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: 2.85). 06/2012; 43(2):271-84. DOI: 10.1016/j.beth.2011.08.002
Source: PubMed

ABSTRACT 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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    ABSTRACT: ScienceDirect j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / p s y n e u e n Summary 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 lev-els. Higher absolute cortisol levels during exposures moderated clinical improvement (avoidance behavior, threat appraisal, perceived control). Therapeutic gains were not just related to expo-sure 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 awaken-ing response and absolute cortisol levels on fear extinction processes during naturalistic,
    Psychoneuroendocrinology 10/2014; 51:331—340. DOI:10.1016/j.psyneuen.2014.10.008 · 5.59 Impact Factor
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    Chapter: Agoraphobia
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    ABSTRACT: The term agoraphobia was first coined by Westphal (1871) in his description of three males who experienced intense anxiety when walking across open spaces. Westphal also noted the physiological symptoms of anxiety (i.e., palpitations, blushing, trembling, and sensations of heat) and the intense subjective anxiety that is elicited upon anticipating entering a feared situation. Today, agoraphobia remains one of the most disabling phobias and one of the most challenging to treat (Wittchen, Gloster, Beesdo-Baum, Fava, & Craske, 2010). In the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association [APA], 1980), agoraphobia was char-acterized as a "marked fear and avoidance of being alone, or in public places from which escape might be difficult, or help not available in case of sudden incapacitation" (p. 227). However, even the DSM-III recognized the linkage between agoraphobia and panic attacks by stipulating that a diagnosis of agoraphobia with panic attacks should be coded if the onset of the disorder included recurring panic attacks. In the third revised edition of the DSM (DSM-III-R; APA, 1987) and subsequently in the fourth edition (DSM-IV; APA, 1994; DSM-IV-TR; APA, 2000), agoraphobia was reconceptualized as a common complicating feature of panic, thus relegating agora-phobia to a panic disorder "subtype" status. In the DSM-IV, the diagnosis "agorapho-bia" no longer exists; rather, in cases of "pure" agoraphobia, clinicians are instructed to use the diagnosis "agoraphobia without history of panic disorder." It is interesting to note that the diagnostic criteria for agoraphobia in the International Statistical Clas-sification of Diseases and Related Health Problems (10th ed.; ICD-10; World Health Organization, 1992)—the diagnostic system used in many other countries outside the United States—still recognizes agoraphobia as taking precedence over panic disorder. There continues to be considerable controversy surrounding the current diagnostic status of agoraphobia. The crux of this controversy concerns whether agoraphobia The Wiley Handbook of Cognitive Behavioral Therapy, First Edition..wbcbt40 942 Specific Disorders should be conceptualized as a complication of panic attacks/panic disorder as outlined in the DSM-IV-TR or whether agoraphobia should be treated as a distinct, phobic syndrome independent of panic disorder as outlined in the ICD-10. The interested reader is referred to Wittchen et al. (2010) for an excellent review of this controversial issue, which has profound implications for both researchers and clinicians.
    The Wiley Handbook of Cognitive Behavioral Therapy, First edited by S. Hofmann, 01/2014: chapter 40: pages 941-978; John Wiley & SOns, Ltd., ISBN: 9781118533208
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    ABSTRACT: Objective: Cognitive behavioral therapy (CBT) is an empirically supported treatment for social phobia. However, not all individuals respond to treatment and many who show improvement do not maintain their gains over the long-term. Thus, alternative treatments are needed. Method: The current study (N = 87) was a 3-arm randomized clinical trial comparing CBT, acceptance and commitment therapy (ACT), and a wait-list control group (WL) in participants with a diagnosis of social phobia based on criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994). Participants completed 12 sessions of CBT or ACT or a 12-week waiting period. All participants completed assessments at baseline and posttreatment, and participants assigned to CBT and ACT also completed assessments 6 and 12 months following baseline. Assessments consisted of self-report measures, a public-speaking task, and clinician ratings. Results: Multilevel modeling was used to examine between-group differences on outcomes measures. Both treatment groups outperformed WL, with no differences observed between CBT and ACT on self-report, independent clinician, or public-speaking outcomes. Lower self-reported psychological flexibility at baseline was associated with greater improvement by the 12-month follow-up in CBT compared with ACT. Self-reported fear of negative evaluation significantly moderated outcomes as well, with trends for both extremes to be associated with superior outcomes from CBT and inferior outcomes from ACT. Across treatment groups, higher perceived control and extraversion were associated with greater improvement, whereas comorbid depression was associated with poorer outcomes. Conclusions: Implications for clinical practice and future research are discussed. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
    Journal of Consulting and Clinical Psychology 07/2014; DOI:10.1037/a0037212 · 4.85 Impact Factor

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May 22, 2014