PHOBIAS VOLUME - PART 6 doc

submitted The long-term drug treatment and follow-up of over 250 patients with social anxiety disorder social phobia over 10 years.. Whether venlafaxine will prove to be more effective t

treatment studies with drugs support the need for chronic treatment formore than a year for relapse prevention [6,8].

REFERENCES

1 Versiani M (submitted) The long-term drug treatment and follow-up of over

250 patients with social anxiety disorder (social phobia) over 10 years

2 Versiani M (2000) A review of 19 double-blind placebo-controlled studies insocial anxiety disorder (social phobia) World J Biol Psychiatry, 1: 27–33

3 Liebowitz M.R (1999) Update on the diagnosis and treatment of social anxietydisorder J Clin Psychiatry, 60 (Suppl 18): 22–26

4 Versiani M., Amrein R., Montgomery S.A (1997) Social phobia: long-termtreatment outcome and prediction of response—a moclobemide study Int Clin.Psychopharmacol., 12: 239–254

5 Stein D.J., Versiani M., Hair T., Kumar R (2002) Efficacy of paroxetine forrelapse prevention in social anxiety disorder: a 24-week study Arch Gen.Psychiatry, 59: 1111–1118

6 Keller M.B (2002) Raising the expectations of long-term treatment strategies inanxiety disorders Psychopharmacol Bull., 36 (Suppl 2): 166–174

7 Katerndahl D.A (2000) Predictors of the development of phobic avoidance

random-3.13Behavioural Toxicity of Pharmacotherapeutic Agents

Used in Social PhobiaIan Hindmarch and Leanne Trick1Stein et al have identified a wide range of different medications which havebeen found to be useful therapeutic agents for the management of socialphobia All psychoactive drugs, by definition, change behaviour Whileappropriate behavioural changes (a reduction in social anxiety andreduction in avoidance behaviours) would be regarded as positive evidence

of clinical efficacy, impairment of cognitive and psychomotor functions,which reduce the patient’s overall quality of life, would be seen as

1 Human Psychopharmacology Research Unit, Medical Research Centre, University of Surrey, Egerton Road, Guildford, Surrey GU2 7XP, UK

unwanted side effects Behavioural toxicity refers not only to the extent towhich these side effects raise the likelihood of a patient having an accident

or cognitive failure while receiving pharmacotherapy, but also to themagnitude of countertherapeutic effects (e.g somnolence, sleep disturb-ance, memory loss, loss of balance etc.) produced by a particularmedication

As behavioural toxicity is an intrinsic property of the peutic agent, it is assessed in those subjects who are not impaired orsuffering from a clinical condition or disorder that, in itself, could changeperformance on the relevant psychometric

pharmacothera-Behavioural toxicity measures are derived from psychometric ments of the effects of drugs on psychomotor and cognitive function Theseinclude tests of memory, sensory speed, mental arithmetic, informationprocessing capacity, mental speed, vigilance, divided attention, reactiontime, balance, motor control, motor coordination, manual dexterity, cardriving ability etc

assess-In isolation, a singular assessment of the pharmacodynamics of aparticular compound reveals little in absolute terms about the behaviouraltoxicity of that drug However, if a database is constructed from the totality

of information available from reports in peer-reviewed journals, then areliance can be made on the results of such a ‘‘meta-analysis’’

The present summary reviews the data contained in 90 studies from reviewed literature featuring the drugs found by Stein et al to have aproven utility in the management of social phobia To be included in theanalysis, the results had to be from cross-over studies with placebo controlsand where the sensitivity of the psychometrics employed was confirmed bythe results from an internal positive control (verum)

peer-No acceptable data were found for phenelzine, tranylcypromine,selequine and escitalopram These drugs are, therefore, removed fromfurther consideration

Data presented in Table 3.13.1 refer to the number of objectivepsychometrics used in the various studies to assess a particular drug Weinclude the number of instances in which a statistically significantimpairment of cognitive and/or psychomotor function is reported, aswell as the total number of tests performed on that particular compound.The number of instances where the results showed no significantimpairment from placebo can be deduced from the difference of the twovalues

