Article

Naturalistic manner of benzodiazepine use and cognitive behavioral therapy outcome in panic disorder with agoraphobia

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Abstract

Benzodiazepines (BZs) are commonly used in conjunction with cognitive behavioral therapy (CBT) in the treatment of panic disorder with agoraphobia (PDA). However, empirical evidence provides little support for the utility of this combined treatment approach over CBT alone. Westra and Stewart [Clin. Psychol. Rev. 18 (1998) 307] have proposed that prn or as-needed use of BZs may inhibit positive CBT outcome to a greater extent than regularly scheduled BZ use. Using a naturalistic design, the present study investigated the impact of manner of BZ use on treatment outcome from CBT in 43 patients with PDA. Among various BZ parameters (chronicity, frequency, dose, and frequency of prn use), prn use of BZs for coping with anxiety symptoms was a significant negative predictor of degree of change in both anxiety sensitivity and anxious arousal from pre- to post-CBT. Although no significant between-group differences were evident in pre-treatment symptomatology, unmedicated subjects demonstrated the most positive overall CBT outcome, while prn BZ users evidenced the fewest gains. Regular BZ users were generally not significantly differentiated from unmedicated subjects in CBT outcome and both tended to obtain post-treatment scores in the nonclinical range. Implications of these findings for clinical management of BZ use throughout CBT for PDA are discussed.

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... The study of the effects of substance administration regimens has proven useful in an older yet related area of research pertaining to the use of benzodiazepines in individuals with anxiety and related disorders (Busto & Sellers, 1986;Westra & Stewart, 2002a;Westra & Stewart, 2002b). In this literature there is evidence suggesting that a "pro re nata" ("PRN") regimen, or as needed use, in response to the occurrence of anxiety-related symptoms is more This preprint research paper has not been peer reviewed. ...
... Electronic copy available at: https://ssrn.com/abstract=4715018 P r e p r i n t n o t p e e r r e v i e w e d common, yet associated with more adverse outcomes in individuals with panic and other anxietyrelated disorders compared to a regularly scheduled (RS) use regimen (i.e., use at specific times of day; e.g., twice a day [BID], three times a day [TID]; Westra & Stewart, 2002;Westra & Stewart, 2002b). For example, a PRN administration regimen has been observed to be more commonly utilized amongst chronic benzodiazepine users than RS schedules, and those originally prescribed benzodiazepines according to an RS schedule tend to shift towards using in a PRN manner over time (Romach et al., 1991). ...
... Consistent with patterns revealed in benzodiazepine regimen research (Westra & Stewart, 2002a;2002b;Romach et al., 1991), and with H1, PRN regimens were much more common than an RS only regimen at the time of testing. In terms of changes in use regimen over time, many This preprint research paper has not been peer reviewed. ...
... For example, Westra and her colleagues have developed, manualized, and evaluated such a broad-band approach for the treatment of panic disorder with or without agoraphobia, social phobia, and generalized anxiety disorder patients. This treatment approach is 10 sessions in duration, is delivered in a group context, and includes psychoeducation, cognitive restructuring, and exposure components (see Westra, Dozois, & Marcus, 2007;Westra, Stewart, & Conrad, 2002, for program description and efficacy data). For practical reasons, it would be useful for future research to focus on the development and evaluation of a 'broad-band' integrated intervention designed to treat a variety of forms of anxiety disordersubstance use disorder co-morbidity. ...
... For practical reasons, it would be useful for future research to focus on the development and evaluation of a 'broad-band' integrated intervention designed to treat a variety of forms of anxiety disordersubstance use disorder co-morbidity. For example, the anxiety management protocol developed by Westra et al. (2002Westra et al. ( , 2007 could be adapted for suitability to the co-morbidity context in the same manner that Kushner et al. (2006) adapted Barlow and Craske's (2000) 'narrow-band' CBT for panic disorder for suitability as an integrated treatment for panic disorder -alcohol abuse co-morbidity. In fact, in their attempt to develop and test an integrated CBT for panic and alcohol dependence, Kushner et al. (2006) identified that an additional obstacle to implementing such a program was the presence of multiple co-occurring anxiety disorders within this co-morbid population. ...
Chapter
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In this concluding chapter to the volume, we first provide a theoretical integration of the material contained in the initial two sections of the book. We review models, theories, and mechanisms to account for the high co-morbidity of anxiety and substance use disorders including notions involving self-medication, substance-induced anxiety, and third variable (e.g., anxiety sensitivity) explanations. Which particular pathway is most likely to be at play in explaining comorbidity onset appears to vary as a function of the precise anxiety disorder involved as well as the specific substance being abused. We then move on to a consideration of processes involved in the maintenance of co-morbidity, as this knowledge may prove most useful in treatment. We consider recent evidence as to whether the presence of a co-morbid anxiety disorder impacts recovery from a substance use disorder. Regardless of the specific pathway to the onset of comorbidity, once both disorders are present, they may serve to maintain one another or even exacerbate one another to create a vicious cycle such that the presence of one disorder can impede recovery from the other. In this chapter, we present an adaptation of Marlatt and Gordon’s (1985) cognitive behavioral model to understand the factors and processes involved in the maintenance of anxiety disorder – substance use disorder co-morbidity. We conclude with a review of promising new approaches to the treatment and prevention of comorbid anxiety and substance use disorders. We contrast sequential, parallel, and integrated approaches and present a theoretical argument for the superiority of integrated interventions, setting an agenda for future clinical trials in this area. Finally, various practical issues around the provision of treatment for co-morbid anxiety disorder – substance use disorder patients are considered.
... Craske & Barlow, 2000;Craske, Barlow, & O'Leary, 1992). Moreover, this particular group program implementing CBT principles has demonstrated efficacy in producing significant anxiety symptom reduction (Westra, Stewart, & Conrad, 2002;Dozois, Westra, Collins, Fung, & Garry, 2004). The therapists were a variety of allied mental health professionals who were all extensively trained by the first author in CBT; each had at least 2 years of experience in successfully implementing group CBT for anxiety. ...
... The ASI has demonstrated adequate reliability and construct validity (Peterson & Reiss, 1992) and has been found to predict the onset of panic disorder for up to 3 years (Maller & Reiss, 1992). The ASI is also highly sensitive to treatment-related changes as a function of CBT (Westra et al., 2002). (FNEB, Leary, 1983) The FNEB is a brief form of the original FNE (Watson & Friend, 1969). ...
Article
Although CBT is a well-supported treatment for anxiety, recovery rates and compliance with treatment procedures are less than optimal. Using adjunctive brief preparatory interventions may help bolster response rates and engagement with therapy procedures. Motivational Interviewing (MI: Miller, W. R., & Rollnick, S. (1991, 2002). Motivational interviewing: preparing people to change addictive behavior. New York: Guilford) is a client-centered, directive method for enhancing motivation for change and has been demonstrated to be a valuable treatment prelude in the addictions domain. Prior to group cognitive behavioral therapy, 55 individuals with a principal anxiety diagnosis (45% panic disorder, 31% social phobia, and 24% generalized anxiety disorder) were randomly assigned to receive either three sessions of MI adapted for anxiety or no pretreatment (NPT). The MI pretreatment group, compared to NPT, showed significantly higher expectancy for anxiety control and greater homework compliance in CBT. Although both groups demonstrated clinically significant anxiety symptom improvements, the MI pretreatment group had a significantly higher number of CBT responders compared to NPT. At 6-month follow-up, both groups evidenced maintenance of gains. These results provide suggestive evidence that brief pretreatments, such as MI, may enhance engagement with and outcome from CBT. The promising results also justify the future investigation of these effects using more powerful designs which may discern whether the effects are specific to MI or to some type of pretreatment.
... The secondary data analysis of the BAI measure from the clinical trial dataset indicated globally that the positive impact of psychotherapy on reducing anxiety symptoms was not significantly different whether or not benzodiazepines were taken 12 months prior to tCBT initiation. These results are consistent with studies that also found that benzodiazepines had no impact on CBT outcomes (Arch & Craske, 2007;Melani et al., 2020;Schmidt & Smith, 2005;Watanabe et al., 2009;Westra et al., 2002). The qualitative interviews provided a complementary and in-depth perspective through the nuanced contributions of the participants. ...
Article
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La thérapie cognitivo-comportementale (TCC) est un traitement des troubles anxieux basé sur des données probantes. Au moment d’initier une TCC, il n’est pas rare que les patients utilisent un traitement pharmacologique, généralement des antidépresseurs. Les benzodiazépines sont également couramment utilisées, bien qu’elles soient recommandées comme traitement d’appoint et à court terme en raison de leurs effets secondaires. Cette étude, reposant sur une méthodologie mixte imbriquée à un essai contrôlé randomisé d’une intervention de TCC transdiagnostique de groupe (TCCt), visait à explorer l’effet de la prise de benzodiazépines avant la TCCt ainsi que l’expérience des participants quant à leur utilisation de cette médication avant, pendant et après la psychothérapie. Le groupe expérimental a reçu la TCCt et les soins usuels (SU; n = 117) durant 12 semaines; le groupe témoin a reçu les SU (n = 114). Les symptômes d’anxiété ont été évalués par l’Inventaire d’anxiété de Beck (IAB). Les différences pré- et post- IAB avec la prise de benzodiazépines au cours des 12 derniers mois, la TCCt ainsi que leur interaction ont été examinées au moyen d’une analyse de régression linéaire multiple. Des entretiens semi-structurés ont été menés auprès de 13 participants ayant déclaré avoir utilisé des benzodiazépines 12 mois avant le début du traitement. Le contenu des entretiens a été analysé au moyen d’une approche descriptive interprétative. Les résultats quantitatifs suggèrent que la TCCt a influencé significativement la diminution des symptômes anxieux, mais que cet effet était non différentiel quant à la prise de benzodiazépines 12 mois avant la TCCt. Les résultats qualitatifs ont nuancé l’utilité perçue des benzodiazépines. Les participants ont rapporté que l’usage de benzodiazépines avait facilité le partage durant la thérapie de groupe et la réalisation d’exercices d’exposition. Malgré certains avantages, des participants ont perçu que les benzodiazépines avaient pu nuire à l’efficacité des exercices d’exposition et à l’acquisition de concepts en raison de leur effet sédatif. Cette étude met en lumière l’importance de sensibiliser les thérapeutes et les patients aux effets potentiels des benzodiazépines dans le cadre d’une TCCt.
... The same issue has been debated in combined therapy of pharmacotherapy and CBT for anxiety disorders. [90][91][92][93] Concurrent anxiolytics such as benzodiazepines have been associated with reduced long-term outcomes of CBT in anxiety disorders. 93 Dose-dependent suppression of cortisol by benzodiazepines 94 is partially responsible for the decreased effect of CBT. ...
Article
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Anxiety disorders are the most common comorbid psychiatric disorders in patients with bipolar disorder. Managing anxiety symptoms in comorbid conditions is challenging and has received little research interest. The findings from preclinical research on fear conditioning, an animal model of anxiety disorder, have suggested that memory reconsolidation updating (exposure-based therapy) combined with valproate might facilitate the amelioration of fear memories. Here, three cases of successful amelioration of agoraphobia and panic symptoms through valproate adjuvant therapy for cognitive behavioral therapy in patients who failed to respond to two to three consecutive standard pharmacotherapy trials over several years are described. To the best of the author’s knowledge, this is the first attempt to combine CBT with valproate in patients with panic disorder, agoraphobia, and comorbid bipolar disorder. Additionally, the background preclinical research on this combination therapy based on the reconsolidation-updating mechanism, the inhibition of histone deacetylase 2, and critical period reopening, off-label use of valproate in panic disorder, plasticity-augmented psychotherapy, and how to combine valproate with CBT is discussed.
