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Prognostic indices with brief and standard CBT for panic disorder: I. Predictors of outcome

Published online by Cambridge University Press:  10 May 2007

MICHAEL G. T. DOW ,
JUSTIN A. KENARDY ,
DEREK W. JOHNSTON ,
MICHELLE G. NEWMAN ,
C. BARR TAYLOR  and
AILEEN THOMSON
MICHAEL G. T. DOW*
Affiliation:
NHS Fife, Department of Clinical Psychology, Stratheden Hospital, Cupar, Fife, UK
JUSTIN A. KENARDY
Affiliation:
Centre for National Research on Disability and Rehabilitation Medicine, and School of Psychology, University of Queensland, Brisbane, Queensland, Australia
DEREK W. JOHNSTON
Affiliation:
Department of Psychology, Kings College, University of Aberdeen, UK
MICHELLE G. NEWMAN
Affiliation:
Department of Psychology, Pennsylvania State University, PA, USA
C. BARR TAYLOR
Affiliation:
Department of Psychiatry and Behavioral Science, Stanford University School of Medicine, Stanford, CA, USA
AILEEN THOMSON
Affiliation:
Health Psychology Department, Gloucestershire Royal Hospital, Gloucester, UK
*
*Address for correspondence: Dr Michael G. T. Dow, Department of Psychology, University of Stirling, Stirling FK9 4LA, UK. (Email: [email protected])
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Abstract

Background

Although the effectiveness of cognitive behavioural therapy (CBT) in the management of panic disorder (PD) is now well established, there have been few studies of predictors of outcome with this patient group using clinical effectiveness trial data, a hypothesis-testing model, and a dependent measure of clinically significant change.

Method

The data for this study came from a randomized controlled trial of three forms of CBT delivery for PD with and without agoraphobia (two 6-week CBT programmes, one of which was computer assisted, and one therapist-directed 12-week CBT programme), comprising a total of 186 patients across two sites. Based on previous related research, five hypothesized predictors of post-treatment and follow-up outcome were identified and examined, using a series of bivariate and multivariate analyses.

Results

The results in general supported the hypotheses. Strength of blood/injury fears, age of initial onset of panic symptoms, co-morbid social anxieties and degree of agoraphobic avoidance were predictive of both measures of post-treatment outcome. Degree of residual social difficulties and the continued use of anxiolytics at post-treatment were also shown to predict poor outcome at the 6-month follow-up. However, strength of continuing dysfunctional agoraphobic cognitions by the end of active treatment did not predict outcome at follow-up for the sample as a whole.

Conclusions

The identification of consistent predictors of outcome with CBT has many clinical and research benefits. As CBT, however, is being delivered increasingly in a variety of brief formats, further research is required to identify moderators of response to these ‘non-standard’ treatment formats.

Type
Original Article
Information
Psychological Medicine , Volume 37 , Issue 10 , October 2007 , pp. 1493 - 1502
Copyright
Copyright © Cambridge University Press 2007

