Evaluation of psychotherapeutic interventions.

Procedures across treatments must be equal for key variables:

-Dosage of treatment--> Length, intensity, and frequency of contact with clients

-Access to additional treatments (e.g. medication)

-Setting (individual vs. group)

-aus rationaler sicht mögliche wirksamkeit der intervention

-Degree of involvement of persons close to client (partner, friends)

-surges of intense fear or intense discomfort that reach a peak within minutes with following symptoms:

-accelerated heart rate

-sweating

-shaking

-shortness of breath

-chest pain or discomfort

-fear of loosing control

-fear of dying

-recurrent unexpected panic attacks

-At least one of the attacks has been followed by 1 month (or more) of...

a) persistent concerns or worries about having more panic attacks

b) behavior changes in maladaptive ways because of the panic attacks (e.g., avoidance of exercise or of unfamiliar locations)

-12 month prevalence: 2-3%, women vs men: 2:1 (DSM-5)

-Only a minority of individuals have full remision

-2/3 occur with agoraphobia

-High comorbidity with other disorders

-Cognitive restructuring via acquiring skiilz for re-evaluating beliefs(nalysis of faulty logic, reattribution, decatastrophizing, self instruction)

-from 6th session: cognitive skills were applied to anxiety provoking situations and sensations, in the form of an
individualized 10 item hierarchy

-Interoceptive exposure (from 6th session):
• Cognitive skills were applied to anxiety provocing situations through visualization of anxiety scenes and overbreathing.

-Learning R in first sessions and exercising 2x per day

-Relaxation skill was applied to everyday anxiety and panic provoking situations, arranged in a graduated manner
on the basis of an individualized 10 item hierarchy

-From 6th session: Patients should approach a situation three times a week with the use of muscle relaxation as a
coping skill

At the begin emphasis on relaxation, with progressively more attention to cognitive- and exposure procedures

-Patients continued daily monitoring for 15 weeks, after which time they would receive treatment

-Therapists phone-contacted clients every 2 to 3 weeks to provide feedback regarding their weekly records.

-Clients were informed that help would be available in the event of a crisis

inclusion: Patients who already got other treatments not related to anxiety; Stable medication

exclusion: Alcohol- or substance abuse; Major depression, psychosis, organic brain syndrome; Other therapies of anxiety;

Begin of Psychopharmacological treatment
• less than 3 Mon. Benzodiazepines--> schlaf/beruhigungsmittel; gabarezeptoren-->inhibitorisch
• less than 6 Mon. MAO-Hemmer, tricyclic antidepressants--> Monoaminoxidasen verringert; haben aufgabe neurotransmitter im hirn aufzuspalten

-Hamilton Anxiety and Depression Scales

-Clinical rating of severity (0 to 8)

-State-Trait Anxiety Inventory (Spielberger, Gorusch, & Lushene, 1970)

-Cognitive Somatic Anxiety Questionnaire, (Marks & Mathews, 1979)

-Fear Questionnaire (Marks & Mathews, 1979)

-Beck Depression Inventory (Beck et al., 1961)

-Psychosomatic Rating Scale (Cox, Freundlich & Meyer, 1975)

-Subjective Symptom Scale (Modification, Hafner & Marks, 1978)

zudem gabs in der studie noch self-observation--> Anxiety Rating from 0 to 8; Panic yes/no; stressful events?

Pre – Post – Follow up: 3, 6, 12, 24 months

drop outs:
* R < WL
* E&C < WL

Comparison of drop-outs vs. completers (ANOVAS)
Drop-outs had sig. lower severity at pre treatment
and sig. higher consumption of anxiolytics

mindert meist die effektstärke der experimentaldesigns, da auch hier spontanremissionen auftreten und die dann rausgerechnet werdne können

regression to the mean als anderer punkt

-reduction in clinical rating of the severity of the panic disorder--> alle gruppen haben signi profitiert außer der wait list group; waren also auf signi besser als WL

-hamilton axiety score--> genau gleich wie die severity

-psychosomatic symptoms-->Exposi+CBT haben nix gebracht, nur die PMR hat signi besserung im vergleich zur wait list gebracht

-keine signi unterschiede in anderen erhebungen

-Treatment responder 20% Improvement in three of four measures (post- compared to pre-measure)--> also nicht panic free sondern nur signi verbesserung

-bei PMR über 80% der VPN responder; exposi+cbt sowie kombie von allem um die 60% trotzdem alle signi besser als WL

HES = criteria completed in three of five measures:--> wichtig: erhebung direkt nach der letzten session, kein follow up
− Clinical rating of severity score ≤ 2,
− Patients self rating of severity score ≤ 2
− Mean anxiety rating ≤ 2
− no panic attack
− Subjective Symptom Total score ≤ 10

