Coping Skills and Exposure Therapy in Panic Disorder and Agoraphobia: Latest Advances and Future Directions

Classified as probably not a substantial claim.

Respiratory abnormalities have been proposed as a key factor in how PD/A develops or persists.

“Respiratory abnormalities have been postulated as an important factor in the development or maintenance of PD/A (Gorman et al., 1988; Klein, 1993; see Meuret & Ritz, 2010, for a review)”

• cites Gorman et al., 1988 sourceNot checked — no full text of the source
• cites Klein, 1993 sourceNot checked — no full text of the source
• cites Meuret & Ritz, 2010 sourceSupported

May combine two claims.

Most mediation studies of CT for PD/A measure change in purported mediators and outcomes over the same interval or lack complete mediation models.

“Most studies of mediation of CT for PD/A merely measure change in purported mediators (i.e., reappraisal) as well as outcomes (i.e., panic symptom reduction) across the same interval of time, from pre- to posttreatment”

• cites Hofmann et al., 2007 sourcePartly supported

  The Discussion (page not available) says this study assessed the proposed mediator and panic severity concurrently and could not establish that mediator change preceded outcome change. The Method (page not available) identifies pretest, posttest, and follow-up measurements. These passages support the same-interval concern, but they do not establish that most CT studies of panic disorder with or without agoraphobia use this approach or lack complete mediation models. (LLM, conf=0.85)

  Experimental — accuracy not yet measured
• cites Clark et al., 1994, 1999Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Schmidt & Bates, 2003 sourceNot checked — no full text of the source

May combine two claims.

In a first randomized controlled study, CART (n=20) compared with a delayed wait-list control (n=17) led to sustained increases in PCO2 levels and reduced panic severity and frequency.

“CART, but not WL, led to sustained increases in PCO2 levels and reduced panic severity and frequency.”

• cites Meuret et al., 2008 sourceSupported

May combine two claims.

Reductions in rate of breathing did not mediate reductions in panic fear of bodily sensations, panic symptom severity, or cognitions including perceived control.

“reductions in rate of breathing neither mediated reductions in panic fear of bodily sensations (Meuret et al., 2009) nor panic symptom severity or cognitions (including perceived control) (Meuret et al., 2010).”

• cites Meuret et al., 2009 sourceSupported
• cites Meuret et al., 2010Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Longitudinal mediation analyses indicated that changes in PCO2 measured continuously during between-session exercises mediated and preceded changes in fear of bodily sensations and cognitive reappraisal of symptoms and perceived control in CART but not CT.

“longitudinal mediation analyses indicating that changes in PCO2, measured continuously during between-session exercises, indeed mediated and preceded changes in fear of bodily sensations (Meuret et al., 2009) and cognitive reappraisal of symptoms and perceived control (Meuret et al., 2010) in CART but not CT.”

• cites Meuret et al., 2009 sourcePartly supported

  Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured
• cites Meuret et al., 2010Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• AssumptionThe authors state this as an assumption: PCO2 is the primary mediator of CART.

Probably not a substantial claim: may not pass S3 (load-bearing).

Patients were very receptive to and compliant with recording devices for physiology and verbalizations.

“Overall, patients were very receptive to and compliant with the recording devices for their physiology and their verbalizations.”

May combine two claims.

In a feasibility trial, results indicated high compliance with homework exercises and significant improvements in symptom appraisal, mindfulness, and panic symptom severity.

“The results of this feasibility trial were promising and indicated high compliance with homework exercises and significant improvements in symptom appraisal, mindfulness, and panic symptom severity.”

Probably not a substantial claim: may not pass S3 (load-bearing).

It is still unknown whether biological factors that trigger or maintain panic symptoms are safe for the body.

“The extent to which biological factors that may elicit or sustain panic symptoms are without harm to the system remains unknown.”

May combine two claims.

Murphy et al. (1998) found CT plus graded exposure beat graded exposure alone and graded exposure plus relaxation.

