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Experiential Cognitive Therapy in the Treatment of
Panic Disorders with Agoraphobia: A Controlled Study
F. VINCELLI, Ph.D.,
1,2
L. ANOLLI, Ph.D.,
2
S. BOUCHARD, Ph.D.,
3
B.K. WIEDERHOLD, Ph.D., M.B.A., BCIA,
4
V. ZURLONI, M.S.,
2
and G. RIVA, Ph.D.
1,2
ABSTRACT
The use of a multicomponent cognitive-behavioral treatment strategy for panic disorder with
agoraphobia is actually one of the preferred therapeutic approaches for this disturbance. This
method involves a mixture of cognitive and behavioral techniques that are intended to help
patients identify and modify their dysfunctional anxiety-related thoughts, beliefs and behav-
ior. The paper presents a new treatment protocol for Panic Disorder and Agoraphobia, named
Experiential-Cognitive Therapy (ECT) that integrates the use of virtual reality (VR) in a mul-
ticomponent cognitive-behavioral treatment strategy. The VR software used for the trial is
freely downloadable: www.cyberpsychology.info/try.htm. Moreover, the paper presents the
result of a controlled study involving 12 consecutive patients aged 35–53. The selected sub-
jects were randomly divided in three groups: ECT group, that experienced the Cognitive
Behavioral Therapy–Virtual Reality assisted treatment (eight sessions), a CBT group that ex-
perienced the traditional Cognitive Behavioral approach (12 sessions) and a waiting list con-
trol group. The data showed that both CBT and ECT could significantly reduce the number of
panic attacks, the level of depression and both state and trait anxiety. However, ECT procured
these results using 33% fewer sessions than CBT. This datum suggests that ECT could be bet-
ter than CBT in relation to the “cost of administration,” justifying the added use of VR equip-
ment in the treatment of panic disorders.
321
CYBERPSYCHOLOGY & BEHAVIOR
Volume 6, Number 3, 2003
© Mary Ann Liebert, Inc.
INTRODUCTION
W
ITHIN THE
Diagnostic and Statistical Manual of
Mental Disorders
framework,
1
the essential fea-
ture of panic disorder (PD) is the occurrence of panic
attacks. A panic attack is a sudden onset period of in-
tense fear or discomfort associated with a cluster of
physical and cognitive symptoms, which occur unex-
pectedly and recurrently, such as pervasive appre-
hension about panic attacks, persistent worry about
future attacks, worry about the perceived physical,
social or mental consequences of attacks, or major
changes in behavior in response to attacks. The disor-
der is often associated with circumscribed phobic
disorders such as specific phobias, social phobias,
and especially with agoraphobia.
2
Indeed, avoidance
of public places to reduce fear or panic becomes the
main cause of incapacity in patients, who, in more se-
rious cases, are confined to their homes patterns.
Clark, Salkovskis, Barlow, and other colleagues
have outlined the traditional Cognitive-Behavioral
Treatment (CBT) for PD with agoraphobia (PDA).
3–6
Evidence collected over the past 20 years has consis-
tently shown the effectiveness of a multicomponent
cognitive-behavioral strategy in the treatment of
panic disorder with agoraphobia.
1
Laboratorio Sperimentale di Psicologia, ATN-P Lab, Istituto Auxologico Italiano, Verbania, Italy.
2
Department of Psychology, Università Cattolica, Milan, Italy.
3
Department of Psychology, Universite du Quebec a Hull, Canada.
4
Virtual Reality Medical Center, San Diego, California.
The treatment package includes exposure to the
feared situation, interoceptive exposure, cognitive
restructuring, breathing retraining, and applied re-
laxation. On average, the duration of the protocol is
12–15 sessions.
7
The protocol involves a mixture of
cognitive and behavioral techniques, which are in-
tended to help patients identify and modify their
dysfunctional anxiety-related thoughts, beliefs and
behavior. Emphasis is placed on reversing the main-
taining factors identified in the cognitive and behav-
ioral patterns.
The paper presents a new treatment protocol for
PDA, named Experiential-Cognitive Therapy (ECT),
that integrates the use of virtual reality (VR) with the
traditional multicomponent CBT strategy.