In order to compare a discrete clinical entity with the totality of drugs inthe database, i.e the extent to which a particular drug produces behaviouraltoxicity (impairment of the various psychometrics) when compared to allother drugs in the database, a proportional impairment ratio (PIR) iscalculated for each substance

The calculation of the PIR is adapted from that used in vigilance [1] and has been previously used successfully in rating thesedative potential of antihistamines [2] The greater the PIR, the greater thebehavioural toxicity If the PIR value is less than unity (1.00), then thatparticular drug is less behaviourally toxic than the other members of thegroup Unity represents parity with the group and a PIR greater than 1.0represents a proportionally greater behavioural toxicity than the group (e.g.fluvoxamine and buproprion have no measurable behavioural toxicity,moclobemide possesses a third of the behavioural toxicity of the group as awhole, venlafaxine is as behaviourally toxic as the average for the group,and alprazolam is twice as behaviourally toxic as the average).

pharmaco-There are many reasons as to why a particular drug may benefit anindividual patient, but the use of a PIR can identify those substances, otherthings being equal, which may prove countertherapeutic or increase thechance of accident or cognitive failure

While PIRs may not necessarily be the principal guide for prescribing aparticular substance, there is sufficient cause for concern regarding theimpact of psychoactive drugs on a patient’s safety and quality of life toseriously consider such ratings of a drug’s intrinsic behavioural toxicitywhen using pharmacotherapy to manage patients suffering from socialphobias

TABLE3.13.1 Proportional Impairment Ratios (PIR): behavioural toxicity of drugsused in the management of social phobia

inter-3.14Medication Treatment of Phobias: Theories Hide

EffectivenessJames C Ballenger1Stein et al have done a masterful job with the difficult assignment to reviewthe medication treatment of phobias They summarize the rich literature onthe various medications which are effective in social phobia, a syndromethat is better described as social anxiety disorder, i.e anxiety specificallyabout being in social situations which patients secondarily phobicallyavoid We now know from controlled trials that both sertraline andvenlafaxine are effective in this syndrome Whether venlafaxine will prove

to be more effective than the other antidepressants in social anxietydisorder, as it appears to be in depression, is an important research issue.The medication treatment of agoraphobia without panic disorder isdifficult to discuss, because it almost never appears in that form intreatment settings and therefore there are almost no valid studies.Agoraphobia without a history of panic disorder appears largely inepidemiologic surveys but, when studied clinically, many patients actuallyhave subthreshold or full panic disorder

Finally, studies of simple phobia are sparse, because predominanttheories have literally inhibited exploration of this area Recent studiessuggest that patients with this disorder are in fact responsive to traditionalanti-anxiety medications such as selective serotonin reuptake inhibitors(SSRIs) This is an important finding, because simple phobias are actuallythe most common mental disorders Although most are not clinicallysignificant, many do involve significant avoidance (phobic) behaviourswhich are personally and occupationally disabling Perhaps the mostcommon is flying phobia, which can significantly hamper some individuals.Similarly, some individuals who fear single objects like spiders and snakes

1 Department of Psychiatry, University of South Carolina, 67 President St., Charleston, SC 29425, USA

can have significant interference with their lives if they live in areas whereexposure to them is likely Also, certain apparently single/simplephobias like using a public toilet or writing a cheque in public are oftenpieces of a broader syndrome like social anxiety disorder Similarly, culturalissues can obscure the true nature of some anxious, phobic behaviour InJapan, taijin-kyofusho is often considered to be a different syndromefrom social anxiety disorder However, in my meetings with Japanesepsychiatrists on this issue, it seems quite clear that it is only superficiallydifferent and in fact is the same disorder Early evidence suggests it is infact SSRI responsive.