“One exception was a study by Murphy, Michelson, Marchione, Marchione, and Testa (1998), in which those receiving CT + graded exposure outperformed those receiving graded exposure alone or graded exposure + relaxation training.”

• cites Murphy et al., 1998 sourceNot checked — no full text of the source

May combine two claims.

CBT for panic disorder is efficacious, but many patients drop out or remain symptomatic.

“Although cognitive-behavioral treatments for panic disorder have demonstrated efficacy, a considerable number of patients terminate treatment prematurely or remain symtpomatic.”

Classified as probably not a substantial claim.

Clark and McNally hold that successful treatment requires changing the catastrophic reading of sensations rather than removing the sensations.

“according to Clark (1986) and McNally (1994), treatment success depends on the correction of the catastrophic interpretation of these sensations, not the sensations themselves.”

• cites Clark, 1986 sourceNot checked — no full text of the source
• cites McNally, 1994Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

In the same trial, attention control changed neither panic symptoms nor avoidance; once exposure was added, avoidance fell as much as in the CT arm.

“Attention control did not change panic symptoms or avoidance, but after adding exposure, avoidance behavior was reduced to the same extent as the CT condition.”

• cites van den Hout et al.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Existing methodologies test whether delivery of coping skills enhances outcomes but do not assess whether acquisition and application during exposure augment outcomes.

“Current methodologies used to study the augmenting effects of coping skills test the degree to which the delivery of coping skills enhances outcomes. However, they do not assess the degree to which acquisition of coping skills and their application during exposure therapy augment outcomes.”

May combine two claims.

In that trial, only adding exposure reduced avoidance and the remaining panic symptoms.

“The latter were only reduced with the addition of exposure.”

• cites van den Hout et al.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Ley (1985) proposed that acute hypocapnia causes panic attacks and can extend before and after them, producing moderate sustained hypocapnia.

“According to Ley (1985) panic attacks are caused by acute states of hypocapnia, which may not be limited to the attack itself, but may precede and follow it, giving rise to moderate sustained hypocapnia.”

• cites Ley, 1985 sourceNot checked — no full text of the source

May combine two claims.

CBT is the psychosocial treatment for PD/A with the strongest empirical support; it centers on repeated exposure and is supported by control-based coping skills.

“The most empirically supported psychosocial treatment for PD/A is cognitive behavioral therapy (CBT), of which the central focus is repeated exposure to feared situations and sensations, supported by a set of control-based coping skills (see Craske & Barlow, 2008).”

• cites Craske & Barlow, 2008Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Hoffart (1995) reported that CT aimed at misappraisals of bodily sensations matched intensive guided mastery exposure over six weeks in moderate-to-severe agoraphobia, though the CT arm contained some exposure elements.

“Hoffart (1995) found that CT targeting misappraisals of bodily sensations was as effective as guided mastery exposure delivered intensively over 6 weeks for individuals with moderate to severe agoraphobia, although some elements of exposure (e.g., hyperventilation tests to elicit sensations) were included in the CT condition.”

• cites Hoffart, 1995 sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

How much using CT during exposure improves outcome is still unknown.

“but conclusions regarding the degree to which actual use of CT during exposure enhances outcome remains unknown.”

Classified as probably not a substantial claim.

Clark's cognitive model holds that catastrophic beliefs about bodily sensations or the situations where they occur cause panic attacks.

“The cognitive theory of panic disorder (Clark, 1986) posits that panic attacks are caused by catastrophic beliefs about bodily sensations or situational contexts in which such sensations occur.”

• cites Clark, 1986 sourceNot checked — no full text of the source

May combine two claims.

The available data suggest CT by itself helps PD/A somewhat, yet little evidence shows it boosts exposure alone.

“Taken together, the extant data indicates that the delivery of CT alone is partially effective for PD/A, but there is little evidence suggesting CT augments the effects of exposure alone.”

May combine two claims.

Van den Hout and colleagues found initial CT lowered panic frequency but did not reduce avoidance or other panic symptoms.

“Initial CT resulted in reductions in panic frequency, but not avoidance behavior or other panic-related symptoms.”