8,9
Using
VR software, it is possible to re-create, with the sub-
ject undergoing treatment, a hierarchy of situations
corresponding to reality. Particularly, the feeling of
actual presence offered by the realistic reproduction
of cybernetic environments and by the involvement
of all the sensorimotor channels, enables the subject
undergoing treatment to live the virtual experience
in a more vivid and realistic manner than he could
through his own imagination.
10,11
The efficacy of the proposed approach is evalu-
ated in a controlled trial.
MATERIALS AND METHODS
The Experiential-Cognitive Therapy protocol
Francesco Vincelli and Giuseppe Riva at the Ap-
plied Technology for Neuro-Psychology Lab of Isti-
tuto Auxologico Italiano, Verbania, Italy, developed
the first version of the ECT protocol for PDA, in
cooperation with the Department of Psychology at
the Catholic University of Milan, Italy. The actual
version includes the efforts of researchers from the
Center for Advanced Multimedia Psychotherapy,
California School of Professional Psychology, San
Diego, from the Department of Psychology, Univer-
site du Quebec a Hull, Canada, and from the Seoul
Paik Hospital, Inje University, Seoul, Korea.
12,13
The clinical protocol.
The goal of ECT is to recon-
dition fear reactions, to modify misinterpretational
cognition related to panic symptoms and to reduce
anxiety symptoms through the integration of VR
experiences and traditional techniques of CBT. The
overall treatment is composed of eight sessions and
of different booster sessions for 6 months after the
therapy (Table 1).
The first goal of session 1 is to discuss with the
patient the etiologic model of PDA and to delineate
the program of ECT. The description is necessary to
obtain an active role of the patient in the therapy.
Then the patient is introduced to VR through the
use of a head-mounted display and a joystick. The
innovative principle of ECT is to integrate cogni-
tive and behavioral techniques with the experien-
tial possibilities offered by VR. Then the next step
of session 1 is to structure the graded exposure
5
procedure to virtual environments: the patient is
exposed to each of the four virtual environments,
with the minimum level of difficulty (e.g., small
number of subjects present in the environments,
ready access to the exits, plenty of room in the ele-
vator), and is asked to evaluate the experience on
subjective units of distress (SUDs) scale. In this
way, the therapist obtains a hierarchy of virtual en-
vironments, from the least anxiety provoking to the
most, which will be used along the treatment.
After a hierarchy of administration between the
environments has been established, the next step is
to establish a hierarchy of stimuli within each en-
vironment. In the ECT treatment program, the vir-
tual environments—an elevator, a supermarket, a
subway ride, and a large square—are designed to
reach this goal. In both the supermarket and under-
ground, the increase in difficulty may be obtained
by increasing the number of persons present in the
environment and by moving at a distance from the
exits of the environments. In the square, it is possi-
ble to increase the number of people present and to
approach narrower spaces that offer fewer ways
out. In the lift, it is possible to arrange for the pres-
ence of other people and to enlarge or restrict the
space inside the lift.
The following step is to show the patient the role
of avoidance as the main source of agoraphobic
and panic behaviors. The therapist underlines the
importance of regular exposure to feared situation
and structures with his patient a self-exposure
schedule.
In vivo
graded self-exposure as home-
work, initially with the co-therapist (when it is pos-
sible), is very important to empower the efficacy
of the therapy. This step can be more easily ap-
proached by graded exposure to virtual reality and
produces important advantages for the patient: re-
ducing the number of sessions, reducing depen-
dency on the therapist, and helping to maintain
therapeutic achievements.
Each session starts with the review of the home-
work, to verify the difficulties that have emerged
during self-exposure and to reinforce the patient for
the tasks that have been carried out. After the graded
exposure procedure and after session 2 focused on
cognitive assessment assisted through graded expo-
sure to virtual environments, session 3 is based on
322 VINCELLI ET AL.
cognitive restructuring.
5
In PD cognitive treatment
focuses upon correcting misappraisals of bodily sen-
sations as threatening. The cognitive strategies re-
duce attentional vigilance for symptoms of arousal,
level of chronic arousal, and anticipation of the recur-
rence of panic.