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References

REFERENCES

APA (1994). Diagnostic and Statistical Manual of Mental Disorders (4th edn). American Psychiatric Association: Washington, DC.Google Scholar
Barlow, D. H. & Craske, M. G. (2000). Mastery of your Anxiety and Panic: Client Workbook for Anxiety and Panic (MAP-3). Graywind Psychological Corporation: San Antonio, TX.Google Scholar
Basoglu, M., Marks, I. M., Kilic, C., Brewin, C. R. & Swinson, R. P. (1994). Alprazolam and exposure for panic disorder with agoraphobia: attribution of improvement to medication predicts subsequent relapse. British Journal of Psychiatry 164, 652–659.CrossRefGoogle ScholarPubMed
Beck, A. T., Steer, R. A. & Garbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clinical Psychology Review 8, 77–100.CrossRefGoogle Scholar
Brown, T. A. & Barlow, D. H. (1995). Long-term outcome in cognitive-behavioral treatment of panic disorder: clinical predictors and alternative strategies for assessment. Journal of Consulting and Clinical Psychology 63, 754–765.Google Scholar
Chambless, D. L., Caputo, G. C., Bright, P. & Gallagher, R. (1984). Assessment of fear in agoraphobics: the Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire. Journal of Consulting and Clinical Psychology 52, 1090–1097.CrossRefGoogle ScholarPubMed
Chambless, D. L., Caputo, C. G., Jasin, S. E., Gracely, E. J. & Williams, C. (1985). The Mobility Inventory for Agoraphobia. Behaviour Research and Therapy 23, 35–44.Google Scholar
Clark, D. M. (1986). A cognitive approach to panic. Behaviour and Research Therapy 24, 461–470.CrossRefGoogle ScholarPubMed
Clark, D. M., Salkovskis, P. M., Hackmann, A., Middleton, H., Anastasiades, P. & Gelder, M. (1994). A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. British Journal of Psychiatry 164, 759–769.Google Scholar
Clark, D. M., Salkovskis, P. M., Hackmann, A., Wells, A., Ludgate, J. & Gelder, M. (1999). Brief cognitive therapy for panic disorder: a randomised controlled trial. Journal of Consulting and Clinical Psychology 67, 583–589.CrossRefGoogle Scholar
Clark, D. M., Salkovskis, P. M., Öst, L.-G., Breitholtz, E., Koehler, K. A., Westling, B. E., Jeavons, A. & Gelder, M. (1997). Misinterpretation of body sensations in panic disorder. Journal of Consulting and Clinical Psychology 65, 203–213.CrossRefGoogle ScholarPubMed
Conners, C. K., Epstein, J. N., March, J. S., Angold, A., Wells, K. C., Klaric, J., Swanson, J. M., Abikoff, H. B., Arnold, L. E., Elliott, G. R., Greenhill, L. L., Hechtman, L., Hinshaw, S. P., Hoza, B., Jensen, P. S., Kraemer, H. C., Newcorn, J., Pelham, W. E., Severe, J. B., Vitiello, B. & Wigal, T. (2001). Multimodal treatment of ADHD in the MTA: an alternative outcome analysis. Journal of the American Academy of Child and Adolescent Psychiatry 40, 159–167.CrossRefGoogle ScholarPubMed
Craske, M. G., Brown, T. A. & Barlow, D. H. (1991). Behavioral treatment of panic disorder: a two year follow-up study. Behavior Therapy 22, 289–304.CrossRefGoogle Scholar
Dewey, D. & Hunsley, J. (1990). The effects of marital adjustment and spouse involvement on the behavioral treatment of agoraphobia: a meta-analytic review. Anxiety Research 2, 69–83.Google Scholar
Durham, R. C., Allan, T. & Hackett, C. A. (1997). On predicting improvement and relapse in generalised anxiety disorder following psychotherapy. British Journal of Clinical Psychology 36, 101–119.Google Scholar
Emmelkamp, P. M. G. & Gerlsma, C. (1994). Marital functioning and the anxiety disorders. Behavior Therapy 25, 407–429.CrossRefGoogle Scholar
Emmelkamp, P. M. G., van Dyck, R., Bitter, M., Heins, R., Onstein, E. J. & Eisen, B. (1992). Spouse-aided therapy with agoraphobics. British Journal of Psychiatry 160, 151–156.Google Scholar
Fava, G. A. (1999). Subclinical symptoms in mood disorders: pathophysiological and therapeutic implications. Psychological Medicine 29, 47–61.CrossRefGoogle ScholarPubMed