• cites van den Hout et al.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Traditional BRT neither measures nor targets its core idea: correcting hypocapnic breathing.

“Most surprisingly, the central tenet of BRT, the correction of hypocapnic breathing, is neither measured nor targeted in traditional BRT.”

May combine two claims.

Reports of BRT strategies and results are limited and inconsistent.

“The descriptions of the therapeutic strategies and outcomes for BRT are sparse and mixed (see Meuret, Wilhelm, Ritz, & Roth, 2003, for a review).”

• cites Meuret et al., 2003 sourceNot checked — no full text of the source

May combine two claims.

A recent ambulatory study and decades of experiments are said to support both proposals.

“Evidence for both postulations has been found in a recent ambulatory study tracing cardio respiratory changes in the hour before out-of-the-blue attacks (Meuret et al., in press) and decades of experimental studies”

• cites Meuret et al., in pressNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Studies differ widely in target breathing rates and in how long and often between-session exercises are done.

“Furthermore, target respiratory rates as well as duration and frequency of between-session exercises vary largely across studies.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In this account, chronic hyperventilation adapts to a lower suffocation alarm threshold by keeping PCO2 low enough to avoid triggering it.

“In this context, chronic hyperventilation is interpreted as an adaptation to a lowered suffocation alarm threshold, in that it keeps PCO2 sufficiently low to avoid triggering the suffocation alarm.”

• cites KleinNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Klein's model holds that a rise in PCO2 triggers the alarm at too low a threshold or with too much sensitivity to CO2 increases, causing disproportionate dyspnea and then panic.

“When a patient's PCO2 rises, the system starts firing at an abnormally low threshold and/or responds with greater sensitivity to increments in CO2. This leads to disproportional dyspnea (sensations of air hunger, breathlessness, suffocation), which due to its distressing nature initiates a cascade of panic symptoms.”

• cites KleinNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Klein viewed hyperventilation as a secondary or compensatory response to an overly sensitive suffocation alarm.

“Hyperventilation according to Klein is viewed as a compensatory or secondary reaction to an overly sensitive “suffocation alarm system” in these patients.”

• cites KleinNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

With such data missing, the statement that no evidence shows breathing therapy normalizes pCO2 is technically correct.

“Given the lack of such data, bold claims such as, “There is no evidence that breathing therapy works by normalizing pCO2” (Bass, 1997, p. 425) technically are accurate.”

• cites Bass, 1997 sourceNot checked — no full text of the source

May combine two claims.

The methods used to study augmenting effects of coping skills test whether delivery of coping skills improves outcomes, but they have not assessed how much acquisition and application during exposure improve outcomes.

“the methodologies used to study the augmenting effects of coping skills test the degree to which the delivery of coping skills enhances outcomes; they have not assessed the differential degree to which acquisition of coping skills, and/or their application during exposure therapy enhance outcomes.”

May combine two claims.

Studies of coping skills augmentation typically fail to show that coping skills augment exposure, and they are limited in number and in the conclusions they can support.

“these studies, which typically fail to show that coping skills augment exposure, are limited not only in number, but in the conclusions that can be drawn using these methodologies.”

May combine two claims.

On a behavioral fear measure, AR beat CT, while in vivo exposure alone did not.

“On a behavioral measure of fear, AR outperformed CT, whereas in vivo exposure alone did not”

• cites Öst et al., 1993Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Schmidt et al. (2000) found no significant group differences, which casts doubt on BRT adding to CBT.

“No significant condition differences were found, thus questioning the additional additive benefit of BRT to CBT.”

• cites Schmidt et al., 2000 sourceNot checked — no full text of the source

May combine two claims.

Bonn et al. (1984) reported BRT plus exposure matched exposure alone at posttreatment but did better six months later.

“While BRT plus exposure was equally effective as exposure alone at posttreatment, BRT plus exposure yielded superior outcome 6 months later.”

• cites Bonn et al., 1984 sourceNot checked — no full text of the source

May combine two claims.

In Öst et al. (1993), CT contained exposure elements and the in vivo exposure-only arm was confounded by panic-coping instructions, so comparison was hindered.