... Medications for anxiety disorders carry side effects [64], and benzodiazepines, which remain commonly prescribed despite no longer being a recommended first-line treatment [24,25], carry risks of both physiological and psychological dependence. Furthermore, benzodiazepines may in fact prolong anxiety symptoms if used alone due to their use as a safety behaviour and potential to impair fear extinction [65,66]. This may be particularly true when physiological anxiety sensations themselves are the feared stimuli (e.g., in panic disorder), and exposure to these symptoms is avoided through the use of benzodiazepines. ...
Article
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Background Anxiety disorders are highly prevalent mental health conditions and are managed predominantly in primary care. We conducted a systematic review and meta-analysis of psychological and pharmacological treatments in countries with universal healthcare, and investigated the influence of treatment provider on the efficacy of psychological treatment. Method PubMed, Cochrane, PsycINFO, CINAHL, and Scopus were searched in April 2017 for controlled studies of evidence-based anxiety treatment in adults in primary care, published in English since 1997. Searches were repeated in April 2020. We synthesised results using a combination of meta-analysis and narrative methods. Meta-analysis was conducted using a random-effects multi-level model to account for intercorrelation between effects contributed different treatment arms of the same study. Moderator variables were explored using meta-regression analyses. Results In total, 19 articles (from an initial 2,247) reporting 18 studies were included. Meta-analysis including ten studies ( n = 1,308) found a pooled effect size of g = 1.16 (95%CI = 0.63 – 1.69) for psychological treatment compared to waitlist control, and no significant effect compared to care as usual ( p = .225). Substantial heterogeneity was present (I ² = 81.25). Specialist treatment produced large effects compared to both waitlist control ( g = 1.46, 95%CI = 0.96 – 1.96) and care as usual ( g = 0.76, 95%CI = 0.27 – 1.25). Treatment provided by non-specialists was only superior to waitlist control ( g = 0.80, 95%CI = 0.31 – 1.28). We identified relatively few studies (n = 4) of medications, which reported small to moderate effects for SSRI/SNRI medications and hydroxyzine. The quality of included studies was variable and most studies had at least “unclear” risk of bias in one or more key domains. Conclusions Psychological treatments for anxiety are effective in primary care and are more effective when provided by a specialist (psychologist or clinical psychologist) than a non-specialist (GP, nurse, trainee). However, non-specialists provide effective treatment compared with no care at all. Limited research into the efficacy of pharmacological treatments in primary care needs to be considered carefully by prescribers Trial registration PROSPERO registration number CRD42018050659
... Bromazepam is a long acting benzodiazepine which was reported to improve psychic and somatic symptoms of anxiety by producing potent or short term effects to reduce anxiety [212]. These uses are appealing to the patient but not always desirable, as they can reinforce pill taking, serve as a safety signal that undermines self-efficacy [213] and become incorporated into the conditioned fear response. These problems can aggravate if benzodiazepines are taken on as an-needed basis. ...
Article
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Parkinson’s disease (PD) is a progressive neurodegenerative disease which affects millions of population worldwide. It is characterized by motor symptoms such as excessive tremor, bradykinesia, rigidity, postural instability and non-motor symptoms include neuropsychiatric complications like anxiety, depression, insomnia and cognitive impairment, orthostatic hypotension, sexual dysfunction and gastrointestinal complications. Treatment of anxiety in PD poses extensive challenge to global healthcare which makes it urgent to develop innovative treatment for the better management of the disease. The gold standard treatment by Levodopa provides symptomatic relief and its effect on neuropsychiatric complications like anxiety is elusive. Presence of anxiety worsens the condition and challenges therapeutic management of the PD. The in-depth analysis and understanding the molecular mechanism and pathophysiological pathways associated with the onset of anxiety in PD is essential. The disturbances in serotonergic, adrenergic and GABAergic neurons and hypothalamic pituitary adrenal axis play a significant role in the pathophysiology of anxiety. The drugs like Selective Serotonin Reuptake Inhibitors, tricyclic antidepressants and benzodiazepines are useful in the management of anxiety but due to severe side effects and progression of the disease it results in the failure of treatment. The present review imparts an insight in the management of anxiety in PD by understanding molecular mechanism and application of alternative treatment options which can enlighten the perception of researchers towards better therapeutic management of the disease.
... Some authors state that there is a small advantage in associating BDZs and EBIs, although they question whether this advantage outweighs the disadvantages (Spiegel & Bruce, 1997;Wardle, 1990;Westra & Stewart, 1998), such as the risk of withdrawal syndrome (Otto et al., 2010). On the other hand, others suggest that BDZs can jeopardize the efficacy of EBIs (van Balkom, de Beurs, Koele, Lange, & van Dyck, 1996;Brown & Barlow, 1995;Otto, Pollack, & Sabatino, 1996;Westra, Stewart, & Conrad, 2002). And finally, some advocate that this combination does not interfere with EBI's efficacy (Hegel, Lewis Ravaris, & Ahles, 1994). ...
Article
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Background and Objectives Exposure‐based interventions (EBIs) are the first‐line treatment for anxiety disorders and posttraumatic stress disorder. Although common, the association between EBIs and benzodiazepines is controversial. Therefore, we systematically reviewed the literature to evaluate if benzodiazepines could undermine the efficacy of EBIs in treating these disorders. Methods We conducted a systematic review aiming for randomized clinical trials (RCTs) in ISI Web of Science, Scopus, PubMed/MEDLINE, and PsycINFO databases. We scrutinized the reference list of selected papers and other systematic reviews. Finally, we evaluated the methodological quality and the scientific evidence of the studies. Results We screened 1,529 studies and included 12 RCTs in this review (all showing some concerns or high risk of bias). Benzodiazepines did not impact the efficacy of EBIs in nine studies at posttreatment, improved efficacy in two, and reduced it in one. In the follow‐up, benzodiazepines (after its discontinuation) did not impact the efficacy in six studies and reduced it in five. The scientific level of evidence achieved was B for both phases. Conclusions Until now there is no definitive evidence that benzodiazepines could hinder the EBIs' efficacy for treating posttraumatic stress disorder and anxiety disorders.
... Wardle et al. (1994) konnten diesen negativen Effekt auf die Ergebnisse einer Konfrontationsbehandlung in einer placebokontrollierten Studie nicht replizieren. Westra et al. (2002) zeigten einen signi fikant negativen Einfluss von kontinuierlicher wie auch bedarfs mäßiger Medikation mit Benzodiazepinen auf den Therapieeffekt einer kognitiven Verhaltenstherapie bei Agoraphobie. Bei Flug phobikern (Wilhelm und Roth 1997) kam es bei der Kombination von Konfrontation mit Alprazolam zu vermindertem Angst erleben während des ersten Fluges im Vergleich zu Placebo. ...
Chapter
Die Kombination von Pharmakotherapie und Verhaltenstherapie ist mehr als die simultane Anwendung zweier Behandlungsverfahren. Pharmako- und Psychotherapeut müssen eine Vielzahl wechselseitiger Interaktionen im therapeutischen Prozess berücksichtigen. Neben der Kenntnis dieser Wechselwirkungen muss der Psychotherapeut über Grundkenntnisse in Pharmakotherapie, der mitbehandelnde Arzt über Grundkenntnisse in der angewandten Psychotherapiemethode verfügen. Weiterhin muss ein Konsens über die Kombinationsbehandlung bestehen, und Veränderungen müssen in der jeweiligen Therapie zwischen den Therapeuten abgestimmt werden. Der Patient sollte sowohl über die Psycho- als auch über die Pharmakotherapie genau Bescheid wissen. Negative Effekte von Psychopharmaka auf die Verhaltenstherapie müssen ebenfalls erkannt und ggf. vermieden werden. Dies gilt insbesondere für die negative Beeinflussung bei Alkohol- und Benzodiazepinabhängigkeit auf Reizkonfrontationsverfahren sowie die Aufrechterhaltung von kognitiver Vermeidung durch Anxiolytika. Soweit die Datenlage es zulässt, sollte die Entscheidung für oder gegen eine Kombinationsbehandlung aufgrund empirischer Untersuchungen getroffen werden.
... We did find that CBT may be less effective in individuals taking benzodiazepines, consistent with clinical trial and observation data. [11,12,34] As such, prior to considering augmentation of CBT with these patients, strategies for treatment in the context of benzodiazepine discontinuation should be considered. [35] A number of limitations of our study deserve note. ...
Article
Background: Initial studies have provided a mixed perspective of the efficacy of d-cycloserine (DCS) for augmenting the efficacy of exposure-based cognitive behavioral therapy (CBT) for panic disorder. In this multicenter trial, we examine the magnitude of DCS augmentation effects for an ultra-brief program of CBT. Methods: We conducted a double-blind, controlled trial at three treatment sites, randomizing 180 adults with a primary diagnosis of panic disorder to five sessions of treatment, with study pill (50 mg DCS or matching placebo) administered 1 hr prior to the final three sessions. Two booster sessions were subsequently provided, and outcome was assessed at posttreatment and 1-month, 2-month, and 6-month follow-up assessments. The primary outcome was the degree of reduction in the Panic Disorder Severity Scale. Additional analyses examined the role of severity and current antidepressant or benzodiazepine use as moderators of DCS augmentation effects. Results: DCS augmentation resulted in significant benefit only early in the trial, with no beneficial effects of DCS augmentation evident at follow-up evaluations. We did not find that baseline severity or antidepressant or benzodiazepine use moderated DCS efficacy, but benzodiazepine use was associated with lower efficacy of CBT regardless of augmentation condition. Conclusions: Consistent with other recent multicenter trials, the benefit of DCS was less than indicated by pilot study and reflected an acceleration of treatment response evident at treatment endpoint, but no advantage in response over follow-up evaluation. Our results did not support severity or concomitant medication moderators observed in previous trials of DCS augmentation.
... We did find that CBT may be less effective in individuals taking benzodiazepines, consistent with clinical trial and observation data. [11,12,34] As such, prior to considering augmentation of CBT with these patients, strategies for treatment in the context of benzodiazepine discontinuation should be considered. [35] A number of limitations of our study deserve note. ...
Conference Paper
The paper details the primary outcomes for a 3-site multicenter trial randomizing over 176 adults with panic disorder to a brief (5 weekly sessions plus 2 booster sessions) exposure-based CBT for panic disorder in conjunction with either 50mg d-cycloserine or placebo. A single study pill (DCS or placebo) was administered in a double-blind fashion, on each of sessions 3-5. Outcome was assessed at mid-treatment (prior to session 3), at one week post-treatment (week 6), and at 1, 3, and 6 month follow-up assessments. Current estimates suggest excellent retention (90%) across the follow-up period. In this presentation, results will be presented for primary outcome measures: the Panic Disorder Severity Scale and the CGI-severity score assigned by clinicians. Secondary outcomes—including self-report of anxiety sensitivity and quality of life; and clinician-rated measures of depression, general anxiety, and role functioning--will also be presented.