--> in jeder gruppe um die 50% der teilnehmnden und damit signi besser als WL

gab durchgängig in allen gruppen dropouts

Decrease of trait-anxiety and somatic symptoms
(Post vs. 24 months)

BDI-Scores
• Increase in R-group
• Decrease in E & C-group

bedeutet, dass die symptomatik signifikant abgenommen hat

grundlegend ergebnisse gebiased weil dropouts nicht gewertet wurden

high-end-state: kein signi Unterschied

panic free: signi höher bei exposi+cbt als bei PMR + kombitherapie

Post Assessment: (R, E&C, E&C&R) > Wait list--> in relaxation group, less patients were panic free, However anxiety and psychosomatic symptoms were reduced

Maintenance of therapy success for patients with interoceptive
exposure and cognitive restructuring

Patients in relaxation group less stable patterns--> Highest drop out rate, Highest rate of additional treatment

Cognitive behavioral therapy with relaxation (E&C&R) was not
more efficacious than E&C

-Panic disorder without agoraphobic avoidance can be efficaciously treated with a combination of interoceptive exposure(das ist quasi ne in sensu exposi) + cognitive restructuring

-Directly after treatment, relaxation is as efficacious as interoceptive exposure + cognitive restructuring, but in the long run it is less efficacious

-Compared to results in the literature, long term effects of interoceptive exposure and cognitive restructuring seem to be
better than for pharmacological treatment

-small sample size welche die power negativ beeinflusst

-conditions in der follow up(24months): wurde ned kontrolliert ob zwisschendrin medis oder ne psychotherapie gemacht/genommen wurde--> diese daten sind least robust

-wenn man generell schon angstlösende medis gibt, dann ist die wirkung der exposi vermindert da ne habituation ufgrund des mediinduzierten niedrigen arousals ned stattfinden kann

-initially developed as a tranquilizer for patients with schizophrenia, antidepressant effects were discovered serendipitously

-increases the extracellular level of neurotransmitters (serotonin, norepinephrine) by limiting their reabsorption (reuptake) into the presynaptic cells

-broad range of effects: Improves mood, reduces symptoms of agitation and anxiety

-side effects: e.g. dry mouth, drowsiness, dizziness, blurred vision, low blood pressure,

-Relative and combined efficacies of drug and PT treatment for PD have not been evaluated

ziel herauszufinden, ob...

-drug and PT for PD are each more efficacious than placebo

-one treatment is more efficacious than the other

-combined therapy is more efficacious than either therapy alone?

expectancy effects

- CBT: individual 50-minute sessions --> Interoceptive exposure, cognitive restructuring, and breathing training

-Psychopharmacotherapy (Imipramine or Placebo) + Clinical Management: jede session gabs nen 30minuten kontakt wo die vitalwerte überprüft wurden und fragen gestellt wurden, ob alles passt

-Combined Treatment (Imipramine or Placebo + CBT) -->individual contacts with 2 therapists for about 75 minutes per week.

zudem bei allen kontrolle, ob benzos eingenommen wurden

--> die maintenance phase hat insgesamt 6 monate gedauert bevor man sie beendet hat

-at baseline--> also direkt am ende der maintenance phase
▪ after acute phase (3 months after baseline)
▪ after 6 months maintenance phase (9 months after baseline)
▪ after 6 months follow-up phase (15 months after baseline)

patienten wurden gejudged auf basis von...

-Panic Disorder Severity Scale (PDSS)--> Response was defined > 40% reduction of PD symptoms

-Clinical Global Impression Scale (CGI)--> 7-point ratings on 2 items: overall improvement and severity

-Definition responder: CGI much improved (≤ 2) and mild or less (≤ 3) on CGI severity

-Patients who received non-study treatment for anxiety wurden automatisch zu nonresponders + nonimproved erklärt

Potential participants met DSM-III-R or DSM-IV criteria for PD with no
more than mild agoraphobia (ADIS-R avoidance scale ≤ 18)
▪ Panic attack(s) in the 2 weeks before treatment
▪ Patients with comorbid unipolar depression were not excluded
▪ Patients were permitted to take benzodiazepines (limited doses) until
end of acute phase

psychotic, bipolar, or significant medical illnesses,
▪ suicidality, significant substance abuse,
▪ contraindications to either treatment,
▪ prior nonresponse to similar treatments,
▪ concurrent competing treatment or pending disability claims

alle gruppen ähnlich(80-60vpn) nur die placebo only gruppe hatte dtl. weniger(24vpn); ethin. aspekt dabei im fokus