Cognitive treatment starts by reviewing with the
patient a recent panic attack and identifying the main
negative thoughts associated with the panic sensa-
tions. Once patient and therapist concord that the
panic attacks involve an interaction between bodily
sensations and negative thoughts about the sensa-
ECT AND PANIC DISORDERS WITH AGORAPHOBIA 323
TABLE 1. THE EXPERIENTIAL-COGNITIVE THERAPY PROTOCOL FOR
THE TREATMENT OF PANIC DISORDER WITH AGORAPHOBIA
Session 1
Description of the etiologic model of PDA according to cognitive behavioral approach
Connection between the model and a recent PDA of the patient
Introduction to Virtual Environments
Graded exposure to virtual environments and set a hierarchy of the virtual stimulus
Homework: diary of panic attacks
Session 2
Homework review
Cognitive assessment assisted through graded exposure to virtual environments
Introduction and scheduling of
in vivo
self-exposure
Homework: diary of panic attacks,
in vivo
self-exposure
Session 3
Homework Review
Cognitive restructuring assisted through graded exposure to virtual environments
Homework: diary of panic attacks,
in vivo
self-exposure
Session 4
Homework review
Graded exposure to virtual environments
Cognitive restructuring face to face
Homework: panic attacks diary,
in vivo
self-exposure
Session 5
Homework review
Interoceptive exposure
Interoceptive exposure assisted through graded exposure to virtual environments
Homework:
in vivo
interoceptive exposure, panic attacks diary
Session 6
Homework review
Interoceptive exposure assisted through graded exposure to virtual environments
Cognitive restructuring face to face
Homework:
in vivo
interoceptive exposure, diary of panic attacks
Session 7
Homework review
Interoceptive exposure assisted through graded exposure to virtual environments
Cognitive restructuring face to face
Homework:
in vivo
interoceptive exposure, diary of panic attacks
Session 8
Homework review
Cognitive restructuring and prevention relapse
Follow-up session schedule
Retest
Booster sessions
Follow-up after 1 month, 3 months, and 6 months
Review and reinforcement of patient’s tasks
Management and prevention of future relapse
tions, a variety of procedures is used to help patients
challenge their misinterpretations of the symptoms.
Many patients interpret the unexpected nature of
their panic attacks as an indication that they are
suffering from some physical abnormality. In these
cases, a psycho-education program presenting the
nature of anxiety can help, especially if it is tai-
lored to patient’s idiosyncratic concerns. One of the
prevalent errors in cognitions is overestimation.
The panickers are inclined to jump to negative con-
clusions and to treat negative events as probable
whereas they are unlikely to occur. Another type of
cognitive error is misinterpreting events as cata-
strophic. Decatastrophizing means to realize that
the occurrences are not as “catastrophic” as stated,
which is achieved by contemplating how negative
events are managed versus how “bad” they are.
This is best done in a Socratic style,
5
so that clients
examine the content of their statements and reach
alternatives. The cognitive strategies are conducted
in conjunction with behavioral technique of graded
exposure in virtual reality. The schedule of session
4 is analogous to the one of session 3. The first part
is dedicated to graded exposure. The second part is
dedicated to the careful inquiry of cognitive distor-
tions and their modification.
The key feature of sessions 5–7 is interoceptive
exposure.
5
The theoretical basis for interoceptive
exposure is one of fear extinction, given the con-
ceptualization of panic attacks as “conditioned”
alarm reactions to particular bodily cues. Since ac-
cording to the cognitive model panic disorder is
considered as a “phobia of internal bodily cues,”
the purpose is to modify associations between spe-
cific bodily sensations and panic reactions. This
technique is also used during the exposure to the
virtual environments.
After cognitive restructuring, prevention relapse is
an important step of the last session, session 8. In this
session, the therapist schedules the self-exposure
homework and reinforces the patient for the tasks
that have been carried out and for the future tasks.
VR software.
For its use in ECT, Giuseppe Riva
designed the Virtual Environments for Panic Disor-
ders (VEPD) virtual reality system. VEPD is a four-
zone virtual environment developed using the
Superscape VRT 5.6 toolkit.
The four zones reproduce different potentially
fearful situations—an elevator, a supermarket, a
subway ride, and large square. In each zone, the
therapist, through a setup menu, defines the char-
acteristics of the anxiety-related experience. Specif-
ically, the therapist can define the length of the
virtual experience, its end and the number of vir-
tual subjects (from none to a crowd) to be included
in the zone.
Zone 1
: In this zone, an elevator in which the
subject has to enter, the subject becomes ac-
quainted with the proper control device, the
head mounted display and the recognition of
collisions.