Fava, G. A., Rafanelli, C., Grandi, S., Conti, S., Ruini, C., Mangelli, L. & Bellvardo, P. (2001). Long-term outcome of panic disorder with agoraphobia treated by exposure. Psychological Medicine 31, 891–898.Google Scholar
Fischer, M., Hand, I., Angenendt, J., Büttner-Westphal, H. & Manecke, C. (1988). Failures in exposure treatment of agoraphobia: evaluation and prediction. In Panic and Phobias II: Treatment and Variables Affecting Course and Outcome (ed. Hand, I. and Wittchen, H. U.), pp. 195–208. Springer: New York.Google Scholar
Foa, E. B., Franklin, M. E. & Moser, J. (2002). Context in the clinic: how well do cognitive-behavioral therapies and medications work in combination? Biological Psychiatry 52, 987–997.CrossRefGoogle ScholarPubMed
Foa, E. B. & Kozak, M. J. (1986). Emotional processing of fear: exposure to corrective information. Psychological Bulletin 99, 20–35.CrossRefGoogle ScholarPubMed
Green, S. B. (1991). How many subjects does it take to do a regression analysis? Multivariate Behavioral Research 26, 499–510.CrossRefGoogle Scholar
Hackmann, A. (2004). Panic disorder and agoraphobia. In Oxford Guide to Behavioural Experiments in Cognitive Therapy (ed. Bennett-Levy, J., Butler, G., Fennell, M., Hackmann, A., Mueller, M. and Westbrook, D.), pp. 59–78. Oxford University Press: Oxford.Google Scholar
Hafner, R. J. & Ross, M. W. (1983). Predicting the outcome of behaviour therapy for agoraphobia. Behaviour Research and Therapy 21, 375–382.Google Scholar
Katschnig, H. & Amering, M. (1998). The long-term course of panic disorder and its predictors. Journal of Clinical Psychopharmacology 18, 6S–11S.CrossRefGoogle ScholarPubMed
Keijsers, G. P. J., Hoogduin, C. A. L. & Schaap, C. P. D. R. (1994). Prognostic factors in the behavioural treatment of panic disorder with and without agoraphobia. Behavior Therapy 25, 689–708.Google Scholar
Kenardy, J., Dow, M. G. T., Johnston, D. W., Newman, M. G., Thomson, A. & Taylor, C. B. (2003 a). A comparison of delivery methods of cognitive-behavioral therapy for panic disorders: an international multicenter trial. Journal of Consulting and Clinical Psychology 71, 1068–1075.Google Scholar
Kenardy, J., McCafferty, K. & Rosa, V. (2003 b). Internet-delivered indicated prevention for anxiety disorders: a randomised controlled trial. Behavioural and Cognitive Psychotherapy 31, 279–289.CrossRefGoogle Scholar
Lecrubier, Y. (1998). The impact of comorbidity on the treatment of panic disorder. Journal of Clinical Psychiatry 59 (Suppl. 8), 11–14.Google Scholar
Liebowitz, M. R. (1997). Panic disorder as a chronic illness. Journal of Clinical Psychiatry 58, 5–8.Google ScholarPubMed
Marks, I. M. & Mathews, A. M. (1979). Brief standard self-rating for phobic patients. Behaviour Research and Therapy 17, 263–267.Google Scholar
Marks, I. M., Swinson, R. P., Basoglu, M., Kuch, K., Noshirvani, H., O'Sullivan, G., Lelliott, P., Kirby, M., McNamee, G., Sengun, S. & Wickwire, K. (1993). Alprazolam and exposure alone and combined in panic disorder with agoraphobia. British Journal of Psychiatry 162, 776–787.Google Scholar
Mavissakalian, M. & Michelson, L. (1986). Agoraphobia: relative and combined effectiveness of therapist-assisted in vivo exposure and imipramine. Journal of Clinical Psychiatry 47, 117–122.Google ScholarPubMed
McCusker, J., Boiulenger, J.-P., Bellavance, F., Boyer, R. & Miller, J.-M. (2000). Outcomes in a referral cohort of patients with anxiety disorders. Journal of Nervous and Mental Disease 188, 3–12.Google Scholar
Newman, M. G. (2000). Recommendations for a cost-offset model of psychotherapy allocation using generalised anxiety disorder as an example. Journal of Consulting and Clinical Psychology 68, 549–555.Google Scholar
Norton, G. R., Pidlubny, S. R. & Norton, P. J. (1999). Prediction of panic attacks and related variables. Behavior Therapy 30, 319–330.Google Scholar
Oei, T. P. S., Llamams, M. & Evans, L. (1997). Does concurrent drug intake affect the long-term outcome of group cognitive behaviour therapy in panic disorder with or without agoraphobia? Behaviour Research and Therapy 35, 851–857.Google Scholar