“Again, CT was intermingled with exposure elements, whereas the in vivo exposure “only” training appeared to be confounded by “instructions for coping with panic during exposure” (p. 387), thus impeding comparative testing.”

• cites Öst et al., 1993Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

In PD/A, BRT is seldom tested apart from other therapies, and trials of its added effect on exposure are few and inconsistent.

“Taken together, BRT has been rarely tested in isolation from other therapeutic strategies in the treatment of PD/A, and studies examining the potentiation of BRT upon exposure are limited and yield mixed results.”

Classified as probably not a substantial claim.

How much learning PMR and using it during exposure improves exposure therapy is still unknown.

“Thus, the degree to which acquisition of PMR skills and their application during exposure therapy augment exposure therapy remains unknown.”

May combine two claims.

In the treatment of PD/A, traditional coping skills either do not augment exposure or their augmenting effects on exposure are unknown.

“one may conclude that traditional coping skills either bear no augmenting effect over exposure or their effects upon exposure are unknown in the treatment for PD/A.”

May combine two claims.

Mediation studies of CT relied on retrospective self-report measures of thoughts and beliefs, which are likely confounded by responder biases and demand characteristics and unlikely to match ongoing cognition.

“These studies, however, relied upon retrospective self-report measures of thoughts and beliefs, which are likely to be confounded by responder biases and demand characteristics, and unlikely to match ongoing, moment-to-moment cognition (Jarrett, Vittengl, Doyle, & Clark, 2007).”

• cites Jarrett, Vittengl, Doyle, & Clark, 2007 sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

Whether traditional BRT truly reverses hypocapnic breathing compared with controls is still unknown.

“Most problematically, it remains unknown whether traditional BRT actually reverses hypocapnic breathing relative to control conditions.”

May combine two claims.

Hoffart et al. (2008) found that fear of bodily sensations influenced catastrophic beliefs, which influenced avoidant behavior, and that reducing avoidance decreased fear of bodily sensations.

“In another study by Hoffart et al. (2008), fear of bodily sensations influenced catastrophic beliefs, which in turn influenced avoidant behavior. A reduction in the latter decreased the fear of bodily sensations.”

• cites Hoffart et al., 2008 sourceNot checked — no full text of the source

May combine two claims.

Only one trial measured in-session PCO2; it found levels moving from hypocapnic to normocapnic by posttreatment.

“In-session PCO2 was assessed in only one study (Salkovskis et al., 1986) with evidence of normalization from initial hypocapnic to normocapnic levels at posttreatment.”

• cites Salkovskis et al., 1986 sourceNot checked — no full text of the source

May combine two claims.

Hibbert and Chan (1989) found BRT and supportive therapy equal in the first two weeks, but after exposure training BRT produced more clinician-rated improvement, though not more self-reported improvement.

“The interventions were equally effective in the first 2-week phase, but BRT yielded greater improvement in clinician (but not self-report) ratings than supportive therapy following the additional exposure training.”

• cites Hibbert & Chan, 1989 sourceNot checked — no full text of the source

May combine two claims.

Measures such as the Anxiety Sensitivity Index capture dispositional characteristics but not occurrent responding.

“measures such as the Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally, 1986) capture dispositional characteristics, but not occurrent responding (Fridhandler, 1986).”

• cites Reiss, Peterson, Gursky, & McNally, 1986 sourceNot checked — no full text of the source
• cites Fridhandler, 1986 sourceNot checked — no full text of the source

May combine two claims.

Öst (1988) reported that PMR alone greatly reduced panic severity but was weaker than PMR plus interoceptive exposure.

“In another study, Öst (1988) found that PMR alone resulted in large reductions of panic symptom severity, although it was less effective than the combination of PMR + interoceptive exposure (i.e., applied relaxation).”

• cites Öst, 1988Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Marks et al. (1993) found all four conditions improved on panic measures, with no differences on most panic symptoms during treatment or follow-up.