Zone 2
: This zone shows a supermarket in which
the patient can go for shopping. The subject
can pick up objects and pay for them at the cash
register.
Zone 3
: This zone reproduces a subway ride. The
subject is located in the train that moves between
different stations.
Zone 4
: The last zone is a large square in which
are located a medieval church, different build-
ings, and a pub.
The VEPD software can be freely downloaded at
the web site www.cyberpsychology.info/try.htm. It
can be used on a standard PC with Pentium IV/
Celeron/Athlon 1.2 GHz or better, 64 MB of RAM
or better, graphic card with 32 MB of VRam or bet-
ter, using Windows 95/98/2000/NT/XP.
VR hardware.
The VR hardware includes the
following:
The head mounted display:
Glasstron PLM-A35 de-
veloped by Sony Inc., Japan. The Glasstron uses
LCD technology (two 0.7 inch active matrix color
LCD’s) displaying 180000 pixels (PLM-A35:
800H 2 225V) to each eye. Sony has designed its
Glasstron so that no optical adjustment at all is
needed, aside from tightening two ratchet knobs
to adjust for the size of the wearer’s head.
The motion gyroscopic tracker:
InterTrax 30 (serial
interface; azimuth, ±180 degrees; elevation, ±80
degrees; Refresh rate, 256 Hz; latency time, 38 6
2 msec)
A PC Pentium IV:
2 Ghz processor, 128 MB Ram
and a GeForce 4 Ti 200 graphic card
A joystick.
The controlled clinical trial
Sample.
Participants were recruited from people
who requested treatment at the Anxiety Units of
both the S. Carlo Hospital and the Niguarda Hospi-
tal in Milan, Italy. Eighteen female participants
were invited. To participate in the study, subjects
had to meet DSM-IV research criteria for anxiety
disorders for a minimum of 6 months determined
by independent clinicians on clinical interviews.
324 VINCELLI ET AL.
Individuals were excluded in the following
cases: if they were among people with psychotic or
bipolar disorders, or among those who show high
suicidal risks, or those who are medically ill (i.e.,
cardiac conduction disease, vestibular dysfunction)
and, finally, pregnant women. Twelve participants
met the inclusion criteria and took part in the study
(mean age, 43.83 66.68; range, 35–53 years).
The subjects who satisfied the entry criteria were
randomly assigned to one of the three conditions:
ECT group, CBT or waiting list control group. The
subjects in the ECT group were submitted to the
eight-session protocol described above. The subjects
in the CBT group were submitted to a standard
12-session protocol,
7
including classical CBT: cogni-
tive restructuring, Socratic style, interoceptive ex-
posure, and imaginative exposure to the feared
situations. The therapist involved in both CBT and
ECT (the first author of this paper) is a chartered
psychotherapist with a 4-year degree in CBT.
People on medication were not allowed to mod-
ify the prescribed dosage during the treatment. Be-
fore starting the trial, the nature of the treatment
was explained to the patients, and their written in-
formed consent was obtained.
Assessment.
Independent assessment clinicians
who were not involved in the direct clinical care of
any subject assessed subjects. They were M.A.-level
psychologists or Ph.D.-level psychotherapists. For
the clinical interview, they used a semi-structured
interview with the aim of identifying relevant DSM
IV diagnostic criteria in the subjects. All the sub-
jects were assessed at pretreatment and upon
completion of the clinical trial. The following psy-
chometric tests were administered at each assess-
ment point:
BDI-II—Beck Depression Inventory
14
: the BDD-
II consists of 21 items to assess the intensity of
depression in clinical and normal patients. Each
item is a list of four statements arranged in in-
creasing severity about a particular symptom of
depression.
STAI—State-Trait Anxiety Inventory for
Adults
15,16
: The State-Trait Anxiety Inventory
for Adults (STAI-A) is comprised of 40 multi-
ple choice questions used for measuring anxi-
ety in adults. This scale differentiates between
the temporary condition of “state anxiety” and
the more general and long-standing quality of
“trait anxiety.”
ACQ—Agoraphobic Cognitions Questionnaire
17
:
The Agoraphobic Cognitions Questionnaire con-
sists of 14 items, which may be scored as a total
scale or according to its two subscales: Loss of
Control and Physical Concerns. Each of the sub-
scales consists of seven items.