... One early study showed that alprazolam combined with CBT produced worse panic disorder outcome in the long term, compared with CBT alone, 65 and an observational analysis indicated poorer outcome in panic patients receiving benzodiazepines during group CBT. 66 There has been longstanding speculation that these agents could interfere with desensitization in phobic disorders, perhaps by blocking the anxiety response needed to initiate an extinction process, perhaps by preventing a more internal locus of control needed for successful CBT, or perhaps by interacting in complex ways with context. However, randomized trials with the exception of the Marks study do not support adverse effects of benzodiazepines on anxiety disorder outcomes with CBT. ...
Article
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A sizable proportion of psychiatric patients will seek clinical evaluation and treatment for anxiety symptoms reportedly refractory to treatment. This apparent lack of response is either due to "pseudo-resistance" (a failure to have received and adhered to a recognized and effective treatment or treatments for their condition) or to true "treatment resistance." Pseudo-resistance can be due to clinician errors in selecting and delivering an appropriate treatment effectively, or to patient nonadherence to a course of treatment. True treatment resistance can be due to unrecognized exogenous anxiogenic factors (eg, caffeine overuse, sleep deprivation, use of alcohol or marijuana) or an incorrect diagnosis (eg, atypical bipolar illness, occult substance abuse, attention deficit-hyperactivity disorder). Once the above factors are eliminated, treatment should focus on combining effective medications and cognitive behavioral therapy, combining several medications (augmentation), or employing novel medications or psychotherapies not typically indicated as first-line evidence-based anxiety treatments.
... There is some evidence that treatment gains made through CBT while patients are on antipsychotics still hold after the antipsychotic has been tapered off (Goldstein et al., 2009). On the contrary, there are concerns that patients receiving both CBT and benzodiazepines for anxiety disorders experience a loss of efficacy after the benzodiazepine treatment is discontinued (Otto, Bruce & Deckersbach, 2005;Westra, Stewart & Conrad, 2002). The treatment team felt that Amy's anxiety and "panic" were a by-product of OCD, rather than actual panic disorder. ...
Article
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The initial treatment of obsessive-compulsive disorder (OCD) has generally been limited to serotonergic agents, cognitive-behavioral therapy (CBT), or a combination of the two. These findings were supported by the POTS study for OCD in children and adolescents. However, treatment with serotonergic agents or CBT can take several weeks before benefit is seen; severe cases of OCD may require more immediate treatment. The authors present a case of severe OCD in an adolescent that required immediate treatment due to her critical medical condition. The patient's symptoms included not eating or taking medications or fluids by mouth due to fears of contamination. A medical hospitalization was previously required due to dehydration. As treatment with an SSRI would not have quick enough onset and the patient was initially resistant to participating in CBT, the patient was psychiatrically hospitalized and first started on liquid risperidone. After several doses of risperidone, the patient was able to participate in CBT and start sertraline. The authors discuss the differential diagnosis of such a patient, including the continuum of OCD symptoms and psychotic symptoms. The authors discuss the different treatment options, including the utilization of inpatient psychiatric hospitalization. The authors discuss the potential risks and benefits of using atypical antipsychotics in lieu of benzodiazepines for the initial treatment of severe adolescent OCD. The authors also discuss other current treatment recommendations and rationale for the treatment that was pursued. This patient received benefit of her symptoms relatively quickly with psychiatric hospitalization and an atypical antipsychotic. The diagnosis of a psychotic disorder should be considered. These treatment options must be weighed against the risks of atypical antipsychotics, including extrapyramidal symptoms, weight gain, and metabolic syndrome; benzodiazepines also have their risks and benefits. Additionally, the cost of time and finances of inpatient hospitalization must be considered. More research is needed regarding the short- and long-term efficacy and safety of antipsychotics in the treatment of OCD in the child and adolescent population.
... One study reported that benzodiazepine use was not associated with significantly worse response to CBT for panic disorder, assessed at a 6 month follow-up, although this study did note that there was a significant decline in the number of patients using benzodiazepines from pre to post treatment, and to follow-up assessment (Arch & Craske, 2007). Another study reported that "as needed" use of benzodiazepines during CBT for panic with agoraphobia negatively predicted treatment response, as assessed immediately post-CBT; in contrast, regular benzodiazepine users exhibited similar treatment response to non-medicated patients (Westra, Stewart, & Conrad, 2002). Finally, a third study reported that patients who entered remission from panic disorder medication free were less likely to relapse than those who remained on medications throughout treatment and into remission (Otto, Pollack, & Sabatino, 1996). ...
... One study reported that benzodiazepine use was not associated with significantly worse response to CBT for panic disorder, assessed at a 6 month follow-up, although this study did note that there was a significant decline in the number of patients using benzodiazepines from pre to post treatment, and to follow-up assessment (Arch & Craske, 2007). Another study reported that "as needed" use of benzodiazepines during CBT for panic with agoraphobia negatively predicted treatment response, as assessed immediately post-CBT; in contrast, regular benzodiazepine users exhibited similar treatment response to non-medicated patients (Westra, Stewart, & Conrad, 2002). Finally, a third study reported that patients who entered remission from panic disorder medication free were less likely to relapse than those who remained on medications throughout treatment and into remission (Otto, Pollack, & Sabatino, 1996). ...
Article
In recent years the gap between psychological and psychiatric research and practice has lessened. In turn, greater attention has been paid toward how psychological and pharmacological treatments interact. Unfortunately, the majority of research has indicated no additive effect of anxiolytics and antidepressants when combined with psychological treatments, and in many cases pharmacological treatments attenuate the effectiveness of psychological treatments. However, as psychology and psychiatry have come closer together, research has started to investigate the neural and molecular mechanisms underlying psychological treatments. Such research has utilised preclinical models of psychological treatments, such as fear extinction, in both rodents and humans to determine multiple neural and molecular changes that may be responsible for the long-term cognitive and behavioural changes that psychological treatments induce. Currently, researchers are attempting to identify pharmacological agents that directly augment these neural/molecular changes, and which may be more effective adjuncts to psychological treatments than traditional anxiolytics and antidepressants. In this review we describe the research that has led to this new wave of thinking about combined psychological/pharmacological treatments. We also argue that an increased emphasis on identifying individual difference factors that predict the effectiveness of pharmacological adjuncts is critical in facilitating the translation of this preclinical research into clinical practice.
... Since anxious arousal may be a crucial component of effective therapy, and animals have typically been shown to reduce anxious arousal, AAT might reduce the efficacy of CBT. This would be comparable to the way that benzodiazepines reduce short-term anxiety, but impair long-term emotional processing and new learning in CBT for anxiety disorders (Westra, Stewart and Conrad 2002). That is, AAT may impede emotional processing by directly reducing the emotional arousal associated with distressing memories, or might distract people from engaging the emotionally relevant material fully. ...
Article
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Despite an increase in the popularity of animal-assisted therapy, little is known about the impact of animals on processes relevant to effective psychotherapy. This study tested the impact of having a dog present on process variables relevant to cognitive behavioral therapy, including emotional arousal, the content of trauma narratives, and cognitive change. We employed an expressive writing paradigm as an analog of exposure therapy, a common evidence-based treatment for anxiety and trauma disorders. Participants were randomly assigned to either a trauma or control writing condition, with or with-out a dog present. Writing about a trauma resulted in significantly more acute anxious arousal than control writing, but participants in the trauma/dog con-dition showed less distress than those in the trauma/no dog condition. Despite the palliative effect of the dog on acute anxious arousal, process variables in the two trauma conditions were no different. Both trauma groups wrote com-parable essays (rated on negative emotionality, cognitive insight, and severity of trauma). At follow-up, only the participants in the trauma condition with a dog showed significant decreases in depressive symptoms. The results suggest that dogs can lower acute distress without compromising emotional processing or therapeutic mechanisms, and may actually improve long-term outcome for some individuals. ❖ AZ 27-3.Text.qxp:Layout 1 6/12/14 2:56 PM Page 457 UNCORRECTED PROOF
... 26 For panic disorder, the use of PRN medication can inhibit positive outcomes of cognitive behavioral therapy, decreasing the ability to cope with anxiety symptoms. 27 The same mechanism may occur in patients with BPD with the excessive use of PRN medication in individuals in distress, hampering their ability to face challenges that provoke distress and not teaching them the coping skills required to have a better level of functioning in the community. 28 This problem is especially relevant for patients with BPD when we consider that most of those who 29 for which it is necessary to possess the abilities to deal with internal distress and flexibility in interpersonal relationships. ...
Article
The use of pro re nata (PRN; as needed) psychotropic medication in patients with borderline personality disorder (BPD) has not been well characterized. This study had 3 purposes, which are as follows: (1) to describe the prevalence of PRN psychotropic medication use among patients with BPD and comparison subjects with other personality disorders (OPD) over 14 years of prospective follow-up, (2) to examine the rates reported by patients with BPD who ever recovered and never recovered, and (3) to examine the reasons for taking PRN medication reported by these patients. Overall, the prevalence of PRN psychotropic medication use was initially approximately 3 times higher among patients with BPD than comparison subjects with OPD, with a significant one-third decline in the use of PRN medication reported by patients with BPD over time. In analyses restricted to patients with BPD, patients with BPD who never recovered were approximately twice as likely to use PRN medication than patients with BPD who ever recovered over time. In reasons for use, the rates of PRN medication use to decrease agitation for both diagnostic groups declined significantly over time, whereas they remained significantly higher among patients with BPD. Likewise, patients with BPD who never recovered reported higher use of PRN medication to decrease agitation than patients with BPD who ever recovered over time. The results of this study indicate that PRN psychotropic medication is widely used for the treatment of patients with BPD, particularly those who have not achieved a recovery in both the symptomatic and psychosocial realms. They also suggest that patients with BPD use proportionally more PRN medication to decrease agitation than comparison subjects with OPD, with lower proportional use to reduce agitation found among recovered patients with BPD.
... The Pollack et al. study can now inform the choice of that adjunctive medication, i.e., a benzodiazepine, which could be compared with CBT (probably the best choice since a recent study found that it was superior to psychodynamic therapy [13]). Including a third option of combined CBT and benzodiazepine would address longstanding concerns about benzodiazepines interfering with the efficacy of CBT (14) (however, there is no consistent evidence for this) and address the hypothesis that combined medication and psychotherapy treatment might be superior in phase 2, just as it has been in phase 1 (10). This would likely not only advance the science but also the clinical practice of treating social anxiety disorder. ...
... This finding suggests that adding a benzodiazepine interferes with the effect of exposure. Westra, Stewart, and Conrad (2002) found that this interference is true particularly when benzodiazepines are taken on an as-needed (PRN) basis. In this study, patients who took benzodiazepines PRN had worse outcomes after CBT for panic disorder with agoraphobia, whereas those individuals who took benzodiazepines regularly had outcomes equivalent to unmedicated patients. ...
Chapter
Exposure-based strategies are effective treatments for many psychological disorders, yet there have been mixed findings regarding the processes underlying fear reduction during exposure. The purpose of this chapter is to provide an overview of exposure techniques and to discuss the current evidence regarding their effectiveness and the mechanisms by which exposure leads to fear reduction. The historical roots of exposure, as well as contemporary methods of exposure, are discussed. Possible mechanisms underlying exposure are reviewed, with the goal of understanding how and why fear reduction occurs during exposure. Guidelines for conducting exposure practices are discussed in the context of current empirical research.