It is clear that medications work, but how well? There is the ‘‘rule ofthirds’’ here as in many things In recent trials, usually a third have anexcellent response, one third a partial response, and about a third little to noresponse The emerging consensus is that we certainly should be treating toremission, i.e complete or almost complete resolution of symptoms and anyfunctional impairment [1,2] Remission is what each patient wants, and this

is the goal which should guide clinician treatment choices Clinicians need

to continue aggressive treatment until remission is either achieved orrealistically seems unattainable There are increasing data in the anxietyfield that treatment beyond the acute phase (6 to 12 weeks) leads toincreasing numbers of patients who actually experience a remission Ingeneralized anxiety disorder, approximately a third of patients reachremission in 6 to 12 weeks, whereas treatment for 6 months generallydoubles the number [3] This requires clinicians to change how they thinkabout partial remission Whereas most patients and clinicians conclude that

a treatment for 6 to 8 weeks is sufficient to determine optimal response,many partial responders will become complete responders if treated for 6months We should probably continue treatment in partial responders,rather than switch to another agent

Stein et al also touch on an absolutely critical question, i.e whethertreating anxiety disorders which begin in childhood, such as social anxietyand panic disorder, could block the full evolution of the adult syndromeand its consequences Could the low educational and vocational entertain-ment, lower rates of marriage, and high rates of substance abuse anddepression in social anxiety disorder be prevented by effective treatment ofthese children? This is a critical question with a disorder that ultimatelyaffects 13% of the population However, our general unwillingness to treatchildren with medications has slowed the exploration of this importantquestion

Stein et al also touch on the issue that although cognitive-behaviouraltherapy has been demonstrated to be effective in carefully controlledtrials, it remains unclear which patients should be treated withpsychotherapy alone or in combination with medications In many

instances, combination treatment has been demonstrated to havegreater efficacy, although this has not been a consistent finding The largerproblem is that cognitive-behavioural therapy is simply unavailable in mostcities However, the delivery of this treatment by manuals or computerprograms is under development and is a promising approach to this criticalproblem.

_ 4 Psychotherapeutic Interventions for

Phobias: A Review

David H Barlow, David A Moscovitch

and Jamie A Micco

Center for Anxiety and Related Disorders at Boston University,

648 Beacon Street, Boston, MA 02215-2002, USA

INTRODUCTION

There have been considerable advancements in the development ofempirically supported treatments for phobias over the past three decades.Prior to the advent of exposure-based treatments for agoraphobia, socialphobia and specific phobia, relatively little was known about theapplication of psychotherapeutic interventions to relieve the suffering ofindividuals who were diagnosed with these disorders Below, we willprovide a critical, comprehensive review of the treatment outcomeliterature for each of these disorders We will also describe patient andother treatment variables that may influence therapy response and relapserates Finally, we will summarize the empirical literature as it currentlystands and provide directions for future research

AGORAPHOBIA AND PANIC

Individuals with panic disorder and agoraphobia experience significantinterference in social, occupational and physical aspects of their lives [1,2].This interference signifies the importance of researching and disseminatingthe most effective treatments for these individuals Since the development

of agoraphobia is nearly always preceded by full-blown or symptom panic attacks [3,4], it is often necessary to address panic in thePhobias Edited by Mario Maj, Hagop S Akiskal, Juan Jose´ Lo´pez-Ibor and Ahmed Okasha.

limited-&2004 John Wiley & Sons Ltd: ISBN 0-470-85833-8

treatment of agoraphobia Over the past several decades, however, it hasbeen traditional to separate treatments for agoraphobia and panic disorderinto two categories: (a) treatments for agoraphobia and other avoidancebehaviours; and (b) treatments targeting panic attacks and anxiety focused

on panic [5] The review of psychosocial treatments presented here willfollow this tradition, beginning with treatments for agoraphobia

Agoraphobia

Initial treatments for agoraphobia were developed in the 1960s and 1970s.These mainly consisted of systematic desensitization, with little attentiongiven to panic attacks [6] Systematic desensitization involves imaginalexposure to the feared situation, simultaneously accompanied by musclerelaxation This technique was used primarily because it was thought thatactual exposure to feared situations would be too overwhelming foragoraphobic patients However, studies evaluating the use of systematicdesensitization for treatment of agoraphobia have found the technique to beineffective [7,8] Around the same time, some researchers began success-fully treating people with agoraphobia using in vivo exposure [9], wherebypatients were encouraged to venture away from ‘‘safe places’’ and entertheir feared situations Since then, in vivo exposure has become the mostwidely studied psychotherapy for agoraphobia