FQ—Fear Questionnaire
18
: The Fear Question-
naire consists of 20 items surveying a wide range
of reasonably common sources of disturbed reac-
tions. Most items consist of phrases with 2–6
words evaluated on a five-point Likert scale: 0
(Not at all) to 4 (Very much).
During the assessment, the following were also
used:
Subjective measurements (self reports, diaries)
Subjective units of distress (SUDs) during expo-
sure to virtual environments. In particular, SUDs
were taken at baseline, after 10 min, and after
20 min.
Statistical analysis.
Given the limited size of the
sample, we decided to use three non-parametric
test: the Wilcoxon Mann-Whitney Test, the Wilcoxon
Signed Ranks Test, and the Kruskal-Wallis test.
19
The Wilcoxon Mann-Whitney Test is one of the
most powerful of the non-parametric tests for com-
paring two populations. It is used to test the null
hypothesis that two populations have identical dis-
tribution functions against the alternative hypothe-
sis that the two distribution functions differ only
with respect to location (median), if at all.
The Wilcoxon Signed Ranks Test is designed to
test a hypothesis about the location (median) of a
population distribution. It often involves the use of
matched pairs, for example, before and after data,
in which case it tests for a median difference of
zero. The Wilcoxon Signed Ranks test does not re-
quire the assumption that the population is nor-
mally distributed.
The Kruskal-Wallis test is a non-parametric test
used to compare three or more samples. It is used
to test the null hypothesis that all populations have
identical distribution functions against the alterna-
tive hypothesis that at least two of the samples dif-
fer only with respect to location (median), if at all.
RESULTS
Pre-treatment tests
No differences were found between the waiting
list condition and the treatment conditions at pre-
treatment in demographic and clinical variables:
age, duration of the fear, and level of perceived im-
pairment.
ECT AND PANIC DISORDERS WITH AGORAPHOBIA 325
Moreover, the Kruskal-Wallis tests showed no
significant discrepancies among the three groups
for the scales included in the assessment protocol.
Pre-post treatment tests
The Wilcoxon Signed Ranks test showed signif-
icant differences in the BDI-II, STAI and FQ scores
in the ECT and CBT group between pre- and post-
measurements (Table 2). In particular, both sam-
ple reported a general improvement in both the
level of depression and anxiety. Specifically, both
state and trait anxiety was lower after the treat-
ment. No differences were detected in the waiting
list group.
Then we used the Wilcoxon Mann-Whitney Test
to verify any significant difference between ECT
and CBT groups. The tests have not reported any
difference.
Clinically significant improvement
All the participants in the ECT and CBT group
achieved a clinically significant improvement using
strict criteria. In particular, the number of panic at-
tacks after the therapy in both cases decreased to
zero (Table 2).
None of the participants in the waiting list group
showed clinically significant improvement on the
post-test.
Drop-out
None of the participants refused treatment, and
none of them dropped out of the study.
Simulation sickness
None of the subjects who entered the ECT treat-
ment experienced simulation sickness during the
treatment.
CONCLUSION
One of the needed parameters in assessing the
effectiveness of therapies is the ratio existing be-
tween the “cost” of administration of the therapeu-
tic procedure and the resulting “benefits”