O'Rourke, D., Fahy, T. J., Brophy, J. & Prescott, P. (1996). The Galway study of panic disorder. III. Outcome at 5 to 6 years. British Journal of Psychiatry 168, 462–469.CrossRefGoogle ScholarPubMed
O'Sullivan, G. & Marks, I. M. (1990). Long-term outcome of phobic and obsessive-compulsive disorders after treatment. In Handbook of Anxiety, Vol. 4 (ed. Noyes, R., Roth, M. and Burrows, G. D.), pp. 87–108. Elsevier: Amsterdam.Google Scholar
Otto, R. W. & Gould, R. A. (1996). Maximizing treatment outcome for panic disorder: cognitive-behavioral strategies. In Challenges in Clinical Practice: Pharmacologic and Psychosocial Strategies (ed. Pollack, M. H., Otto, M. W. and Rosenbaum, J. F.), pp. 113–140. Guilford Press: New York.Google Scholar
Otto, M. W., Pollack, M. H. & Sabatino, S. A. (1996). Maintenance of remission following cognitive behavior therapy for panic disorder: possible deleterious effects of concurrent medication treatment. Behavior Therapy 27, 473–482.Google Scholar
Ramnerö, J. & Öst, L.-G. (2004). Prediction of outcome in the behavioural treatment of panic disorder with agoraphobia. Cognitive Behaviour Therapy 33, 176–180.Google Scholar
Reed, V. & Wittchen, H.-U. (1998). DSM-IV panic attacks and panic disorder in a community sample of adolescents and young adults: how specific are panic attacks? Journal of Psychiatric Research 32, 335–345.CrossRefGoogle Scholar
Ronalds, C., Creed, F., Stone, K., Webb, S. & Tomenson, B. (1997). Outcome of anxiety and depressive disorders in primary care. British Journal of Psychiatry 171, 427–433.Google Scholar
Salkovskis, P. M. (1988). Phenomenology, assessment and the cognitive model. In Panic: Psychological Perspectives (ed. Rachman, S. and Maser, J.), pp. 111–136. Lawrence Erlbaum: New Jersey.Google Scholar
Scheibe, G. & Albus, M. (1997). Predictors and outcome in panic disorders: a 2-year prospective follow-up study. Psychopathology 30, 177–184.Google Scholar
Schmidt, N. B., Lerew, D. R. & Jackson, R. J. (1997). The role of anxiety sensitivity in the pathogenesis of panic: prospective evaluation of spontaneous panic attacks during acute stress. Journal of Abnormal Psychology 106, 355–364.CrossRefGoogle ScholarPubMed
Sharp, D. M. & Power, K. G. (1999). Predicting treatment outcome for panic disorder and agoraphobia in primary care. Clinical Psychology and Psychotherapy 6, 336–348.Google Scholar
Sheehan, D. V. (1986). The Anxiety Disease. Bantam Books: New York.Google Scholar
Shinoda, N., Kodama, K., Sakamoto, T., Yamanouchi, N., Takahashi, T., Okada, S., Noda, S., Komatsu, N. & Sato, T. (1999). Predictors of 1-year outcome for patients with panic disorder. Comprehensive Psychiatry 40, 39–43.CrossRefGoogle ScholarPubMed
Spielberger, C. D., Gorsuch, R. & Lushene, R. E. (1970). The State-Trait Anxiety Inventory (Self-Evaluation Questionnaire). Consulting Psychologists Press: Palo Alto, CA.Google Scholar
Steketee, G. & Chambless, D. L. (1992). Methodological issues in prediction of treatment outcome. Clinical Psychology Review 12, 387–400.Google Scholar
Steketee, G. & Shapiro, L. J. (1995). Predicting behavioral treatment outcome for agoraphobia and obsessive compulsive disorder. Clinical Psychology Review 15, 317–346.Google Scholar
Van Balkom, A. J. L. M., de Beurs, E., Koele, P., Lange, A. & Van Dyck, R. (1996). Long-term benzodiazepine use is associated with smaller treatment gain in panic disorder with agoraphobia. Journal of Nervous and Mental Disease 184, 133–135.Google Scholar
Ware, J. E. & Sherbourne, C. D. (1992). The MOS 36-item Short Form Health Survey (SF-36): conceptual framework and item selection. Medical Care 30, 473–483.Google Scholar
Wells, A. C., Clark, D. M., Salkovskis, P., Ludgate, J., Hackmann, A. & Gelder, M. G. (1995). Social phobia: the role of in-situation safety behaviors in maintaining anxiety and negative beliefs. Behavior Therapy 26, 153–161.Google Scholar