Basic Components of In Vivo Exposure

In vivo exposure begins with the construction of a hierarchy of situationsthat the agoraphobic individual fears and avoids, arranged from least tomost frightening Common items on a fear and avoidance hierarchy include

‘‘driving alone on the highway’’, ‘‘eating at a crowded restaurant’’,

‘‘shopping at the mall’’ and ‘‘riding on the subway’’ Patients are thenencouraged to repeatedly and systematically enter the situations on theirhierarchy and remain in the situations for as long as possible, often with theuse of coping strategies learned in session Although the presence of thetherapist during in vivo exposure may be necessary for it to be effective withseverely agoraphobic individuals [10], those with mild to moderate levels ofagoraphobia are usually able to engage in exposures on their own or with afriend or family member serving as a supportive coach [5]

Efficacy of In Vivo Exposure

Research has consistently supported the efficacy of in vivo exposure fortreating agoraphobia By the mid-1980s, studies revealed that 60–70% ofagoraphobic patients who completed in vivo exposure treatment showedsignificant clinical improvement, with follow-up assessments indicatingthat treatment gains were maintained for four or more years [11–17] Theseresults were replicated in several controlled studies, which used no-treatment or placebo control groups [18–20]

In vivo exposure for agoraphobia has been the subject of more recentresearch as well Fava et al [21] completed a long-term follow-up study of 90patients who received 12 sessions of graduated, self-paced exposuretreatment, conducted biweekly over a 6-month period At post-treatmentassessment, 87% were panic-free and ‘‘much improved’’ on global clinicalmeasures The authors used survival analysis to predict the probability thattreatment responders would remain in remission, and they determined that96% of treatment responders remained panic-free through the first two years,77% through five years, and 67% through seven years Predictors of relapse inthis study included the presence of residual agoraphobia and comorbidpersonality disorders; this finding emphasizes the importance of thoroughlytreating all vestiges of avoidance before termination

A number of studies have shown that other cognitive-behaviouraltechniques combined with in vivo exposure are no more effective for thetreatment of agoraphobia than in vivo exposure alone [22–24] On the otherhand, one study by Michelson et al [25] showed that the addition ofcognitive therapy to situational exposure can be significantly beneficial topeople with agoraphobia and panic, especially when compared to exposuretreatment plus relaxation training Other controlled studies have shownthat relaxation or breathing exercises confer no treatment advantage over invivo exposure [26–28] A study by Schmidt et al [28] suggested that patientswith panic disorder and agoraphobia receiving breathing retraining tended

to have lower end-state functioning at follow-up when compared to patientsnot receiving breathing retraining These findings suggest that breathingretraining and relaxation training may put patients with panic andagoraphobia at risk for relapse, perhaps because the exercises teach patients

to minimize and distract from physical sensations during situationalexposure, with breathing and relaxation becoming ‘‘safety behaviours’’ [5]

Combined In Vivo Exposure and Pharmacotherapy

A number of studies have studied the efficacy of in vivo exposure combinedwith tricyclic antidepressants, with most studies showing that the combined

treatment is superior at the post-treatment assessment [29–31] However, atthe follow-up assessments, after the tricyclic antidepressant is discontinued,the benefits of the combined treatment tend to disappear [32–34] Similarly,Marks et al [35] found that alprazolam plus in vivo exposure was equallyeffective as either treatment alone at post-treatment, but those who hadreceived the combined treatment showed significantly higher rates ofrelapse at six-month follow-up, after the alprazolam had been discontinued.More recent studies have examined the addition of selective serotoninreuptake inhibitors (SSRIs) to in vivo exposure for agoraphobia De Beurs et

al [36] found that the addition of fluvoxamine to situational exposurereduced avoidance significantly more than exposure alone at post-treatment However, at two-year follow-up, the treatment gains wereequivalent for both groups [37] These studies indicate that although theaddition of pharmacotherapy confers a short-term treatment advantageover situational exposure alone, this advantage disappears in the long term,after the medication has been discontinued