11
. By cost
it is meant the expenditure not only in terms of
money and time, but also in terms of emotional in-
volvement by the person to whom the therapy is
directed. The benefits regard the effectiveness of
the treatment, that is, the achievement of the target
set, in the shortest time possible. Exposure therapy
traditionally is carried out “in imagination” or “
in
vivo
.” In the first case, the subject is trained to pro-
duce the anxiety-provoking stimuli through mental
images; in the second case, the subject actually
experiences these stimuli in semi-structured situa-
tions. Both methods present advantages and limita-
tions regarding the cost-benefit ratio. In the first
326 VINCELLI ET AL.
TABLE 2 SIGNIFICANT DIFFERENCES BETWEEN
THE THREE SAMPLES (PRE-POST ANALYSIS)
Waiting list CBT CBT-VR
Panic attacks
Pre 1.75 6 0.50 1.50 6 0.58 1.50 6 0.58
Post 1.75 6 0.50 0.00 6 0.00
a
0.00 6 0.00
a
BDI-II scores
Pre 23.00 6 0,16 24.00 6 0,82 23.25 6 2.75
Post 23.75 6 1.50 9.50 6 1.73
a
9.50 6 3.11
a
State anxiety scores
Pre 48.75 6 2.20 48.25 6 2.06 48.50 6 3.00
Post 49.00 6 3.16 38.00 6 2.83
a
38.75 6 6.08
a
Trait anxiety scores
Pre 47.75 6 1.71 48.25 6 2.63 48.50 6 3.37
Post 47.75 6 3.50 38.00 6 1.41
a
39.00 6 5.60
a
FQ scores
Pre 46.50 (5.00) 51.50 (7.55) 52.50 (13.80)
Post 48.00 (5.60) 41.50 (9.18)
a
38.00 (18.78)
a
a
The pre-post scores were significantly different (
p
< 0.05—Wilcoxon
Signed-Rank Test).
case, the prevalent difficulty is represented by
teaching the subject to produce the images that re-
gard experiences associated with anxiety: most fail-
ures linked to this therapy are those subjects who
present particular difficulties in visualizing scenes
of real life. The cost of the application, however, is
minimal, because the therapy is administered in
the physician’s office, thus avoiding situations that
might be embarrassing for the patient and safe-
guarding his privacy. In the second case, the diffi-
culty lies in structuring, in reality, experiences
regarding the hierarchically ordered anxiety-pro-
voking stimuli, so the cost in terms of time, money
and emotions is high. Then, the advantage of con-
tending with real contexts augments the likelihood
of effectiveness of the “
in vivo
” procedure.
In this paper, we proposed a new approach—
ECT—that integrates VR experiences with the tra-
ditional CBT. The feeling of actual presence offered
by the realistic reproduction of cybernetic environ-
ments and by the involvement of all the sensori-
motor channels enables the subject undergoing
treatment to live the virtual experience in a more
vivid and realistic manner than he could through
his own imagination. Moreover, VR constitutes a
highly flexible tool, which makes it possible to pro-
gram an enormous variety of procedures of inter-
vention on psychological distress. The possibility
of structuring a large amount of controlled stimuli
and, simultaneously, of monitoring the possible re-
sponses generated by the user of the program of-
fers a considerable increase in the likelihood of
therapeutic effectiveness, as compared to tradi-
tional procedures.
In the proposed method, we decided to integrate
the experience of the virtual environments with the
techniques included in the CBT approach because
they showed high levels of efficacy. Through vir-
tual environments we can gradually expose the
patient to feared situation: virtual reality consent
to re-create in our clinical office a real experiential
world. The patient faces the feared stimuli in a con-
text that is nearer to reality than imagination. Other
significant advantages are the supervised exposure
to agoraphobic situations and the possible boost to
the effectiveness of cognitive restructuring by prac-
ticing it in anxiety-inducing situations.
The result of this controlled studies showed that
ECT—like CBT—was able after the treatment to
significantly reduce the number of panic attacks,
the level of depression, and both state and trait
anxiety. Yet, ECT obtained these results using 33%
fewer sessions than CBT (eight vs. 12). This datum
suggests that ECT could be better than CBT in rela-
tion to the “cost of administration,” justifying the
added use of VR equipment in the treatment of
panic disorders.
Despite these findings we would like to address
some of the limitations of our study. First, the sam-
ple was carefully selected, but relatively small.
Studies with larger samples are needed. Second, we
did not include a follow-up assessment (e.g., 6
months later).
In conclusion, the present study demonstrated
that the exposure to the VR environments included
in ECT elicited strong psychological responses.
The anxiety and depression levels associated to
these responses decreased with exposure and with
repetition of exposures. In addition, ECT was
faster than CBT in reducing panic attacks as well
as anxiety and depression scores. We conclude
that VR—added to traditional CBT—offers a new
and promising approach for the treatment of PD
and presumably also for other phobias and anxiety
disorders.
ACKNOWLEDGMENTS
The present work was partially supported by the
Commission of the European Communities (CEC),
specifically by the IST program through the VEPSY
Updated (IST-2000–25323) research project (www.
cyberpsychology.info).
REFERENCES
1. APA. (1994). Diagnostic and statistical manual of mental
disorders, 4th ed. Washington, DC: American Psychi-
atric Association.
