Moderators of short- and long-term outcomes in panic control treatment and panic-focused psychodynamic psychotherapy.

OBJECTIVE: The objective was to test the hypothesis that externalizing and internalizing helpfulness beliefs and learning styles at baseline moderate panic severity and overall mental illness as short-term and long-term outcomes of two panic-focused psychotherapies, Panic Control Treatment (PCT) and Panic-Focused Psychodynamic Psychotherapy (PFPP). METHOD: Participants were 108 adults with DSM-IV Panic Disorder with or without Agoraphobia (PD/A) who were randomized to treatment in a trial of PCT and PFPP. Piece-wise/segmented multilevel modeling was used to test three-way interactions (Treatments × Moderator × Time), with participants and therapists as random factors. Outcome variables were clinician-rated panic severity and self-rated mental illness post-treatment and during follow-up. RESULTS: Patients' externalizing (but not internalizing) helpfulness beliefs moderated mental illness outcomes during follow-up (but not during treatment); low levels of Externalization were facilitative for PFPP but not PCT. Internalizing and externalizing helpfulness beliefs and learning style did not moderate clinician-rated panic severity, whether short- or long-term. CONCLUSIONS: These results suggest that helpfulness beliefs and learning style have limited use in assignment to either PCT or PFPP for PD/A. Although further research is needed, low levels of helpfulness beliefs about externalizing coping may play a role in mental illness outcomes for PFPP.

Effects of panic-specific cognitive behavioural and psychodynamic psychotherapies on work ability in a doubly randomised clinical trial.

Objective: The effects of panic-specific psychotherapy on occupational functioning remain under-researched. This study tests whether two brief psychotherapies for Panic Disorder with or without Agoraphobia (PD/A) may generate improvement in work ability. Methods: Adults (N = 221) with a primary diagnosis of PD/A were randomised to wait-list, panic-focused psychodynamic psychotherapy (PFPP), panic control treatment (PCT), or to the choice between the two treatments. Participants completed the Work Ability Inventory (WAI) at baseline, post-treatment, and during 24-month follow-ups. Change in WAI scores were assessed using segmented multilevel linear growth models, and mediation was explored through path analysis. Results: WAI scores changed from the moderate to good range between baseline and post-treatment (SMD = 0.45; 95% CI [0.33, 0.57]) and continued to increase throughout the follow-up (SMD = 0.16; 95% CI [0.03, 0.28]) with no differences between treatments or allocation forms. In PFPP (but not in PCT) pre- to post-treatment change in WAI was mediated by reduction in panic symptoms and WAI predicted employment status and absences. Conclusions: Two brief panic specific psychotherapies, one cognitive behavioural and one psychodynamic, produced short and long-term increases in work ability.

Preferences for panic control treatment and panic focused psychodynamic psychotherapy for panic disorder - who chooses which and why?

Objective: Few studies have examined factors associated with patient's choice of particular psychological treatments. The present study explores possible associations to, and the reasons given for, patient's choice of Panic Control Treatment (PCT) or Panic-Focused Psychodynamic Psychotherapy (PFPP) for Panic Disorder with or without Agoraphobia (PD/A).Method: Both quantitative and qualitative analyses were applied to data obtained from 109 adults with PD/A who were randomized to the Choice condition in the doubly randomized controlled preference trial from which this data are drawn.Results: The strongest associations were between treatment credibility ratings and the treatment choice (d = -1.00 and 1.31, p < .01, for PCT and PFPP respectively). Treatment choice was also moderately associated with patient characteristics, treatment helpfulness beliefs, and learning style. Qualitative analysis revealed that patients gave contrasting reasons for their treatment choice; either a focus on the present, symptom reduction and problem-solving for those who chose PCT or a focus on the past, symptom understanding and reflection for those who chose PFPP.Conclusions: When offered a choice between two evidence-based psychotherapies for PD/A, the resulting choice was primarily a function of the patient's beliefs about the chosen therapy, its potential for success, and their preferred learning style.

The Effect of Patient's Choice of Cognitive Behavioural or Psychodynamic Therapy on Outcomes for Panic Disorder: A Doubly Randomised Controlled Preference Trial.

