2008; Meuret et al., 2012a). Pharmacological enhancement of extinction processes has been attempted using drugs such as D-cycloserine (DCS) (e.g., Hofmann et al., 2006) and glucocorticoids (GCs) (Soravia et al., 2006; de Quervain et al., 2011). "
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    ABSTRACT: Background: Research suggests that elevated stress hormones during exposure can facilitate fear extinction in laboratory settings. However, prospective studies on the clinical benefits of endogenous cortisol on clinical improvements in naturalistic exposures are lacking. Methods: Twenty-six patients with panic disorder and agoraphobia completed three weekly in-vivo exposure sessions and a fourth session 2 months following therapy completion, resulting in a total of 94 in-vivo exposure sessions. Salivary cortisol was collected at multiple times during the first exposure day (cortisol morning response, prior, -during, -after exposure) and at subsequent exposure sessions (prior, -during, -after exposure). Cortisol collection on a non-exposure comparison day followed the same time schedule as session 1. Results: Exposure day anxiety and cortisol levels were significantly higher than control day levels. Higher absolute cortisol levels during exposures moderated clinical improvement (avoidance behavior, threat appraisal, perceived control). Therapeutic gains were not just related to exposure day cortisol levels, but were also linked to non-exposure day levels. Greater morning rises in cortisol on exposure day predicted greater treatment gains, but greater rises on the control day were associated with poorer outcomes. Conclusions: The study provides first evidence for a moderating effect of cortisol awakening response and absolute cortisol levels on fear extinction processes during naturalistic, prospective exposure-therapy. Additionally, we replicated and extended prior findings on the therapeutic benefits of high exposure cortisol levels. Together, the findings suggest that cortisol may act as a general moderator of facilitated learning during exposure therapy.
    Psychoneuroendocrinology 10/2014; 51:331—340. DOI:10.1016/j.psyneuen.2014.10.008 · 4.94 Impact Factor
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    • "This view is strengthened by research, showing that solely exposure-based treatments can lead to significant clinical improvements in patients with PD/AG [21,35-38]. Meta-analyses compared the relative effectiveness of the different CBT elements in the treatment of PD/AG [23,39,40]. The findings indicate that teaching coping skills, or using cognitive restructuring, do not increase clinical outcomes above exposure exercises alone (but see the work of Sanchez-Meca et al.) [41]. "
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    ABSTRACT: Panic disorder and agoraphobia are debilitating and frequently comorbid anxiety disorders. A large number of patients with these conditions are treated by general practitioners in primary care. Cognitive behavioural exposure exercises have been shown to be effective in reducing anxiety symptoms. Practice team-based case management can improve clinical outcomes for patients with chronic diseases in primary care. The present study compares a practice team-supported, self-managed exposure programme for patients with panic disorder with or without agoraphobia in small general practices to usual care in terms of clinical efficacy and cost-effectiveness. This is a cluster randomised controlled superiority trial with a two-arm parallel group design. General practices represent the units of randomisation. General practitioners recruit adult patients with panic disorder with or without agoraphobia according to the International Classification of Diseases, version 10 (ICD-10). In the intervention group, patients receive cognitive behaviour therapy-oriented psychoeducation and instructions to self-managed exposure exercises in four manual-based appointments with the general practitioner. A trained health care assistant from the practice team delivers case management and is continuously monitoring symptoms and treatment progress in ten protocol-based telephone contacts with patients. In the control group, patients receive usual care from general practitioners. Outcomes are measured at baseline (T0), at follow-up after six months (T1), and at follow-up after twelve months (T2). The primary outcome is clinical severity of anxiety of patients as measured by the Beck Anxiety Inventory (BAI). To detect a standardised effect size of 0.35 at T1, 222 patients from 37 general practices are included in each group. Secondary outcomes include anxiety-related clinical parameters and health-economic costs.Trial registration: Current Controlled Trials [ISCRTN64669297].
    Trials 04/2014; 15(1):112. DOI:10.1186/1745-6215-15-112 · 1.73 Impact Factor
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    • "Moreover, past reports have raised concern about the effects of " arousaldampening " coping strategies or safety behaviors such as breathing retraining (e.g., Craske, Rowe, Lewin, & Noriega-Dimitri, 1997; Rachman, Radomsky, & Shafran, 2008, for a review). However , empirical evidence for this thesis is surprisingly absent (see Meuret, Wilhelm, Ritz, & Roth, 2003, for a review), in part because proof of concept would require careful assessment and testing of successful skill acquisition (i.e., normalization of CO 2 ) and subsequent application during exposure (i.e., less arousal during exposure; Meuret et al., 2012). "
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    ABSTRACT: Objective: Fear reactivity during exposure is a commonly used indicator of learning and overall therapy outcome. The objective of this study was to assess the predictive value of fear reactivity during exposure using multimodal indicators and an advanced analytical design. We also investigated the degree to which treatment condition (cognitive training vs. respiratory skill training) moderated fear reactivity and therapeutic outcome. Method: Thirty-four patients with panic disorder and agoraphobia completed a total of 123 in-vivo exposure sessions, comprising 3 weekly sessions and a 4th session 2 months following therapy completion. Sessions varied in length and phobic stimuli. Cardiorespiratory physiology (heart rate, carbon dioxide partial pressure [PCO2], respiration rate) and experiential symptoms (panic symptoms and anxiety) were assessed repeatedly throughout exposure sessions, in addition to weekly assessments of panic cognitions, avoidance, and functioning. Results: Panic symptomatology decreased substantially in both treatment conditions during therapy and follow-up. Significant cardiorespiratory and experiential reactivity was observed during all exposures, characterized by activation followed by reduction. Greater within-session activation of anxiety and panic symptoms was inversely related to improvement in panic symptoms severity, but neither physiological activation nor within- or between-session reduction of either physiological or experiential variables was predictive of outcome. No moderating effects of treatment condition were found. Conclusions: Fear activation and reduction during exposure are weak predictors of corrective learning and fear extinction. Clinical implications for exposure therapy and directions for future research are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
    Journal of Consulting and Clinical Psychology 04/2012; 80(5):773-85. DOI:10.1037/a0028032 · 4.85 Impact Factor
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