... Benzodiazepines are also used for their potent, short-term effects (e.g., flying on an airplane) or to help reduce anxiety during the initial weeks of an antidepressant when anxiolytic effects have yet to occur (Goddard et al., 2001). These uses are appealing to the patient but not always desirable, as they can reinforce pill taking, serve as a safety signal that undermines self-efficacy (Westra, Stewart, & Conrad, 2002), and become incorporated into the conditioned fear response. These concerns are exacerbated when benzodiazepines are taken on an as-needed basis. ...
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Modern pharmacological treatments for anxiety disorders are safer and more tolerable than they were 30 years ago. Unfortunately, treatment efficacy and duration have not improved in most cases despite a greater understanding of the pathophysiology of anxiety. Moreover, innovative treatments have not reached the market despite billions of research dollars invested in drug development. In reviewing the literature on current treatments, we argue that evidence-based practice would benefit from better research on the causes of incomplete treatment response as well as the comparative efficacy of drug combinations and sequencing. We also survey two broad approaches to the development of innovative anxiety treatments:the continued development of drugs based on specific neuroreceptors and the pharmacological manipulation of fear-related memory. We highlight directions for future research, as neither of these approaches is ready for routine clinical use.
... Such studies have been conducted in other areas. Within the field of psychiatry, a study comparing subjects who had a predominantly regular pattern, with those who had a predominantly PRN pattern of benzodiazepine use for panic disorder with agoraphobia was conducted to examine the effectiveness of CBT in these two groups [43]. A study comparing patients randomised to a regular or PRN regimen of eye drops for allergic conjunctivitis [14] may also provide a useful basis for development of methodologies for such studies in adults with ADHD. ...
Article
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Adherence to a regular medication regimen may be challenging for adults with attention deficit hyperactivity disorder (ADHD). Some report taking psychostimulants on a pro re nata (PRN) basis. This review aims to establish the rate of adherence, and reasons for and consequences of non-adherence to medication for ADHD in adults, and to review literature on PRN dosing of psychostimulants in these patients. A systematic literature search was conducted. Four primary research studies have investigated the rate of adherence to medication in adults with ADHD. Mean adherence rate in two studies ranged from 52% to 87%. A number of possible reasons for poor adherence have been suggested. Prospective studies are needed to further define the rate of adherence and causes of poor adherence. Evidence examining whether differences in adherence affect clinical outcomes is equivocal. Therefore, caution should be applied to the assumption that maximising adherence to regular medication regimens will improve clinical outcomes. Two articles acknowledge that patients take medication on a PRN basis. Studies comparing the effectiveness of a regular and PRN regimen of psychostimulants are needed. If PRN dosing is as effective as a regular regimen, advantages might include enhanced doctor-patient communication, reduced side effects and cost savings.
... The practice of as needed dosing, which could be motivated by efforts to prevent dependence, is also not without its risks. The APA guidelines warns that such practice 'promotes fluctuating blood levels that may aggravate anxiety' (American Psychiatric Association, 2009) and cite evidence suggesting PRN benzodiazepine dosing is associated with worse outcomes in patients receiving cognitivebehavioural therapy (CBT) for PD ( Westra et al., 2002). Rapid relief of distressing symptoms is a potent behavioural reward, which potentially drives repeated use towards later dependence. ...
Article
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To investigate the potential impact of increasing prescription rates of alprazolam for the treatment of panic disorder (PD) in Australia through a review of efficacy, tolerability and adverse outcome literature. Data were sourced by a literature search using MEDLINE, Embase, PsycINFO and a manual search of scientific journals to identify relevant articles. Clinical practice guidelines from the American Psychiatric Association, National Institute of Clinical Excellence, Royal Australian and New Zealand College of Psychiatrists and World Federation of Societies of Biological Psychiatry were sourced. Prescription data were sourced from Australian governmental sources. Alprazolam has shown efficacy for control of PD symptoms, particularly in short-term controlled clinical trials, but is no longer recommended as a first-line pharmacological treatment due to concerns about the risks of developing tolerance, dependence and abuse potential. Almost no evidence is available comparing alprazolam to current first-line pharmacological treatment. Despite this, prescription rates are increasing. A number of potential issues including use in overdose and impact on car accidents are noted. conclusion: Although effective for PD symptoms in clinical trials, a number of potential issues may exist with use. Consideration of its future place in PD treatment in Australia may be warranted.
... Bruce et al. (1995) reported that the baseline to post-taper changes in ASI scores was the only significant predictor associated with discontinuation success, with individuals reporting minor declines in anxiety sensitivity at a greater chance of relapse. Westra, Stewart, and Conrad (2002) examined the impact of manner of benzodiazepine use on 10-week group session CBT outcome for 43 individuals who met the DSM-IV (APA, 1994) criteria for panic disorder with agoraphobia. ...
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Anxiety sensitivity is a cognitive, individual difference variable that is differentiated by an individual's fear of anxiety sensations and centred on the belief that such sensations result in harmful consequences. In order to test anxiety sensitivity, Reiss, Peterson, Gursky, and McNally (1986) developed the Anxiety Sensitivity Index (ASI). However, one contentious issue in the area concerns the factor analytic structure of anxiety sensitivity and this has important consequences for the construct. Numerous investigations have been conducted using the ASI, and the results have varied appreciably with some researchers arguing for a unidimensional construct. However the general consensus now is that anxiety sensitivity is multidimensional. It has been argued that the repeated attempts to clarify the dimensionality of anxiety sensitivity, using the 16-item ASI, is problematic because the scale was never designed to measure a multidimensional construct in the first instance. Thus, the objective of the dissertation was to critically examine the anxiety sensitivity construct by using an expanded, multidimensional measure of anxiety sensitivity referred to as the Anxiety Sensitivity Index - Revised ([ASI-R] Taylor & Cox, 1998) and establish the psychometric properties of the measure by conducting a series of empirical investigations to assess the clinical utility of the measure. A series of three empirical investigations are presented in the current dissertation. The first investigation aimed to critically examine the factor structure and psychometric properties of the ASI-R. Confirmatory factor analysis using a clinical sample of adults revealed that the ASI-R could be improved substantially through the removal of 15 problematic items in order to account for the most robust dimensions of anxiety sensitivity. The modified measure was re-named the 21-item Anxiety Sensitivity Index (21-item ASI) and re-analysed with a large sample of nonclinical adults, revealing configural and metric invariance across groups. Further, comparisons with other alternative models that also include comparisons with previous published ASI models indicated the 21-item ASI to be the best fitting model for both groups. There was also evidence of internal consistency, test-retest reliability, and construct validity for both samples. The aim of the second investigation was to critically examine differences between and within various anxiety classifications, a mood disorder classification, and a nonclinical control sample, with respect to both general and specific dimensions of anxiety sensitivity as identified by the 21-item ASI. In most instances, the results revealed that the differences between and within the diagnostic groups were consistent with theoretical expectations. Finally, the third investigation aimed to examine differences within each diagnostic category before and after cognitive behavioural therapy in order to provide a further test of validity for the revised 21-item ASI. The results revealed significant differences within all but one diagnostic group on the pre and post-treatment scores, using the global and specific dimensions of the 21-item ASI. The strengths, theoretical contribution, limitations, and directions for future research are discussed. It is concluded that the overall findings relating to the series of empirical investigations presented in the current dissertation make a significant and valid theoretical contribution to the field of anxiety sensitivity in particular, and anxiety research in general, by enhancing our understanding of anxiety sensitivity and how the 21-item ASI can be used to improve therapeutic interventions in clinical practice.
... psychotropic medication may not be good policy. Westra et al. 34 conducted an observational study of patients being treated for anxiety (which, as noted above, is considered a core feature of agitation by some researchers) and found that although p.r.n. use of benzodiazepines may be associated with a greater feeling of patient self-control, such use also resulted in poorer symptom control and did not produce lower overall dosage relative to fixed dosing. ...
Article
The use of medications on a p.r.n. basis on psychiatric inpatient wards is common and widespread but without clear evidence of effectiveness. While individual studies have explored the use of p.r.n. medications in patients receiving scheduled psychotropic medications, no systematic review of the effectiveness of this use of p.r.n. medications has been done. A MEDLINE search was performed of all articles published in English between 1966 and November 2008. Studies were included only if they involved psychiatric patients and if they quantitatively explored the effectiveness of p.r.n. medications. Ten retrospective studies were identified that met inclusion criteria. Among the studies involving adult inpatients, estimates of effectiveness, primarily in the management of agitation, were consistently moderately high, averaging approximately 75%. These studies mainly involved use of antipsychotics and benzodiazepines. Lower estimates of about 30% were obtained in studies involving non-adult inpatients who had few psychotic disorders and among whom there was only minimal use of p.r.n. benzodiazepines. The meaning of effectiveness was often unclear across these retrospective studies. It also appears that important outcome measures, such as duration of hospitalization, may not be affected. Administration of p.r.n. medication was also associated with a greater risk of adverse events. Future studies concerning use of p.r.n. medications in psychiatric patients should examine objective ratings of agitation, medication effects, and adverse events.
Article
Introduction Understanding the specific strategies individuals use to cope with their suicidal thoughts may have implications for suicide prevention. This study developed a classification system of coping strategies and applied this system to individual coping behaviors documented in a safety planning intervention smartphone application called Beyond Now. Method 725 Beyond Now safety planning app users, aged 16 to over 55 years, entered coping strategies that were used to develop a classification system through content analysis. Entries were either user generated or selected from a list of suggested coping strategies, and 2960 entries were classified using the system. Results Our classification system featured 11 distinct descriptive categories, with media consumption being the most popular coping strategy among Beyond Now users, followed by relaxation and self‐care activities, exercise and creative activities. More than half (57%) of the entries were suggested coping strategies with the remainder being user‐generated entries (43%). Conclusion A wide range of coping strategies were entered into safety plans, with activities that aim to either distract or provide reductions in emotional arousal common. Future research is needed to evaluate the efficacy of the coping strategies listed in safety plans.
Chapter
Benzodiazepines and related compounds (benzodiazepine receptor agonists [BzRAs]) cause a wide range of adverse reactions, including withdrawal symptoms, even when normal or low dosages are used. Deprescribing is recommended when there is loss of efficacy, major side effects, or use longer than four weeks. The withdrawal syndrome is due to physiologic dependence based on various receptor adaptations. Psychological, neurophysiologic, and somatic complaints can be misdiagnosed as psychiatric, psychosomatic, or substance use disorder. These symptoms may be severe and prolonged. The discontinuation process should include careful planning, support, and the use of cognitive behavioral therapy. Tapering, perhaps after substituting with a long-acting BzRA, should be patient-led and proceed slowly, anticipating completion over 12 to 18 months or even longer. In a proportion of patients, symptoms may continue months or years after complete BzRA cessation, requiring ongoing medical care.
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We discuss a rather new approach for the Russian psychotherapeutic practice — animal-assisted therapy. Russian scientific and psychotherapeutic literature lacks scientific studies that comprehensively consider the effectiveness of animal-assisted therapy (both positively and negatively), its use in cognitive behavioral therapy (CBT) and analyze in detail the researchers’ own experience of using animal therapy with a description of specific cases. Hence we discuss the key characteristics of animal-assisted therapy, describe the procedure of registering an animal for participation in therapy, analyze the results of using animal-assisted therapy for various psychotherapeutic and psychocorrectional problems, and substantiate the efficiency of animal-assisted therapy within CBT and its catalytic role in therapeutic processes. We describe the experience of using animal-assisted therapy as part of CBT. Using the example of two thematic cases that illustrate various goals and conditions, the structure and relevance of the inclusion of an animal in CBT depending on the client’s problem are considered, and methods of using an animal relevant to the client’s problem and psychotherapeutic goals are presented.
