Exploring termination setback in a psychodynamic therapy for panic disorder.

Thomas Nilsson; Fredrik Falkenström; Sean Perrin; Martin Svensson; Håkan Johansson; Rolf Sandell

doi:10.1037/ccp0000678

Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials

The British Journal of Psychiatry ◽

10.1192/bjp.2021.148 ◽

2021 ◽

pp. 1-13

Author(s):

Davide Papola ◽

Giovanni Ostuzzi ◽

Federico Tedeschi ◽

Chiara Gastaldon ◽

Marianna Purgato ◽

...

Keyword(s):

Systematic Review ◽

Panic Disorder ◽

Randomised Controlled Trials ◽

Meta Analysis ◽

Risk Of Bias ◽

Psychodynamic Therapy ◽

Controlled Trials ◽

First Line ◽

Short Term ◽

Randomised Controlled

Background Psychotherapies are the treatment of choice for panic disorder, but which should be considered as first-line treatment is yet to be substantiated by evidence. Aims To examine the most effective and accepted psychotherapy for the acute phase of panic disorder with or without agoraphobia via a network meta-analysis. Method We conducted a systematic review and network meta-analysis of randomised controlled trials (RCTs) to examine the most effective and accepted psychotherapy for the acute phase of panic disorder. We searched MEDLINE, Embase, PsycInfo and CENTRAL, from inception to 1 Jan 2021 for RCTs. Cochrane and PRISMA guidelines were used. Pairwise and network meta-analyses were conducted using a random-effects model. Confidence in the evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). The protocol was published in a peer-reviewed journal and in PROSPERO (CRD42020206258). Results We included 136 RCTs in the systematic review. Taking into consideration efficacy (7352 participants), acceptability (6862 participants) and the CINeMA confidence in evidence appraisal, the best interventions in comparison with treatment as usual (TAU) were cognitive–behavioural therapy (CBT) (for efficacy: standardised mean differences s.m.d. = −0.67, 95% CI −0.95 to −0.39; CINeMA: moderate; for acceptability: relative risk RR = 1.21, 95% CI −0.94 to 1.56; CINeMA: moderate) and short-term psychodynamic therapy (for efficacy: s.m.d. = −0.61, 95% CI −1.15 to −0.07; CINeMA: low; for acceptability: RR = 0.92, 95% CI 0.54–1.54; CINeMA: moderate). After removing RCTs at high risk of bias only CBT remained more efficacious than TAU. Conclusions CBT and short-term psychodynamic therapy are reasonable first-line choices. Studies with high risk of bias tend to inflate the overall efficacy of treatments. Results from this systematic review and network meta-analysis should inform clinicians and guidelines.

Download Full-text

Supplemental Material for Exploring Termination Setback in a Psychodynamic Therapy for Panic Disorder

Journal of Consulting and Clinical Psychology ◽

10.1037/ccp0000678.supp ◽

2021 ◽

Keyword(s):

Panic Disorder ◽

Psychodynamic Therapy

Download Full-text

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

Psychotherapy and Psychosomatics ◽

10.1159/000511469 ◽

2020 ◽

pp. 1-12

Author(s):

Martin Svensson ◽

Thomas Nilsson ◽

Sean Perrin ◽

Håkan Johansson ◽

Gardar Viborg ◽

...

Keyword(s):

Panic Disorder ◽

Psychodynamic Therapy ◽

Post Treatment ◽

Work Status ◽

Random Assignment ◽

Treatment Assessment ◽

Cognitive Behavioural ◽

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.

Download Full-text

Psychodynamic Therapy for Treating Panic Disorder

PsycEXTRA Dataset ◽

10.1037/e655812010-001 ◽

2008 ◽

Author(s):

Barbara Milrod

Keyword(s):

Panic Disorder ◽

Psychodynamic Therapy

Download Full-text

Identifying Patterns in Complex Field Data

Zeitschrift für Psychologie ◽

10.1027/2151-2604/a000310 ◽

2017 ◽

Vol 225 (3) ◽

pp. 268-284 ◽

Cited By ~ 1

Author(s):

Andrew J. White ◽

Dieter Kleinböhl ◽

Thomas Lang ◽

Alfons O. Hamm ◽

Alexander L. Gerlach ◽

...

Keyword(s):

Heart Rate ◽

Panic Disorder ◽

Latent Class ◽

Treatment Protocol ◽

Situational Factors ◽

Self Report ◽

Complex Field ◽

Cluster Assignment ◽

Experimental Conditions ◽

Conventional Analysis

Abstract. Ambulatory assessment methods are well suited to examine how patients with panic disorder and agoraphobia (PD/A) undertake situational exposure. But under complex field conditions of a complex treatment protocol, the variability of data can be so high that conventional analytic approaches based on group averages inadequately describe individual variability. To understand how fear responses change throughout exposure, we aimed to demonstrate the incremental value of sorting HR responses (an index of fear) prior to applying averaging procedures. As part of their panic treatment, 85 patients with PD/A completed a total of 233 bus exposure exercises. Heart rate (HR), global positioning system (GPS) location, and self-report data were collected. Patients were randomized to one of two active treatment conditions (standard exposure or fear-augmented exposure) and completed multiple exposures in four consecutive exposure sessions. We used latent class cluster analysis (CA) to cluster heart rate (HR) responses collected at the start of bus exposure exercises (5 min long, centered on bus boarding). Intra-individual patterns of assignment across exposure repetitions were examined to explore the relative influence of individual and situational factors on HR responses. The association between response types and panic disorder symptoms was determined by examining how clusters were related to self-reported anxiety, concordance between HR and self-report measures, and bodily symptom tolerance. These analyses were contrasted with a conventional analysis based on averages across experimental conditions. HR responses were sorted according to form and level criteria and yielded nine clusters, seven of which were interpretable. Cluster assignment was not stable across sessions or treatment condition. Clusters characterized by a low absolute HR level that slowly decayed corresponded with low self-reported anxiety and greater self-rated tolerance of bodily symptoms. Inconsistent individual factors influenced HR responses less than situational factors. Applying clustering can help to extend the conventional analysis of highly variable data collected in the field. We discuss the merits of this approach and reasons for the non-stereotypical pattern of cluster assignment across exposures.

Download Full-text