Methods of In Vivo Exposure Delivery

After the efficacy of in vivo exposure for agoraphobia and panic wasestablished, researchers turned their attention to discovering the mosteffective methods of delivering in vivo exposure to patients First, massedexposures, or exposures conducted during long, frequent sessions, havebeen compared to spaced exposures, or shorter exposure sessionsconducted weekly or biweekly While earlier studies found that massedexposures lead to greater attrition [38,39] and relapse rates [15,40],Chambless [41] found no detrimental outcomes associated with massedexposure in a study comparing massed to spaced exposures Another study[42] also found that massed exposures resulted in superior treatment effectswhen compared to spaced exposures Recent research based on modernlearning theory has shown that expanding-spaced schedules of exposures,with exposures initially massed and then gradually spaced out toward theend of treatment, are effective in treating specific phobias [43,44].Expanding-spaced exposures appear to be promising for the treatment ofagoraphobia as well [45], although further research is needed to determineits efficacy

Exposures conducted in a gradual fashion have been compared tointensive exposures, where the patient immediately enters his or her mostdifficult situations Using massed exposures over a ten-day period to treatseverely agoraphobic patients, Feigenbaum [46] compared ungraded tograded exposures and found that both were equally effective at post-treatment and eight-month follow-up At five-year follow-up, however,

ungraded exposures proved to be more effective The long-term efficacy ofungraded exposures was replicated in another follow-up study [47] InBoston, we are testing an intensive form of cognitive-behavioural therapyfor people with panic disorder with moderate to severe agoraphobia, calledsensation-focused intensive therapy (S-FIT), which emphasizes the experi-ence of panic-like physical sensations integrated with in vivo exposurepractices [48] S-FIT is conducted over eight days, with two of the daysdevoted to therapist-assisted massed and ungraded exposures andsymptom-induction exercises, and an additional two days of independentexposure Preliminary results based on 23 subjects show that 87% are

‘‘much’’ or ‘‘very much’’ improved on self-reports and clinician-ratedmeasures at post-treatment, with treatment gains maintained at follow-up[49] Thus, ungraded exposures appear to be as effective as, if not moreeffective than, graded exposures in the treatment of agoraphobia

Using computers, telephones and self-help manuals, researchers haveexamined more cost-effective methods of delivering in vivo exposure topeople with agoraphobia In one study, patients participated in a ten-weekexposure treatment with three conditions: therapist-directed, self-directedand computer-directed Results showed that all three conditions wereeffective, with no significant differences between conditions in treatmentoutcome [50] Another study compared telephone-administered exposuretreatment for moderate to severe agoraphobia to a waiting list control groupand found that the treatment group showed significantly better improve-ment than the waiting list group at post-treatment, with gains maintained atthree- and six-month follow-ups [51] This study is in contrast to a previousfinding that bibliotherapy is ineffective for treating patients with moresevere agoraphobia [10] Thus, severity of agoraphobia may predict theefficacy of treatments with minimal therapist contact

In conclusion, in vivo exposure for agoraphobia can be administered in anumber of formats: massed versus spaced, graduated versus intense, andtherapist-administered versus computer- or telephone-administered Theliterature reviewed above suggests that these methods of exposure deliveryare fairly comparable, with the advantages of using massed, intenseexposures found in some follow-up studies The choice of which method touse appears to depend on patient variables, such as patient motivation andwillingness to engage independently in difficult exposures, degree ofpatient avoidance, and availability of financial resources and access tobehavioural therapists

Panic Disorder

The majority of treatment studies for panic disorder with and withoutagoraphobia have been developed since the publication of DSM-III, with

most studies focusing on cognitive-behavioural treatments that tend toinclude psychoeducation, cognitive restructuring, exposure and copingskills components Most of these panic treatment studies have includedindividuals with no more than mild to moderate levels of agoraphobia.