Chapter
In this chapter, we critically reviewed findings suggesting the existence of two psychopathological dimensions: apprehension/fear and somatic concern/somatisation. The complex interplay between environment, genetics, endocrine and immune systems, and brain circuitries underlying these two dimensions is discussed, with a specific focus on relevance in terms of trans-diagnostic expression. Furthermore, starting with the data presented in Chap. 2, we provide evidence of a clear expression of these two dimensions across traditional diagnostic boundaries, further highlighting the need for a dimensional approach to psychiatric syndromes. Finally, we describe some clinical cases that in our clinical experience might represent an important portrait of a real-word scenario in which these theoretical notions could be applied. Starting with these considerations, an overview of the potential implication for treatment is provided.
Article
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the beneficial and harmful effects of pharmacological treatment for adolescents and adults with borderline personality disorder (BPD).
Article
Objective: To investigate the population of patients with anxiety disorders in a general hospital in Germany who required treatment by a consultation psychiatrist. Method: A retrospective investigation of psychiatric consultations concerning 119 patients with anxiety disorders (DSM-IV criteria) from January 1, 2011, to December 31, 2012, was conducted in a general hospital of the Charité Berlin, Berlin, Germany. The frequency of different anxiety disorders, the distribution of anxiety disorders among the departments of the general hospital, and the recommended treatment procedure were investigated. Results: The largest group of patients with anxiety symptoms presented panic attacks. Many of these patients sought treatment in the emergency department of the hospital primarily due to their anxiety symptoms. Within the group of somatically ill patients, panic attacks were prominent, especially in patients with cardiac or respiratory diseases. Treatment procedures comprised pharmacologic and psychotherapeutic interventions. Benzodiazepines and psychoeducation were common acute treatments; antidepressants, pregabalin, and psychotherapy were recommended for long-term treatment. Conclusions: Many patients who primarily suffer from symptoms of anxiety seek treatment in a general hospital, especially in the emergency department. It is therefore very important for the individual patient as well as the health care system that the correct treatment is initiated. The consultation-liaison psychiatric service within a general hospital is important to ensure the best possible diagnostic procedures as well as treatment for patients with anxiety disorders.
Chapter
The Efficacy of BZ Treatment for the Anxiety DisordersCombination Treatment: The Wish and the RealitySpecific BZ Effects on Memory for CBTAdditional Negative Effects of Combination Treatment - Discontinuation EffectsA Model of Combined BZ and CBTCBT for BZ DiscontinuationSummary and Conclusions References
Article
Background The revision of the psychotherapy guidelines in 2011 broadened the options for treating substance use disorders (SUD) in outpatient psychotherapy (OP). Aim The aims of this study were to answer the following questions: how frequently are SUDs treated in OP? What opinions do psychotherapists (PT) hold concerning the new treatment possibilities? Material and methods In this study the frequency of OP for patients with SUD, e.g. harmful use and abuse of as well as dependence on psychotropic substances according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and the International Statistical Classification of Diseases and Related Health Problems (ICD-10), by private practice PTs as well as their attitude towards the treatment of patients with these diagnoses were investigated. Private practice PTs in five states in East Germany were asked to participate in a postal survey. Results Of the 1,382 PTs contacted, 229 (16.6 %) participated in the study. Of the respondents 94.3 % had treated at least one patient with SUD (4-week prevalence including nicotine dependence). These rates ranged from 3.1 % to 26.6 % depending on the substance and diagnosis (SUD as primary reason for treatment). The highest rates of strong affirmation for OP of approximately 20 % were found for disorders related to alcohol, tobacco and medication. Conclusion Most PTs treated at least one patient with SUD in OP. However, this particular type of treatment offer should be further extended. Information about the options of treating SUD in OP should be further disseminated and conducting such treatment should be supported by (e.g.) therapist training.
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Benzodiazepines (BDZs) continue to be shrouded in controversy, mainly because of dependence associated with their long-term use and some of their side effects. Despite treatment recommendations favoring newer antidepressants, BDZs are still commonly prescribed for anxiety and related disorders. Recent studies have demonstrated that long-term use of BDZs for these conditions can be effective and safe and that BDZs can be combined with psychological therapy and antidepressants to produce optimal outcomes. Such findings, along with a failure to convincingly demonstrate the overall superiority of alternative pharmacotherapy for anxiety and related disorders, have given an impetus to a reconsideration of the role of BDZs. This article reviews BDZs and other pharmacotherapy options for anxiety and related disorders and suggests that treatment guidelines should acknowledge that BDZs can be used as first-line, long-term pharmacological treatment for panic disorder, generalized anxiety disorder and social anxiety disorder.
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The identification of efficacious psychological and psychiatric therapies is arguably one of the most significant achievements in the pediatric anxiety disorders field. Controlled trials have supported the usefulness of psychological and pharmacological monotherapies for pediatric obsessive–compulsive disorder, social anxiety disorder, panic disorder, agoraphobia, generalized anxiety disorder, specific phobia, posttraumatic stress disorder, and separation anxiety disorder (Compton et al., 2004; Feeney, Foa, Treadwell, & March, 2004; In-Albon & Schneider, 2007; Reinblatt & Riddle, 2007; Seidel & Walkup, 2006; Watson & Rees, 2008). Clinical practice guidelines, developed from a synthesis of research evidence and expert opinion, have recommended cognitive-behavioral therapy (CBT) as the first line psychotherapy and treatment of choice (American Academy of Child and Adolescent Psychiatry (AACAP), 2007; Canadian Psychiatric Association (CPA), 2006). The selective serotonin reuptake inhibitors (SSRIs) are the recommended first-line pharmacological agents for pediatric anxiety disorders. Second or third-line pharmacotherapy alternatives include noradrenergic antidepressants (tricyclic antidepressants (TCAs), venlafaxine), benzodiazepines, and buspirone.
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Über Jahrzehnte standen Psychotherapeuten und Pharmakotherapeuten der Kombination von Psychotherapie und Pharmakotherapie skeptisch bis ablehnend gegenüber. Diese Haltung hatte verschiedene Gründe.
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This article describes a comprehensive treatment of a case of panic disorder with agoraphobia. A thorough history taking revealed that experiential contributors had a pivotal role in the development of the condition. Therefore, eye movement desensitization and reprocessing (EMDR) was used to address early traumatic events as well as the present stimuli that caused disturbance and had maintained symptomatology for the past 12 years. Although the client's symptoms were resolved after 15 sessions, EMDR was also effective in addressing future behaviors and resolving anticipatory anxiety. During EMDR processing, the client demonstrated emotional and cognitive changes consistent with trauma resolution, insight, and personal growth. The client gradually enacted functional new behaviors spontaneously as treatment unfolded. The therapeutic process and the targets are described in detail.
Book
Using the practical yet comprehensive approach found in the first edition, the author considers each anxiety disorder's clinical complexity while simultaneously using an integrative orientation toward finding clinical solutions. The author considers the presentation of each disorder as it occurs and is treated in the "real world" of clinical practice. Finally, the volume addresses effective therapeutic procedures and recommendations, including pharmacological and psychological treatment approaches. A true "must read" for any psychiatrist interested in anxiety disorders.
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major advances have occurred in the conceptualization and treatment of panic disorder (PD) and agoraphobia / newer psychosocial treatment techniques target panic attacks directly by addressing fearfulness of bodily sensations and are presumed to affect change by altering cognitive and associative processes / traditional in vivo exposure is still required to address agoraphobic avoidance / covers the theoretical developments, treatment outcome data, and [cognitive-behavioral] treatment methods context of treatment [setting, interpersonal context, therapist variables, client variables, concurrent pharmacological treatment] / assessment / treatment description: components [cognitive restructuring, breathing retraining, relaxation, interoceptive exposure, situational exposure] / treatment description: protocol [sessions 1–15] (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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In laboratory studies with nonanxious participants, benzodiazepines (BZ) reliably induce anterograde amnesia. It remains unclear whether memory impairments exist for information presented in therapy among anxiety patients who are concomitantly taking BZs. This naturalistic study compared 16 panic disorder patients who were daily BZ users with 16 age- and education-matched, nonmedicated panic disorder patients. An incidental memory task assessed memory for psychoeducation material on the origins and management of somatic anxiety symptoms presented during group cognitive behavioral therapy (CBT). BZ users showed significantly poorer memory performance than controls although there were no group differences in anxiety symptoms, rates of psychiatric comorbidity, or sedation. Among BZ users, a higher number of minutes away from post peak drug-blood concentration when encoding began, was also associated with better incidental memory performance. Although causation cannot be inferred from this naturalistic study, the memory impairments observed among BZ users may contribute to the poorer efficacy of CBT previously documented in panic disorder patients receiving adjunctive BZs.
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Although prescription rates may be declining, benzodiazepines (BZs) are still very commonly prescribed for the treatment of anxiety disorders. Because many anxiety patients require assistance in successfully discontinuing BZs, cognitive behavioral therapy (CBT) approaches have been specifically developed to target this issue, and an evidence base now exists to support their use in this manner. In this paper, we first provide the rationale for why BZ discontinuation is desirable. We then present a self-help handout that we have used productively in our cognitive-behavioral practice to assist patients in deciding whether they are ready to attempt discontinuation of their BZs, and to prepare them with strategies for successful discontinuation. The clinical use of this handout is discussed and suggestions offered for integrating it effectively into CBT for anxiety.
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Despite significant advances in the treatment of anxiety disorders in recent times, limitations such as suboptimal efficacy, side effects and delay of clinical effect remain. Ongoing research conducted within the boundaries of the existing psychiatric nomenclature is producing real improvements in our understanding of these prevalent and impairing conditions. A broadening of our understanding of both classical and contemporary neurotransmitter systems, in addition to the disorder-specific knowledge base, is informing new directions for anxiety disorder treatments. This article reviews patent activity for anxiolytic compounds released since 2000 within both anxiety disorderspecific and neurotransmitter-specific contexts.
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Dialectical behavior therapy (DBT) identifies emotion dysregulation as central to the dangerous impulsivity of borderline personality disorder (BPD) including substance use disorders, and DBT targets improved emotion regulation as a primary mechanism of change. However, improved emotion regulation with DBT and associations between such improvement and behavioral outcomes such as substance use has not been previously reported. Thus, the goal of this study was to assess for improvement in emotion regulation and to examine the relationship between improvements in the emotion regulation and substance use problems following DBT treatment. Emotion regulation as assessed by the Difficulties in Emotion Regulation Scale, depressed mood as assessed by the Beck Depression Inventory, and their associations with substance use frequency were investigated in 27 women with substance dependence and BPD receiving 20 weeks of DBT in an academic community outpatient substance abuse treatment program. Results indicated improved emotion regulation, improved mood, and decreased substance use frequency. Further, emotion regulation improvement, but not improved mood, explained the variance of decreased substance use frequency. This is the first study to demonstrate improved emotion regulation in BPD patients treated with DBT and to show that improved emotion regulation can account for increased behavioral control in BPD patients. SIGNIFICANCE AND FUTURE RESEARCH: Emotion regulation assessment is recommended for future studies to further clarify the etiology and maintenance of disorders associated with emotional dysregulation such as BPD and substance dependence and to further explore emotion regulation as a potential mechanism of change for clinical interventions.