2. Goisman, R.M., Warshaw, M.G., Peterson, L.G., et al.
(1994). Panic, agoraphobia, and panic disorder with
agoraphobia: Data from a multicenter anxiety disor-
ders study. Journal of Nervous and Mental Diseases
182:72–79.
3. Barlow, D.H. (1988). Anxiety and its disorders: the
nature and treatment of anxiety and panic. New York:
Guilford Press.
4. Barlow, D.H., & Craske, M.G. (1994). Mastery of your
anxiety and panic II. San Antonio, TX: Harcourt Brace
& Co.
5. Clark, D.M., Salkovskis, P., Gelder, M., et al. (1988).
Tests of a cognitive theory of panic. In: Hand, I., &
Wittchen, H., (eds.), Panic and phobias II. Berlin:
Springer-Verlag, pp. 78–95.
6. Clark, D.M., Salkovskis, P., Hackmann, A., et al.
(1994). A comparison of cognitive therapy, applied
relaxation, and imipramine in the treatment of panic
disorder. British Journal of Clinical Psychology 164:
756–769.
ECT AND PANIC DISORDERS WITH AGORAPHOBIA 327
7. Rapee, R.M., & Barlow, D.H. (1991). The cognitive-
behavioral treatment of panic attacks and agora-
phobic avoidance. In: Walker, J.R., Norton, G.R.,
Ross, C.A., (eds.), Panic disorders and agoraphobia. Pa-
cific Grove: Brooks/Cole Publishing Company, pp.
103–49.
8. Vincelli, F., Choi, Y.H., Molinari, E., et al. (2000). Expe-
riential cognitive therapy for the treatment of panic
disorder with agoraphobia: definition of a clinical
protocol. CyberPsychology & Behavior 3:375–385.
9. Vincelli, F., Choi, Y.H., Molinari, E., et al. (2001). A
VR-based multicomponent treatment for panic dis-
orders with agoraphobia. Studies in Health Technology
and Informatics 81:544–550.
10. Riva, G., Molinari, E., Vincelli, F. (2002). Interaction
and presence in the clinical relationship: virtual real-
ity (VR) as communicative medium between patient
and therapist. IEEE Transactions on Information Tech-
nology in Biomedicine 6:198–205.
11. Vincelli, F. (1999). From imagination to virtual real-
ity: the future of clinical psychology. CyberPsychology
& Behavior 2:241–248.
12. Vincelli, F., Choi, Y.H., Molinari, E., et al. (2000). Expe-
riential cognitive therapy for the treatment of panic
disorders with agoraphobia: definition of a clinical
protocol. CyberPsychology & Behavior 3:375–386.
13. Vincelli, F., Riva, G. (2002). Virtual reality: a new tool
for panic disorder therapy. Expert Review of Neuro-
therapeutics 2:377–383.
14. Beck, A.T., Ward, C.H., Mendelson, M., et al. (1961).
An inventory for measuring depression. Archives of
General Psychiatry. 4:561–571.
15. Spielberger, C.D., Gorsuch, R.L., Lushene, R.E. (1970).
The State-Trait Anxiety Inventory: test manual for form
X. Palo Alto, CA: Consulting Psychologist Press.
16. Spielberger, C.D., Gorsuch, R.L., Lushene, R., et al.
(1983). Manual for the State-Trait Anxiety Inventor.
Palo Alto, CA: Consulting Psychology Press.
17. Chambless, D.L., Caputo, G.S., Bright, P., et al. (1984).
Assessment of fear of fear on agoraphobics. The Bod-
ily Sensation Questionnaire and the Agoraphobic
Cognitions Questionnaire. Journal of Consulting &
Clinical Psychology 52:1090–1097.
18. Marks, I.M., & Mathews, A.M. (1979). Brief standard
self-rating for phobic patients. Behavior Research and
Therapy 17:263–267
19. Randles, R.H., & Wolfe, D.A. (1979). Introduction to
the theory of nonparametric statistics. London: Wiley.
Address reprint requests to:
Francesco Vincelli, Ph.D.
Laboratorio Sperimentale di Ricerche Psicologiche
Istituto Auxologico Italian
Casella Postale 1
28900, Verbania, Italy
E-mail:
fvincelli@hotmail.com
328 VINCELLI ET AL.