INTRODUCTION: It remains unclear whether offering psychiatric patients their preferred treatment influences outcomes at the symptom level. OBJECTIVE: To assess whether offering patients with panic disorder with/without agoraphobia (PD/A) a choice between 2 psychotherapies yields superior outcomes to random assignment. METHODS: In a doubly randomised, controlled preference trial (DRCPT), 221 adults with PD/A were randomly assigned to: choosing panic-focused psychodynamic therapy (PFPP) or panic control treatment (PCT; a form of cognitive behavioural therapy); random assignment to PFPP or PCT; or waiting list control. Primary outcomes were PD/A severity, work status and work absences at post-treatment assessment. Outcomes at post-treatment assessment, 6-, 12-, and 24-month follow-ups were assessed using segmented multilevel linear growth models. RESULTS: At post-treatment assessment, the choice and random conditions were superior to the control for panic severity but not work status/absences. The choice and random conditions did not differ during treatment or follow-up for the primary outcomes. For panic severity, PCT was superior to PFPP during treatment (standardised mean difference, SMD, -0.64; 95% confidence interval, CI, -1.02 to -0.25); PFPP was superior to PCT during follow-up (SMD 0.62; 95% CI 0.27-0.98). There was no allocation by treatment type interaction (SMD -0.57; 95% CI -1.31 to 0.17). CONCLUSIONS: Previous studies have found that offering patients their preferred treatment yields small to moderate effects but have not employed designs that could rigorously test preference effects. In this first DRCPT of 2 evidence-based psychotherapies, allowing patients with PD/A to choose their preferred treatment was not associated with improved outcomes. Further DRCPTs are needed.

Psychometric analysis of the Swedish panic disorder severity scale and its self-report version.

BACKGROUND: Panic disorder, with or without agoraphobia (PDA or PD, respectively), is a major public health problem. After having established a PD diagnosis based on the DSM or the ICD systems, the Panic Disorder Severity Scale (PDSS) is the most widely used interview-based instrument for assessing disorder severity. There is also a self-report version of the instrument (PDSS-SR); both exist in a Swedish translation but their psychometric properties remain untested. METHODS: We studied 221 patients with PD/PDA recruited to a randomized controlled preference trial of cognitive-behavioral and brief panic-focused psychodynamic psychotherapy. In addition to PDSS and PDSS-SR the participants completed self-reports including the Clinical Outcome in Routine Evaluation - Outcome Measure, Montgomery Åsberg Depression Rating Scale, Sheehan Disability Scale, Bodily Sensations Questionnaire and the Mobility Inventory for Agoraphobia. RESULTS: PDSS and PDSS-SR possessed excellent psychometric properties (internal consistency, test-retest reliability) and convergent validity. A single factor structure for both versions was not confirmed. In terms of clinical utility, the PDSS had very high inter-rater reliability and correspondence with PD assessed via structured diagnostic interview. Both versions were sensitive to the effects of PD-focused treatment, although subjects scored systematically lower on the self-report version. CONCLUSIONS: The study confirmed the reliability and validity of the Swedish versions of PDSS and PDSS-SR. Both versions were highly sensitive to the effects of two PD-focused treatments and can be used both in clinical and research settings. However, further investigation of the factor structures of both the PDSS and PDSS-SR is warranted. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01606592.

The POSE study - panic control treatment versus panic-focused psychodynamic psychotherapy under randomized and self-selection conditions: study protocol for a randomized controlled trial.

BACKGROUND: Panic disorder with or without agoraphobia is a commonly occurring disorder affecting 2 to 3% of the population in Sweden. Untreated, panic disorder is a chronic condition that significantly increases the risk for psychiatric comorbidity, morbidity and mortality, employment difficulties, and healthcare utilization. Cognitive behavioral approaches are the recommended first-line treatment for panic disorder; however, many patients in routine care receive another evidence-based psychotherapy, including psychodynamic therapy. Allowing patients to choose among evidence-based approaches to panic disorder may improve outcomes and reduce overall health costs. Trials comparing the 'gold standard' treatment for panic disorder to other evidence-based psychotherapies are needed, and also trials that can separate patient preferences for treatment from randomization effects on outcome, disability and healthcare utilization in the longer term. METHODS/DESIGN: A phase 2/3 doubly-randomized controlled trial carried out in routine care with 216 adults (aged 18 to 70 years) with a primary diagnosis of DSM-IV Panic Disorder (with or without Agoraphobia). Within each clinic, patients are randomized to self-selection, random assignment of treatment, or wait-list. Patients choose or are randomly assigned to either Panic Control Treatment or Panic-Focused Psychodynamic Psychotherapy. Primary outcomes are changes in panic symptom severity, occupational status, and sickness-related absences from work at post-treatment and 6, 12 and 24 months post-treatment. Secondary outcomes include changes in agoraphobic avoidance, psychiatric comorbidity, disability, and healthcare utilization. The study also employs elements of an effectiveness trial as therapist and service-related effects on outcome will be estimated. Putative change mechanisms for the two treatments are also assessed. DISCUSSION: Cognitive behavioral and psychodynamic therapies are both evidence-based approaches that are routinely offered to panic disordered patients in Sweden. However, little is known about the relative effectiveness of these two approaches for panic/agoraphobia, work-related disability and healthcare utilization over the longer term. The current trial (POSE) also addresses the important but understudied issue of whether patient preference for a particular psychotherapeutic approach moderates outcome. TRIAL REGISTRATION: ClinicalTrials.gov NCT01606592 (registered 19 March 2012).