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The aim of the present review is to summarize available evidence about the efficacy and side effects of novel antidepressants for the treatment of panic disorder. A literature search was undertaken using MEDLINE, ISI web of knowledge and references of retrieved articles. The search included articles published in English up to September 2009. Both controlled and uncontrolled trials were included. The quality of the reviewed articles was also assessed. Fourteen mainly poor-quality studies were included. Mirtazapine showed some efficacy in reducing the number and the severity of panic symptoms in many uncontrolled studies and was comparable to selective serotonin reputake inhibitors (SSRIs) in direct-comparison studies. Reboxetine was significantly more efficacious than placebo but less effective than SSRIs. Further uncontrolled studies suggested preliminary evidence for the use of milnacipran and duloxetine as well. All drugs were usually well tolerated. Current studies do not yet provide convincing evidence supporting the efficacy of mirtazapine, reboxetine, milnacipran and duloxetine for the treatment of panic disorder patients. However, on account of positive preliminary results, further research is warranted.
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Podeu consultar la versió anterior a: http://hdl.handle.net/2445/358 Se abordan diversos aspectos de la agorafobia y el trastorno de pánico: naturaleza, edad de comienzo y curso, frecuencia, problemas asociados, génesis y mantenimiento, métodos e instrumentos de evaluación, y eficacia y utilidad clínica del tratamiento psicológico y farmacológico. Además, se ofrecen guías para aplicar los tratamientos psicológicos más eficaces.
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In a meta-analysis, the authors compared the effectiveness of psychological and pharmacological treatments for panic disorder. Percentage of agoraphobic subjects in the sample and duration of the illness were unrelated to effect size (ES). Type of dependent variable was generally unrelated to treatment outcome, although behavioral measures yielded significantly smaller ESs. Dependent measures of general anxiety, avoidance, and panic attacks yielded larger ESs than did depression measures. Choice of control was related to ES, with comparisons with placebo controls greater than comparisons with exposure-only or "other treatment" controls. Psychological coping strategies involving relaxation training, cognitive restructuring, and exposure yielded the most consistent ESs; flooding and combination treatments (psychological and pharmacological) yielded the next most consistent ESs. Antidepressants were the most effective pharmacological intervention.
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Community norms are reported for the Beck Anxiety Inventory (BAI; A. T. Beck, N. Epstein, G. Brown, & R. A. Steer, 1988), Fear Questionnaire (FQ; I. M. Marks & A. Mathews, 1979), Penn State Worry Questionnaire (PSWQ; T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990), and Social Phobia and Anxiety Inventory (SPAI; S. M. Turner, D. C. Beidel, C. V. Dancu, & M. A. Stanley, 1989). The demographic profile of the samples closely matched the 1990 U.S. national census. On the SPAI, women scored higher than men on the Agoraphobia subscale, and the lowest income group scored higher than higher income participants on the Difference and Social Phobia subscales. Participants under 45 years of age exceeded those aged 45–65 on the BAI, the PSWQ, and FQ Social Phobia, Blood/Injury, and Total Phobia scores. Percentile scores are provided for all measures, as well as discussion of their usefulness for assessing clinical significance of therapy outcomes. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The present study examined the effects of naturalistic benzodiazepine (BZ) use on selective attention to threat cues in 50 patients diagnosed with anxiety disorders, according to DSM-IV (APA, 1994) criteria. Patients provided information on their BZ use histories, demographics, and severity of anxiety symptomatology, and completed a computerized Stroop task involving color naming of social threat, physical threat, and matched no-threat control words. Patients were selected to fill two age-, gender-, and diagnosis-matched groups based on self-reported BZ use histories: 25 current BZ users versus 25 medication nonusing controls. Planned comparisons were conducted to determine whether BZ use groups differed in degree of selective attention to either the physical and/or social threat stimuli, or overall. Even with BZ use group differences in anxiety severity covaried out, the BZ users demonstrated significantly greater selective attention to threat than the medication nonusers, particularly in the case of physical threat stimuli. These findings are consistent with Westra and Stewart's (1998) suggestion that BZ use may increase preferential attention to physical threat cues, since BZs are often taken on an as needed (prn) basis. This prn enhancement interpretation was further supported through the finding of a significant positive correlation between frequency of prn use of BZs and degree of physical threat-related interference on the Stroop among the BZ users group. Theoretical explanations and clinical implications of these findings are discussed.
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 Drug reinforcement may represent the primary behavioral-pharmacological mechanism underlying two types of problematic use of benzodiazepines – recreational abuse by polydrug abusers and inappropriate chronic use by patients. High dose polydrug abuse for the purpose of getting high is readily recognized as a significant social problem. Inappropriate chronic benzodiazepine use is more subtle but relatively common: for anxiolytics, 36% of past-year users (3% of the adult population in the US) report using these drugs for 4 consecutive months or longer. The risks of such long-term use are much better documented than the benefits. This paper provides a current review of various problems that have been identified with the long-term use and the recreational abuse of benzodiazepines, including memory impairment, risk of accidents, falls and hip fractures in the elderly, a withdrawal syndrome, brain damage, overuse in the elderly, overuse by chronic pain patients, overuse by alcoholics and recreational abuse among alcoholics and polydrug abusers. A comprehensive review of the literature on benzodiazepine reinforcing effects in humans and laboratory animals is also provided. Drug self-administration studies in humans and laboratory animals provide models of both types of problematic benzodiazepine use. Recreational abuse of benzodiazepines has been modeled in human research with polydrug abusers and in laboratory animal studies, which show that the reinforcing effect of benzodiazepines is intermediate relative to other sedative compounds and is increased in subjects with histories of previous sedative drug self-administration. The problem of inappropriate long-term use of benzodiazepines by people without histories of drug abuse has been partially modeled in human studies showing that benzodiazepines function as reinforcers in subjects with anxiety, insomnia, and histories of moderate alcohol consumption, and in preclinical studies showing stable, low-rate benzodiazepine self-injection with concurrent physical dependence under conditions of continuous availability. Both human and animal research suggests that the drug history and current behavioral context may be important in the establishment of benzodiazepines as reinforcers. Limited human and animal research provides little support for the common belief that physical dependence enhances benzodiazepine reinforcement.
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The development of a 21-item self-report inventory for measuring the severity of anxiety in psychiatric populations is described. The initial item pool of 86 items was drawn from three preexisting scales: the Anxiety Checklist, the Physician’s Desk Reference Checklist, and the Situational Anxiety Checklist. A series of analyses was used to reduce the item pool. The resulting Beck Anxiety Inventory (BAI) is a 21-item scale that showed high internal consistency (α = .92) and test—retest reliability over 1 week, r (81) = .75. The BAI discriminated anxious diagnostic groups (panic disorder, generalized anxiety disorder, etc.) from nonanxious diagnostic groups (major depression, dysthymic disorder, etc). In addition, the BAI was moderately correlated with the revised Hamilton Anxiety Rating Scale, r (150) = .51, and was only mildly correlated with the revised Hamilton Depression Rating Scale, r (153) = .25.
Article
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The amnestic effects of benzodiazepines (BZs) have attracted considerable research interest. This reflects not only the clinical implications of memory failure for people prescribed these drugs but also the potential of BZs as tools in modelling organic memory problems. As well as impairing certain aspects of human memory functions, BZs affect mood states by reducing anxiety and inducing sedation. An unresolved issue is the extent to which the amnestic effects of BZs are separable from their sedative and anxiolytic effects. The present review focuses on this issue, first presenting a conceptual framework for evaluating the interrelationship between the various effects of BZs, and then summarising recent volunteer and patient research relevant to dissociating amnestic from other effects. Clinical implications are discussed in terms of the use of BZs alone or as adjuncts to psychotherapy for anxiety disorders, and attention is drawn to the need for more ecological validity in psychopharmacological research. Theoretical implications are explored in terms of BZs as tools in studying both memory failure and the relationship between mood and cognition.
Article
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The authors' goal was to determine the clinical characteristics of persistent users of alprazolam or lorazepam who wished to discontinue their medication. Long-term users (daily use for more than 3 months) of alprazolam (N = 34) or lorazepam (N = 97) who entered an outpatient treatment program for discontinuation of benzodiazepines were carefully assessed. Detailed histories of benzodiazepine use were obtained; a structured interview was used to make psychiatric diagnoses based on DSM-III-R criteria. The majority of patients were using low therapeutic doses of medication (lorazepam: mean = 2.7 mg/day; alprazolam: mean = 1.2 mg/day) and had either maintained their initial daily dose over time or decreased it. Individuals tended to shift their use of medication from an as-prescribed to an as-needed pattern. Forty-seven percent of the patients were diagnosed with at least one current anxiety disorder, most commonly generalized anxiety. At least one diagnosable personality disorder was found in 45% of the patients, most commonly obsessive-compulsive personality disorder. Patterns of benzodiazepine use were influenced by age, gender, and past history of alcohol dependence. Long-term users of alprazolam/lorazepam seeking treatment for discontinuation had clinically important past and current psychiatric histories. They used a constant or decreasing dose of medication and made attempts to stop their use. Persistent use of alprazolam/lorazepam for therapeutic purposes did not represent abuse or addiction as the terms are usually understood. A substantial proportion of these patients may be receiving appropriate maintenance therapy for a chronic psychiatric condition.
Article
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A cross-national randomised trial of alprazolam for chronic panic disorder with agoraphobia was run. Compared with previous trials it had three new features: an exposure therapy contrast group, a six-month treatment-free follow-up, and a low rate of early placebo drop-outs ('non-evaluables'). The dose of alprazolam was high (5 mg/day). The 154 patients had eight weeks of: alprazolam and exposure (combined treatment); or alprazolam and relaxation (a psychological placebo); or placebo and exposure; or placebo and relaxation (double placebo). Drug taper was from weeks 8 to 16. Follow-up was to week 43. Results were similar at both sites. Treatment integrity was good. All four treatment groups, including double placebo, improved well on panic throughout. On non-panic measures, by the end of treatment, both alprazolam and exposure were effective, but exposure had twice the effect size of alprazolam. During taper and follow-up, gains after alprazolam were lost, while gains after exposure were maintained. Combining alprazolam with exposure marginally enhanced gains during treatment, but impaired improvement thereafter. The new features put previous trails in a fresh light. By the end of treatment, though gains on alprazolam were largely as in previous studies, on phobias and disability they were half those with exposure. Relapse was usual after alprazolam was stopped, whereas gains persisted to six-month follow-up after exposure ceased. Panic improved as much with placebo as with alprazolam or exposure.