Panic Control Treatment (PCT)

Panic control treatment (PCT) is a cognitive-behavioural therapy for panicdisorder originally developed by Barlow and Craske [52] in the mid-1980s.PCT consists of: (a) interoceptive exposure, which involves symptom-induction exercises (such as hyperventilating or breathing through a straw)that expose patients to physical symptoms resembling those associated withpanic attacks; (b) cognitive restructuring, which teaches patients aboutcommon misconceptions about panic attacks, particularly the emotionalbelief that panic attacks are dangerous, and ways of challenging theseemotional automatic thoughts; and (c) breathing retraining, which wasoriginally included to correct the tendency of patients with panic tochronically hyperventilate However, as reviewed above, Schmidt et al [28]showed that breathing retraining does not appear to add to the efficacy ofPCT, and indeed may be detrimental to the maintenance of treatment gains.PCT has been found to be superior at post-treatment and follow-up whencompared to progressive muscle relaxation and waiting list controls [53,54].There is support for the superiority of PCT over benzodiazepenes as well In

a study by Klosko et al [55], patients received PCT, alprazolam or placebo,

or were placed in a waiting list condition At post-treatment, 87% of patientsreceiving PCT were panic-free, compared to 50% of those receivingalprazolam, 36% receiving placebo and 33% of those in the waiting listcondition

Results from a large multi-site study comparing monotherapies for panic(PCT and imipramine) to combined therapy have recently become available[56] In this study, 312 individuals with panic disorder with no more thanmild agoraphobia were randomly assigned to one of five treatmentconditions: PCT alone, imipramine alone, placebo alone, PCT plusimipramine, and PCT plus placebo Patients received weekly treatment forthree months, and then responders to the acute treatment were seen monthlyfor six months of maintenance treatment Patients then completed a follow-

up assessment six months after the completion of the maintenance treatmentwhen treatments were discontinued At the end of the acute treatment phase,all of the treatment conditions were superior to placebo alone, and PCT plusimipramine was not superior to PCT plus placebo, indicating that thecombined treatment conferred no additional treatment benefit At the end ofthe maintenance treatment phase, these findings continued in effect with the

one change that combined treatment was now somewhat better than PCTplus placebo However, at follow-up, significantly more patients in theimipramine and PCT plus imipramine groups had relapsed than in the PCTalone and PCT plus placebo groups These results show that the treatmentresponse to PCT is more durable than the response to medication, althoughfurther research is necessary to determine if PCT and medication can becombined in other ways, such as sequential combination, that result in anadvantage to patients with panic disorder.

Cognitive-Behavioural Therapy and Other Treatments

In addition to PCT, a number of other cognitive-behavioural treatments(CBTs) for panic disorder are available, including Clark’s [57,58] cognitivetherapy for panic, with a main emphasis on cognitive restructuring ofmisinterpretations of bodily sensations Otherwise, CBT approaches topanic disorder are relatively similar The use of CBT (including PCT) forpanic disorder has been supported by more than 25 controlled clinical trials.One meta-analysis revealed that CBT has the largest effect size and smallestattrition rate compared to pharmacotherapy and combined treatments [59].However, because many studies of panic disorder treatments tend not toinclude patients with higher levels of agoraphobia, these studies may beoverestimating the efficacy of CBT Indeed, panic patients show lessimprovement in samples with higher degrees of agoraphobia: 50% ofpatients with more severe agoraphobia in controlled cognitive-behaviouraltreatment studies for panic disorder with agoraphobia (PDA) showsignificant improvement at post-treatment, while 59% show improvement

at follow-up [6] These improvement rates are clearly lower than thosereported for patients with mild to moderate agoraphobia

As with agoraphobia treatments, briefer, more cost-effective versions ofCBT for panic disorder have also been supported, including bibliotherapy[60], self-directed CBT using the Internet [61] and treatments with reducedtherapist contact [62]

Two non-CBT psychotherapies have also recently been developed for thetreatment of panic disorder: emotion-focused therapy (EFT) and panic-focused psychodynamic psychotherapy (PFPP) EFT [63], which focuses onthe interpersonal triggers of panic attacks, was found to be less effectivethan CBT and imipramine and no more effective than pill placebo in thetreatment of panic disorder [64] Milrod et al [65] recently conducted anopen pilot study examining the effects of a brief psychodynamic therapy(PFPP), conducted twice weekly for twelve weeks, for PDA At the end oftreatment, 16 out of 21 patients experienced remission of panic andagoraphobia across a number of measures, and these gains were

maintained at six-month follow-up This pilot study shows that PFPP mayprove to be a promising alternative to CBT in the treatment of panic andagoraphobia, although PFPP awaits controlled study.