Experiential avoidance as an emotion regulatory function: an empirical analysis of experiential avoidance in relation to behavioral avoidance, cognitive reappraisal, and response suppression.

The purpose of the present study was to empirically test the suggestion that experiential avoidance in an emotion regulation context is best understood as an emotion regulatory function of topographically distinct strategies. To do this we examined whether a measure of experiential avoidance could statistically account for the effects of emotion regulation strategies intervening at different points of the emotion-generative process as conceptualized by Gross' (1998) process model of emotion regulation. The strategies under examination were behavioral avoidance, cognitive reappraisal, and response suppression. The specific hypotheses to be tested were (1) that behavioral avoidance, cognitive reappraisal, and response suppression would statistically mediate the differences in measures of psychological well-being between a clinical and nonclinical sample, but that (2) these indirect effects would be reduced to nonsignificant levels when controlling for differences in experiential avoidance. The results provide clear support for the first hypothesis with regard to all the studied strategies. In contrast to the second hypothesis, the results showed the predicted outcome pattern only for the response-focused strategy "response suppression" and not for cognitive reappraisal or behavioral avoidance. The results are interpreted and discussed in relation to theories on experiential avoidance and emotion regulation.

Effects of analytical and experiential self-focus on rumination after a stress induction in patients with social anxiety disorder: a pilot study.

According to cognitive models, negative post-event processing rumination is a key maintaining factor in social anxiety disorder (SAD). Analogue research has supported the differentiation of self-focus into different modes of self-focused attention with distinct effects on rumination in depression and social anxiety. The purpose of this study was to replicate these effects with a sample of clients with SAD (N = 12) using (a) an experimental, cross-over design and (b) an evaluation situation (impromptu speech) prior to manipulation. Processing an identical list of symptoms, half of a sample was asked to successively adopt an analytic (abstract, evaluative) and an experiential (concrete, process-focused) self-focus; the other half employed the modes in the reversed order. Effects were assessed with a thought-listing (TL) procedure. As predicted, the two modes of self-focused attention affected cognitions differently; participants in the experiential condition showed a tendency for a decreased proportion of negative thoughts, whereas those in the analytical condition reported a decreased proportion of neutral thoughts. No difference was shown on positive cognitions. Furthermore, the participants' self-evaluation following the speech predicted their degree of subsequent negative thinking. After self-focus inductions, however, this effect was only seen in those participants who started by receiving the analytical self-focus induction. The results support previous findings that the analytical and the experiential self-focus modes affect cognitions differently, and that experiential processing may have beneficial effects on rumination in SAD. However, results need to be replicated in a larger sample.

Imagery rescripting of early memories in social anxiety disorder: an experimental study.

INTRODUCTION: Evidence suggests that negative self imagery plays an important role in social anxiety disorder (SAD) as a maintaining factor, and that early memories of traumatic experiences are linked to recurrent catastrophic images. Previous research has showed that cognitive restructuring combined with imagery rescripting of these memories may affect recurrent images resulting in less imagery distress and less anxiety in social situations. The present study replicated these effects using (a) a modified treatment with imagery rescripting without cognitive restructuring, and (b) an experimental between-groups design. METHOD: Patients with SAD (N = 14) were randomised either to imagery rescripting of early memories, or to a reading task. RESULTS: Follow-up after 1 week showed that the intervention led to significant improvements in memory and image distress, and reduced fears of negative evaluation and social interaction. DISCUSSION: The results indicate that imagery rescripting is effective even without cognitive restructuring and question the importance of the latter. However, the small sample limits the strength of the conclusions. CONCLUSION: Imagery rescripting of early distressful memories may be a powerful intervention in the treatment of SAD.

Cognitive reappraisal and acceptance: an experimental comparison of two emotion regulation strategies.

The purpose of the present study was to compare the effect of cognitive reappraisal and acceptance on subjective distress, physiological reactions and behavioral avoidance in relation to aversive emotional states elicited by film-clips. Ninety-four participants were randomized to one of three groups. The Reappraisal group was instructed to think about what they saw in a way that minimized negative emotional reactions, the Acceptance group was told to let their feelings come and go without trying to control or avoid them, while the Watch (control) group was told just to watch the film-clips. Compared to the control condition, both reappraisal and acceptance led to significant reductions of subjective distress, physiological reactions associated with aversive emotions and behavioral avoidance. On the three types of measures there were few significant differences between the Reappraisal and Acceptance groups, but when such differences existed they were to the benefit of the Reappraisal condition. In the reappraisal condition there was however a positive correlation between elicited aversive emotion and avoidance, while no such correlation existed in the acceptance condition. The results are interpreted and discussed in relation to the theories underlying reappraisal and acceptance as well as the conceptual framework for emotion regulation established by Gross (2007).