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Benzodiazepines (BZs) have been widely investigated in terms of clinical efficacy, factors underlying dependence, associated cognitive impairments, and interactions with psychotherapy for anxiety control. However, few studies have systematically considered manner of BZ administration in relation to these variables. Studies of chronic BZ users indicate that as-needed or p.r.n. use is a very common practice, increases with chronicity of BZ use, and is preferred compared to regularly scheduled BZ administration. Moreover, a recent study of physician prescription practices indicated that p.r.n. BZ use is a commonly recommended BZ use regimen for anxiety disorder management. Physician advocates of p.r.n. BZ prescriptions for anxiety disorders cite enhanced patient control over symptoms, facilitation of exposure to fear-provoking situations, and reduced frequency of use as rationales supporting this practice. Available data however, do not consistently support these hypothesized advantages of p.r.n. BZ use. And in general, findings from different investigations relevant to this question suggest that p.r.n. BZ administration may be associated with increased patient preference for BZs over placebo, continued use, and greater impairment on cognitive factors associated with positive long-term anxiety management. Ironically, p.r.n. BZ administration may also be associated with reduced anxiolytic efficacy over time. These suggestive findings argue for greater systematic investigation of manner of BZ administration as an important medication use parameter. Such investigations may also yield practical guidelines for navigating BZ discontinuation and promoting more successful long-term management of anxiety.
Book
This edition of the Mastery of Your Anxiety and Panic Workbook has been updated to include strategies and techniques for dealing with both panic disorder and agoraphobia. The program outlined is based on the principles of cognitive behavioral therapy (CBT) and is organized by skill, with each chapter building on the one before it. It covers the importance of recordkeeping and monitoring progress, as well as breathing techniques and thinking skills. The main focus of the treatment involves learning how to face agoraphobia situations and the often frightening physical symptoms of panic from an entirely new perspective. Self-assessment quizzes, homework exercises, and interactive forms allow patients to become active participants in treatment and to learn to manage panic attacks, anxiety about panic, and avoidance of panic and agoraphobic situations.
Article
Lively controversies related to panic disorder are under active investigation by research groups around the world. However, publications from different laboratories are difficult to compare since there has been little consistency in measures or even in types of assessment used to characterize and follow up patients. Participants in the recently convened National Institutes of Health Consensus Development Conference on the Treatment of Panic Disorder noted this problem and recommended establishment of procedures to ensure comparability of studies. We organized a conference of clinical investigators whose objective was to develop a standard assessment package. Participants represented biological and psychosocial panic disorder treatment research sites in the United States and Canada. The 2-day conference resulted in agreement on a battery of assessments considered essential for panic disorder studies. The purposes of our report are to disseminate the conference conclusions and to encourage adoption of the proposed standards by clinical researchers, journal editors, Public Health Service peer review committees, and the Food and Drug Administration. We also identify some problematic issues that require further work.
Article
The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out by a number of authors. Pasamanick12 in a recent article viewed the low interclinician agreement on diagnosis as an indictment of the present state of psychiatry and called for "the development of objective, measurable and verifiable criteria of classification based not on personal or parochial considerations, but on behavioral and other objectively measurable manifestations."Attempts by other investigators to subject clinical observations and judgments to objective measurement have resulted in a wide variety of psychiatric rating scales.4,15 These have been well summarized in a review article by Lorr11 on "Rating Scales and Check Lists for the Evaluation of Psychopathology." In the area of psychological testing, a variety of paper-and-pencil tests have been devised for the purpose of measuring specific
Article
• Following promising preliminary evidence, the benzodiazepine-derivative alprazolam was studied in a large, placebocontrolled, eight-week, flexible-dose trial in patients with agoraphobia with panic attacks and panic disorder. Of 526 patients, 481 completed three weeks of treatment; however, significantly more placebo (102/234) than alprazolam (21/247) recipients subsequently dropped out of the trial, primarily citing ineffectiveness (of placebo) as the reason. Alprazolam was found to be effective and well tolerated. There were significant alprazolam-placebo differences in improvement for (1) spontaneous and situational panic attacks, (2) phobic fears, (3) avoidance behavior, (4) anxiety, and (5) secondary disability, all significant by the end of week 1. At the primary comparison point (week 4), 82% of the patients receiving alprazolam were rated moderately improved or better vs 43% of the placebo group. At that point, 50% of the alprazolam recipients vs 28% of placebo recipients were free of panic attacks.
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There are three pillars to the new Labour Government’s approach to economic policy; delivering macroeconomic stability, tackling supply-side barriers to growth and delivering employment and economic opportunities to all. This lecture focuses on the new Government’s reforms to deliver macroeconomic stability and the importance of open and transparent institutions and procedures. The lecture outlines four principles for macroeconomic policymaking which flow from changes in the world economy and the world of economic ideas over recent decades. It explains each principle and shows how they are being translated into practice in the macroeconomic policy reforms that the new Government has introduced at the Treasury and the Bank of England.
Article
The past decade has seen significant advances in both psychosocial, notably cognitive behavioral (CBT), and pharmacological treatments for panic disorder. Given the widely acknowledged efficacy of both forms of treatment, it is reasonable to consider that the combination of approaches should yield an extremely potent strategy to treating panic disorder. The present report summarizes scientific evidence for the singular and combined treatment approaches to panic disorder. Data across studies indicate that combined treatments yield immediate and short-term benefits above those provided by either pharmacologic treatment or CBT alone. In the long-term, however, these benefits disappear. In fact, the combination of benzodiazepines and CBT appears to produce poorer end-state functioning than CBT alone. Other data indicate that the sequencing of pharmacotherapy and CBT may be useful for benzodiazepine fading. Although these data are preliminary, combined treatments do not appear to be the treatment of choice for patients with panic disorder. Treatment algorithms are suggested based on existing data.
Article
In a prospective, naturalistic study, we examined the long-term outcome of patients with panic disorder who entered remission following cognitive behavior therapy (CBT) alone or CBT plus medications (combined treatment). Similar to previous studies, severity of the panic disorder and agoraphobic avoidance served as predictors of relapse in a survival analysis. However, the most powerful predictor of maintenance of remission was treatment type. Despite ongoing pharmacotherapy, patients who entered remission with combined treatment and continued their pharmacologic treatment relapsed sooner than patients treated with CBT who entered remission medication-free. Consideration of baseline levels of anxiety severity, comorbidity, and history of previous remissions did not account for the prediction afforded by consideration of treatment type. These findings are discussed in the context of other evidence for deleterious effects of concomitant pharmacotherapy on the long-term outcome of patients with panic disorder treated with CBT. Treatment implications are discussed.
Article
A combined cognitive-behavioral and time-limited alprazolam, treatment model for panic disorder was evaluated within the context of routine clinical practice. Twenty-two patients were followed for 1 year after the completion of cognitive-behavior therapy and alprazolam discontinuation. At 1-year follow-up, 76% of the original sample were medication-free and 85% remained panic-free. These results are comparable to previous reports of cognitive-behavioral therapy alone (e.g., Craske, Brown, & Barlow, 1991) and are far superior to medication-only studies (e.g., Fyer et al., 1987). These results suggest that both rapid and long-lasting treatment effects may be obtained through such a combination, and that the combined treatment approach does not necessarily interfere with the efficacy of cognitive-behavioral therapy. This study represents a first step in evaluating this combined treatment approach and supports the utility of conducting controlled randomized studies to evaluate these issue systematically.
Article
Considerable controversy exists regarding the practice of combining Cognitive Behavioural Therapy (CBT) with Pharmacotherapy (PT) in the management of anxiety. This paper considers whether these two forms of treating anxiety disorders can be effectively combined to enhance treatment outcome. Despite the theoretical appeal of a combined approach, a critical review of treatment outcome findings across CBT and various anxiolytic medications and their combination, suggests a failure of these treatments to operate in a complementary fashion. A detrimental impact of anxiolytic medication on CBT outcome is particularly salient for high potency benzodiazepines. Low potency benzodiazepines and antidepressants generally have a negligible impact with no clear evidence of treatment enhancement and some negative combined treatment effects on medication withdrawal and at long-term follow-up. Thus, we address potential mechanisms that may explain this treatment noncomplementarity and in some cases, treatment incompatibility. Cognitive factors influencing treatment outcome (catastrophic beliefs, self-efficacy, selective attention, and memory) are highlighted in view of the empirically supported mediating role of these variables in accounting for treatment responsiveness. Potential effects of anxiolytic medication on cognitive change in CBT are postulated. A number of suggestions for future research and clinical practice are proposed on the basis of this review.
Article
We compared the effectiveness of pharmacological, cognitive-behavioral, and combined pharmacological and cognitive-behavioral treatments in a meta-analysis of 43 controlled studies that included 76 treatment interventions. Cognitive-behavioral treatments yielded the highest mean effect sizes (ES = 0.68) relative to pharmacological (ES = 0.47) and combination treatments (ES = 0.56). In addition, the proportion of subjects who dropped out of cognitive-behavioral treatments was 5.6% relative to 19.8% in pharmacological treatments and 22.0% in combined treatments. Among cognitive-behavioral treatments, those studies that combined cognitive restructuring with interoceptive exposure yielded the strongest effect sizes (ES = 0.88). With regard to pharmacological treatments, there was no significant difference between antidepressants (ES = 0.55) and benzodiazepines (ES = 0.40). Long-term outcome analyses suggested that cognitive-behavioral interventions were the most successful at maintaining treatment gains. Cost analyses indicated that the lowest cost interventions were imipramine treatment and group cognitive-behavioral therapy. In general, cognitive-behavioral treatments yielded the largest effects sizes and the smallest attrition rates relative to pharmacotherapy and combined treatments, and are cost-effective.
Article
Synopsis Fifty-seven chronic agoraphobic outpatients were treated by 12 hours of exposure in vivo on four days over two weeks to check the effects of oral diazepam versus placebo during group exposure, group versus individual exposure, and high versus medium anxiety arousal during individual exposure. The controlled parallel design allowed comparative evaluation of each treatment condition to six months follow-up. Assessment was blind with respect to drug and psychological treatment. Patients in all treatment conditions improved significantly in phobias and in related life areas. Outcome to group exposure on phobias and other measures was similar in all three drug conditions (placebo, waning diazepam, peak diazepam) with no significant differences between them. Diazepam patients had significantly less discomfort than placebo patients during group exposure treatment. Group exposure patients improved slightly but significantly more than individual exposure patients on non-phobic measures, though group exposure was accompanied by more panics during treatment yet was easier to run by the therapist. Individual exposure under high anxiety arousal was no more therapeutic than with lower anxiety. Diazepam is a mild palliative during group exposure but does not facilitate outcome to treatment. Group exposure in vivo is mildly facilitatory for outcome compared with individual exposure. Anxiety evocation during treatment was not therapeutically helpful.
Article
A one-page self-rating form is described to monitor change in phobic patients. It is derived from earlier versions used in 1000 phobic club members and 300 phobic patients. The form yields four scores: main phobia, global phobia, total phobia and anxiety-depression. The total phobia score is composed of agoraphobia, social and blood-injury subgroups. The form is short, reliable and valid. Adoption of this standard form for research in clinical populations would facilitate comparison of results across centres and studies.
Article
Concern about persistent benzodiazepine use should be informed by data about reasons for such use. Consecutive long term alprazolam users (n = 25) admitted to an advertised outpatient program for discontinuation were characterized with respect to alprazolam use patterns and lifetime and current Axis I and II disorders. Patient characteristics were: females 50 percent; mean age, 46 +/- 12 yrs; prior medication use--benzodiazepines, 47 percent, antidepressants, 23 percent; median duration of use 104 +/- 96 wks; median daily dose, 0.5 mg; continued effectiveness of alprazolam 50 percent. Over the duration of use patients shifted their initial pattern of use from as prescribed to a self-controlled "as required" basis (p less than .05). Interviews using the Structured Clinical Interview for DSM-III-R (SCID) yielded diagnoses of DSM-III-R alprazolam dependence in all patients plus at least one additional psychiatric diagnosis in 65 percent (Axis I 65%; Axis II 39%). Most persistent alprazolam use does not represent abuse or addiction as usually understood. These data are most consistent with the interpretation that alprazolam is the most recent benzodiazepine used by patients to help control clinically important psychopathology and that most users make efforts to control or stop use.