Predictors of Treatment Outcome

Comorbid personality disorders may negatively affect PDA treatmentoutcome [66,67] For example, Marchand et al [68] found that patients withany comorbid personality disorder showed less improvement aftertreatment than panic-disordered patients without a personality disorder

In contrast, other studies have found no difference in response to CBT forpanic disorder between patients with and without personality disorders[69] Hofmann et al [70] found that individual CBT and imipramine were aseffective in reducing symptoms of panic disorder in individuals withpersonality disorder characteristics as in those without personality disordercharacteristics Features of a personality disorder did not predict panicdisorder treatment outcome [70] Surprisingly, initial depression seems tohave no negative effect on panic treatment outcome, regardless of whetherdepression is a principal or secondary diagnosis [71–73] Depressed patientswith PDA engage in as many self-directed exposures as non-depressedpatients, albeit with greater subjective ratings of anxiety [74]

Treatment outcome may also be affected by demographic and culturalvariables Attrition from the multi-site panic treatment study describedabove [56] was predicted by lower education, which in turn was dependent

on lower income [75] This finding suggests that patients who are unable tomake panic treatment the priority in their lives because of financialconstraints will have poorer treatment outcome There are contradictoryfindings about the effect of race on panic treatment outcome, with moststudies comparing African Americans to European Americans Somestudies show that African Americans fare worse in treatment thanEuropean Americans [76,77] On the other hand, other researchers [78]have found no differences in treatment outcome between AfricanAmericans and European Americans More research is crucial in order tounderstand how race/ethnicity affects treatment outcome of panic disorderand agoraphobia

Summary and Future Directions

In vivo exposure appears to be the most efficacious treatment foragoraphobia with and without a history of panic disorder, and there isempirical evidence that it is equally effective alone as when it is combined

with pharmacotherapy More recent research on in vivo exposure hasfocused on its mode of delivery, with massed, intensive exposures provingeffective for patients who are willing to tolerate them Cost-effectiveversions of situational exposure for agoraphobia are also promising In thetreatment of panic disorder, PCT and other forms of CBT appear to besuperior to other psychosocial treatments, such as EFT and relaxationtraining CBT has been shown to have greater durability than medication

in the treatment of panic disorder, particularly in the multi-site panictreatment study reviewed above

Future research needs to eliminate the artificial distinction between panicdisorder and agoraphobia by including more patients with moderate tosevere agoraphobia in treatment outcome studies and integrating theseapproaches more effectively An example of such an integrated treatment isthe S-FIT [47] described above, which targets both fear of panic-likephysical sensations and situational avoidance Studying integrated treat-ment approaches will provide a more realistic estimate of the efficacy ofCBT and PCT in the general panic-disordered population Similarly, morework must be done to determine the effectiveness of in vivo exposure andCBT by studying the treatments at community mental health centres;effectiveness studies would also enable a more thorough examination of theeffect of ethnicity, culture and socioeconomic status on treatment outcome.Wade et al [79] have begun this endeavour, training therapists to use CBT at

a large community health centre, whose panic-disordered population ismore agoraphobic and less formally educated than most patient samples incontrolled studies The study found treatment outcomes that werecomparable to controlled studies, and a one-year follow-up studyconfirmed the durability of these results [80] These promising resultsawait replication Finally, in the era of managed care, cost-effectivetreatments are becoming increasingly important Consequently, moreresearch must be performed to determine the long-term benefits of theabbreviated and self-directed forms of treatment for agoraphobia and panic

SOCIAL PHOBIA

A number of well-controlled studies have established the efficacy ofcognitive-behavioural, exposure-based procedures for treating socialphobia The major CBT components that have been applied to the treatment

of social phobia include: (a) social skills training; (b) relaxation training; (c)exposure; and (d) cognitive restructuring Researchers are still debatingwhich therapeutic ‘‘ingredients’’ are most essential for positive treatmentoutcome in social phobia