“All four treatment conditions showed improvement in panic measures, with no differences between them on most panic symptom measures during treatment or throughout the follow-up period.”

• cites Marks et al., 1993 sourceNot checked — no full text of the source

May combine two claims.

The only studies evaluating muscle tonus throughout exposure therapy used imaginal exposure, and in those PMR was associated with increased rather than reduced autonomic arousal.

“The only studies that have actually evaluated muscle tonus throughout exposure therapy utilized imaginal exposure. In those cases, PMR was associated with increased rather than reduced autonomic arousal (Borkovec & Sides, 1979; Levin & Gross, 1985).”

• cites Borkovec & Sides, 1979 sourceNot checked — no full text of the source
• cites Levin & Gross, 1985 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Compliance and skill acquisition and application can be assessed through electronic data storage.

“Compliance and skill acquisition and application can be assessed by means of electronic data storage.”

May combine two claims.

Implementation of appraisal techniques is largely assessed retrospectively, and assessment of core physiological processes during skill training and application is lacking.

“At present, implementation of appraisal techniques (as taught in CT) are largely assessed retrospectively; likewise the assessment of core physiological processes (i.e., PCO2 in BRT and muscle tonus in PMR) both during skill training (i.e., between-session exercises) and application (i.e., exposure) is lacking.”

May combine two claims.

Empirical evidence supports the efficacy of acceptance approaches for PD/A, but acquisition/application and mechanistic validation of acceptance skills are lacking.

“Empirical evidence for the efficacy of acceptance approaches for PD/A has been demonstrated (e.g., Forman et al., 2007; Levitt, Brown, Orsillo, & Barlow, 2004); however, as with cognitive and behaviorally based treatments, both acquisition/application and mechanistic validation of acceptance skills is lacking.”

• cites Forman et al., 2007 sourceNot checked — no full text of the source
• cites Levitt, Brown, Orsillo, & Barlow, 2004 sourceNot checked — no full text of the source

May combine two claims.

Think-aloud methodologies have been used to evaluate thoughts during experimental exposure to feared situations and are considered valid indicators of covert verbalizations when derived from continuous-stream instructions and limited to brief snippets of time.

“Think-aloud methodologies have been used to evaluate thoughts during experimental exposure to feared situations (Williams et al., 1997) and are considered valid indicators of covert verbalizations when derived from instructions to “say in a continuous stream whatever one is saying to oneself at that moment””

• cites Williams et al., 1997 sourceNot checked — no full text of the source

May combine two claims.

Augmentation techniques are trained, but their adoption and implementation are generally not tracked.

“This review suggests that these augmentation techniques are trained, but that their adoption and implementation are generally not tracked.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

The general cognitive-behavioral treatment package is well supported for PD/A and is considered the first-line psychosocial treatment for PD/A.

“The general cognitive-behavioral treatment package is well supported in the treatment of PD/A, and is considered the first-line psychosocial treatment for PD/A.”

May combine two claims.

Improvements in panic severity across exposure sessions were large and independent of previously acquired coping skills, but PCO2 normalization occurred only after prior CART training, not CT.

“although improvements in panic severity across exposure sessions were large and independent of previously acquired coping skills, normalization in PCO2 was only observed for patients undergoing prior training CART, but not CT (Seidel, Rosenfield, Bhaskara, Hofmann, & Meuret, 2009).”

• cites Seidel, Rosenfield, Bhaskara, Hofmann, & Meuret, 2009Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Those muscle tonus studies were not conducted in PD/A samples, and none met criteria for proper mediational testing.

“these studies were not conducted in samples with PD/A, and none of the above studies met criteria for proper meditational testing.”

Classified as probably not a substantial claim.

Acceptance-based skill training differs from traditional coping skill training in emphasizing acceptance of panic-related sensations and cognitions rather than control.

“Acceptance-based skill training differs to traditional coping skill training as the emphasis is not on control (e.g., of physiology or thoughts) but rather the acceptance of panic-related sensations and cognitions as they occur from moment to moment.”

May combine two claims.