Article
Sixty-five patients with social phobia were treated in a study that compared a cognitive-behavioral group treatment program with pharmacotherapy with alprazolam, phenelzine sulfate, or pill-placebo plus instructions for self-directed exposure to phobic stimuli. Statistically significant repeated-measures effects were shown on all measures, indicating that the treatments studied were associated with substantial improvements in patients with severe and chronic social phobia. Patients who were treated with phenelzine were rated by clinicians as more improved on a measure of work and social disability than patients who were treated with alprazolam or placebo (patients in the cognitive-behavior therapy group were not rated on this measure). Subjects showed positive cognitive changes from before to after treatment, and there were no differences between treatment groups on the cognitive measure. We discuss the implications of these findings within the context of demographic and clinical predictors of response.
Article
Behaviour therapy and benzodiazepines are directed towards common problems and are often used in combination. At present we know little about the beneficial or adverse interactions of these two treatments. This paper reviews the available literature and suggests that there are important theoretical and clinical issues to be resolved.
Article
Studies from 1973 to 1985 of the effects of benzodiazepines on memory are summarised and reviewed. Anterograde amnesia appears a common effect of all benzodiazepines although its onset and duration vary with the particular benzodiazepine, its dose and route of administration. Memory impairments increase with task difficulty. There is some evidence that partial tolerance to amnesic effects develops with repeated doses of diazepam, but research with other benzodiazepines is inconclusive. Amnesia is in part a by-product of the sedative action of benzodiazepines, although these drugs may also have a specific effect of disrupting the consolidation of information in long-term memory. State-dependent effects are partial and relatively small. Methodological problems are discussed and attention is drawn to the lack of repeated dose studies, of studies with patient populations and with anxious volunteers.
Article
Following promising preliminary evidence, the benzodiazepine-derivative alprazolam was studied in a large, placebo-controlled, eight-week, flexible-dose trial in patients with agoraphobia with panic attacks and panic disorder. Of 526 patients, 481 completed three weeks of treatment; however, significantly more placebo (102/234) than alprazolam (21/247) recipients subsequently dropped out of the trial, primarily citing ineffectiveness (of placebo) as the reason. Alprazolam was found to be effective and well tolerated. There were significant alprazolam-placebo differences in improvement for (1) spontaneous and situational panic attacks, (2) phobic fears, (3) avoidance behavior, (4) anxiety, and (5) secondary disability, all significant by the end of week 1. At the primary comparison point (week 4), 82% of the patients receiving alprazolam were rated moderately improved or better vs 43% of the placebo group. At that point, 50% of the alprazolam recipients vs 28% of placebo recipients were free of panic attacks.
Article
In a multicenter placebo-controlled study, the safety, side effects, and patient acceptance of alprazolam for the treatment of panic disorder and agoraphobia were examined. A total of 525 patients meeting DSM-III criteria for agoraphobia with panic attacks or panic disorder were randomly assigned to receive alprazolam or placebo, which they took for eight weeks. The mean daily dose at the end of the study was 5.7 mg of alprazolam or 7.5 capsules of placebo daily. Potentially serious reactions to alprazolam occurred in ten of 263 subjects who received the drug. These included acute intoxication (three), hepatitis (two), mania (two), amnesia (one), aggressive behavior (one), and depression (one). Treatment-related side effects that were worse in patients taking alprazolam than in those taking placebo included sedation, fatigue, ataxia, slurred speech, and amnesia. Sedation was the most frequent but tended to subside with dose reduction or continued administration of the drug. Patient acceptance of alprazolam, as measured by the rate of completion for study participants, was high. Eighty-four percent of patients receiving active drug completed the study compared with 50% receiving placebo.
Article
Data from 74 patients with panic disorder were evaluated to determine the comparative efficacy of imipramine, alprazolam, and trazodone. All patients were treated with placebo for 3 weeks and were then blindly switched to active treatment for 8 weeks. Both imipramine and alprazolam were highly effective in reducing the symptoms of generalized anxiety, the frequency of panic attacks, and phobic avoidance. However, the time course of these effects differed; alprazolam demonstrated therapeutic properties during the first week, whereas the therapeutic efficacy of imipramine was not clearly apparent until the fourth week of treatment. Relative to imipramine and alprazolam, trazodone was not an effective treatment for panic disorder and was poorly tolerated; only 17 trazodone-treated patients completed at least 4 weeks of treatment, and only 2 patients were considered good or complete responders. These findings support the hypotheses that drugs that are efficacious in the treatment of panic disorders act by altering noradrenergic function and that drugs with primary actions on serotonin function are likely to be less effective treatments. The different time courses of therapeutic action of imipramine and alprazolam indicate that these drugs ameliorate panic anxiety via different mechanisms. The possible therapeutic applications of this observation are discussed.
Article
Eighteen patients with chronic specific phobias were allocated at random to exposure for two hours to the real phobic situation (flooding) under one of three conditions: (1) exposure starting four hours after oral diazepam 0.1 mg./kg. (\`waning' group); (2) exposure starting one hour after oral diazepam 0.1 mg./kg. (\`peak' group); (3) exposure starting four hours or one hour after oral placebo. Each patient had two treatment sessions in a balanced sequence, and each patient had either one or two of the three treatment conditions. Assessment was blind for the patient, therapist and independent rater. Exposure under all three conditions produced significant improvement. However, the \`waning' group was significantly superior to placebo, and the \`peak' group was in between. This trend of superiority was consistent for clinical, attitudinal and physiological ratings. The trend was already present significantly after the first treatment session, before crossover. The addition of diazepam did not increase treatment pleasantness. There was no evidence of drug dissociation at the moderate dosage employed. Serum levels of diazepam varied widely between patients, but were reliable within patients over two sessions. Serum levels bore no relation to psychotropic effect of diazepam.
Article
In a previous paper the authors reported survival data for 20 panic disorder patients whose therapeutic doses of alprazolam were tapered by one of two methods: slow, flexible drug taper with supportive medical management or the same taper procedure carried out concurrently with cognitive behavior therapy. This report is an analysis of predictors of drug discontinuation success in that study. In addition, between-group comparisons of clinical measures at follow-up are presented. The subjects in the previous study (10 in each group) were assessed blindly at baseline, 2 weeks after completion of drug taper, and at 3- and 6-month follow-up. Potential predictors of drug discontinuation success were tested by using logistic regression. Between-group differences in symptom severity at 3-month follow-up were examined by using analyses of covariance. Thirteen subjects (nine receiving alprazolam plus cognitive behavior therapy and four receiving alprazolam only) completed the drug taper on schedule and were still medication free at follow-up. A single variable--baseline-to-posttaper change in anxiety sensitivity--predicted drug status at follow-up in 85% of the cases. At follow-up, subjects in the combined-treatment group were significantly more improved on measures of anxiety, depression, catastrophic thinking related to anxiety, perception of emotional control, and disability than subjects in the drug-only group. Across groups, reduction in the fear of anxiety symptoms was the best predictor of patients' ability to achieve and maintain drug abstinence. Some implications of that finding for the pharmacotherapy of panic disorder are discussed.
Article
Experimental psychopathologists have increasingly relied upon the concepts and methods of cognitive psychology in their attempts to elucidate information-processing biases associated with anxiety disorders. Many of these biases presumably constitute instances of automatic, not strategic, processing. But research has shown that attributes of automaticity (i.e. capacity-free, unconsious, involuntary) do not all apply to selective processing of threat associated with anxiety. Experimental and clinical findings suggest that biases are automatic in the sense of being involuntary (and sometimes unconscious), but not in the sense of being capacity-free. Implications of involuntary automatic processing of threat for behavior therapy are discussed.
Article
In a study designed to evaluate the impact of benzodiazepine use on the outcome of behaviour therapy, 91, severe, chronic agoraphobics (46 BDZ users and 45 non-users) were randomly allocated on a double-blind basis to in vivo exposure with low-dose diazepam (ED) or placebo (EP). Drug doses were adjusted on the basis of weekly psychiatric assessments over weeks 1-4. Patients had 8 x 2 hr exposure sessions (weeks 5-12) and were then withdrawn from medication (weeks 13-16). Re-assessments were completed at weeks 4, 12 and 16, and follow-up assessments at approx 20, 46 and 72 weeks. In the analysis of the results, the clinical outcome was evaluated in relation to the therapeutic regime (ED vs EP) and prior BDZ use (users vs non-users). The results showed that the ED group had greater changes in anxiety than the EP group during the drug manipulation phases (anxiety increasing during BDZ withdrawal). There were no group differences in agoraphobic symptoms and no evidence that the outcome of the behavior therapy was significantly affected by concurrent BDZ treatment. There were significant improvements in agoraphobic symptoms over the treatment period, with no evidence for relapse of treatment gains on withdrawal from BDZ, nor for differential responses over the one year follow-up. Initial differences between users and non-users were less marked than expected, although there was a trend for more drop-outs among users across both ED and EP groups.
Article
In a meta-analysis, the authors compared the effectiveness of psychological and pharmacological treatments for panic disorder. Percentage of agoraphobic subjects in the sample and duration of the illness were unrelated to effect size (ES). Type of dependent variable was generally unrelated to treatment outcome, although behavioral measures yielded significantly smaller ESs. Dependent measures of general anxiety, avoidance, and panic attacks yielded larger ESs than did depression measures. Choice of control was related to ES, with comparisons with placebo controls greater than comparisons with exposure-only or "other treatment" controls. Psychological coping strategies involving relaxation training, cognitive restructuring, and exposure yielded the most consistent ESs; flooding and combination treatments (psychological and pharmacological) yielded the next most consistent ESs. Antidepressants were the most effective pharmacological intervention.
Article
After a brief description of cognitive-behavioral approaches for the treatment of panic disorder, the advantages and disadvantages of an integrated approach that combines cognitive-behavioral methods and medications are presented. This is followed by presentation of outcome data regarding combined treatment, and of methods for enhancing the implementation of an integrated approach. Finally, directions for future research are listed. Other psychological treatments are not covered due to lack of evidence for their efficacy.
Article
The last decade has brought exciting advances to the treatment of panic disorder and agoraphobia, and a variety of cognitive-behavioral and pharmacologic treatment strategies offer clear benefit to patients. Nonetheless, treatment nonresponse continues to be a chronic problem, and additional strategies are needed to aid patients who do not respond fully to initial interventions. In the present study, we use 'services' research to document the clinical response of pharmacotherapy nonresponders to a standard program of brief, group cognitive-behavioral therapy. Patients responded well, regardless of whether they had received a full, adequate trial of pharmacotherapy. In addition to its application as an initial treatment for panic disorder, routine application of cognitive-behavioral therapy in pharmacologic treatment algorithms is encouraged, with attention to referral of pharmacotherapy nonresponders to cognitive-behavioral therapy.
Benzodiazepine self-administration in humans and laboratory animalsÐimplications for problems of long-term use and abuse Exposure in vivo of agoraphobics: contributions of diazepam, group exposure, and anxiety evocation
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