Social Skills Training

The rationale for using social skills training in the treatment of social phobia

is based on the assumption that socially phobic patients do not possess thesocial skills necessary to succeed in the social arena Individuals with socialphobia do tend to report perceived deficits in social skills [81] However,such deficits may not be apparent to objective observers, lending credence

to the suggestion that socially phobic patients may underestimate their ownsocial performance and perceive behavioural deficits when none actuallyexist [82] Even when behavioural shortcomings (e.g poor eye contact, poorconversation skills) do exist, it is unclear whether they reflect deficits insocial knowledge per se, or whether they represent avoidance strategies thatare employed intentionally by individuals with social phobia in an attempt

to reduce anxiety and avert an imagined social catastrophe [82]

Although several studies have investigated social skills training as atreatment option, methodological limitations have hampered efforts todetermine whether it contributes significantly to positive treatmentoutcomes [83] The only well-controlled study involving social skillstraining [84] concluded that patients who received 15 weeks of suchtraining fared no better than waiting list controls However, there is someevidence suggesting that combining social skills training with othertechniques, such as exposure or cognitive restructuring, leads to positiveoutcomes [85] Yet, as Heimberg [86] notes, the techniques that are oftenused in social skills training, such as therapist modelling and feedback,behavioural practice exercises and homework assignments, may betherapeutic because they inherently contain elements of exposure andcognitive restructuring, and not necessarily because they lead to anexpansion or improvement in the patient’s repertoire of social skills per se

Relaxation Training

In relaxation training procedures, patients learn strategies to identify andreduce physiological arousal and tension There is little evidence to supportthe use of isolated relaxation techniques, such as progressive musclerelaxation, in the treatment of social phobia [87,88] On the other hand,

‘‘applied’’ relaxation techniques, in which patients learn to use relaxationstrategies when entering anxiety-producing social situations, may holdsome promise in the treatment of social phobia [89] Although establishingthe efficacy of such procedures requires further investigation [85], it islikely, as with social skills training, that the benefits of applied relaxationtreatments are derived more from the patient’s exposure to fearedsituations than the application of relaxation strategies

In Vivo Exposure and Cognitive Restructuring

Real or imagined exposure to feared situations to facilitate the processingand modification of emotional and behavioural responses is a centralcomponent of most CBTs for anxiety disorders [5] In the context of socialphobia, designing appropriate in vivo exposures requires careful collabora-tion with patients Exposures, which typically involve simulating social roleplays, often with the help of confederates, should be tailored to the specificsocial fears of individual patients Exposure is often guided by a fear andavoidance hierarchy, a list of feared and avoided situations that are rank-ordered by subjective severity ratings assigned by the patient Imple-menting the fear and avoidance hierarchy into treatment with sociallyphobic patients follows a process that is similar to that with patients whohave agoraphobia, as described above As patients progress up thehierarchy, they are encouraged to repeatedly confront situations ofincreasing difficulty, and remain in each situation until their anxietyresponse peaks and, eventually, habituates Patients are instructed toexperience each situation fully, and are prevented from using any overt orcovert avoidance strategies or ‘‘safety behaviours’’ that may undermine theexposure procedure

Cognitive restructuring is a therapeutic process which teaches patientshow to identify and challenge maladaptive, negative cognitions triggered

by social situations Patients with social phobia perceive social situations asbeing ‘‘dangerous’’ in some way On the basis of this belief, individualswith social phobia tend to make biased predictions about their ability toachieve positive outcomes in these situations They may believe that theywill behave in an ‘‘unacceptable’’ social manner, that others will be criticaland rejecting of them, or that, in the course of social interaction, they will beoverwhelmed and disabled by their physical symptoms of anxiety In thecontext of cognitive therapy, exposures are framed as behaviouralexperiments that are designed to test these negative predictions On thebasis of the information collected during exposures, patients are encour-aged to re-evaluate the accuracy of their negative predictions andsubstitute, in their place, a more realistic, rational and balanced outlook

A substantial and growing body of literature supports the use ofexposure, with or without explicit cognitive intervention, for the treatment

of social phobia [90] Four meta-analytic reviews have been conducted toexamine the aggregate of studies comparing CBTs with control conditions[91–94] The results of these meta-analyses suggest that exposure therapy,either alone or in combination with cognitive restructuring or appliedrelaxation, produces significantly greater treatment effects than waiting list

or placebo control conditions Although one meta-analysis [92] found thatonly the combination of exposure and cognitive restructuring produced