In that study, reductions in panic symptom severity were comparable to standard CBT and improvements were maintained at 12-month follow-up.

“Reductions in panic symptom severity (PDSS; Shear et al., 1997) were comparable to standard CBT and improvements were maintained at 12-month follow-up.”

• cites Shear et al., 1997 sourceNot checked — no full text of the source

May combine two claims.

Online recording of verbalizations provides a sample of thinking that differs from forced-choice formats and retrospective judgments and appears less susceptible to responder biases.

“This online method of recording verbalizations provides a sample of thinking that differs from the constraints of forced-choice formats and retrospective judgments (e.g., questionnaires), and appears to be less susceptible to responder biases inherent to retrospective judgments.”

Classified as probably not a substantial claim.

Evaluation of how much CART augments exposure therapy relative to exposure alone awaits testing.

“an evaluation of the degree to which CART augments exposure therapy (relative to exposure therapy alone) a waits testing.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

For BRT, the proposed mediator is PCO2, and the coping skill is slow, deep, and/or abdominal breathing intended to restore normal PCO2 levels.

“the purported mediator for BRT is PCO2, which serves as an index of the degree of hyperventilation. The commonly used coping skill is slow, deep, and/or abdominal breathing with the purpose of restoring normal levels of PCO2.”

• AssumptionThe authors state this as an assumption: PMR and BRT reduce anxiety by lowering heightened physiological arousal in PD/A.

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

The think-aloud paradigm would be equally suitable for cognitive coping skills.

“Notably, the think-aloud paradigm would be equally suitable for cognitive coping skills.”

May combine two claims.

Randomized controlled trials of CART are limited but promising.

“Due to the novelty of CART, randomized controlled trials are limited but promising.”

May combine two claims.

Michelson et al. (1990) observed heart rate decrements after both PMR and in vivo exposure for agoraphobia, with no differences between treatments.

“Michelson et al. (1990) observed heart rate decrements after both PMR and in vivo exposure for the treatment of agoraphobia, with no differences between the two treatments.”

• cites Michelson et al., 1990 sourceNot checked — no full text of the source

May combine two claims.

Mediation analysis during exposure showed bidirectional relations for cardiorespiratory changes mediating physical symptoms and cardiac changes mediating cognitive symptoms, significant and consistent across all exposure sessions.

“Mediation analysis examining changes during exposure showed bidirectional relations for cardiorespiratory changes mediating changes in physical symptom and for cardiac changes mediating changes in cognitive symptoms (Seidel et al., 2009); these pathways were significant and consistent across all exposure sessions.”

• cites Seidel et al., 2009Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

For PMR, the proposed mediator is muscle tonus, and the coping skill is physical relaxation intended to restore normal muscle tension.

“For PMR, the purported mediator is muscle tonus, and the coping skill is to “physically relax” with the purpose of restoring a “normal” level of muscle tension.”

• AssumptionThe authors state this as an assumption: PMR and BRT reduce anxiety by lowering heightened physiological arousal in PD/A.

May combine two claims.

It is premature to conclude whether coping skills augment exposure alone because it is unclear whether patients learn and apply the taught skills.

“it is premature to draw conclusions as to whether they augment exposure alone because it remains unclear whether patients learn and apply the taught skills.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

CART is a brief 4-week training that uses immediate feedback of end-tidal PCO2 to teach patients to raise subnormal PCO2 and gain control over dysfunctional respiratory patterns and associated panic symptoms.

“CART is a brief, 4-week training that uses immediate feedback of end-tidal PCO2 to teach patients how to raise their subnormal levels of PCO2 (hyperventilation) and thereby gain control over dysfunctional respiratory patterns and associated panic symptoms”

May combine two claims.

A person scoring high on the ASI is likely to respond fearfully to bodily sensations and to catastrophize about them, but the ASI does not show whether such thoughts and feelings occur in real time.

“a person scoring high on the ASI is likely to respond fearfully to bodily sensations and is more likely to catastrophize about them. Notwithstanding, the ASI does not lend evidence to whether such thoughts and feelings are actually occurring in real time.”