Psychological treatment for panic disorder with agoraphobia: A randomized controlled trial to examine the role of therapist-guided exposure in situ in CBT.
Abstract
OBJECTIVE: Cognitive-behavioral therapy (CBT) is a first-line treatment for panic disorder with agoraphobia (PD/AG). Nevertheless, an understanding of its mechanisms and particularly the role of therapist-guided exposure is lacking. This study was aimed to evaluate whether therapist-guided exposure in situ is associated with more pervasive and long-lasting effects than therapist-prescribed exposure in situ. METHOD: A multicenter randomized controlled trial, in which 369 PD/AG patients were treated and followed up for 6 months. Patients were randomized to 2 manual-based variants of CBT (T+/T-) or a wait-list control group (WL; n = 68) and were treated twice weekly for 12 sessions. CBT variants were identical in content, structure, and length, except for implementation of exposure in situ: In the T+ variant (n = 163), therapists planned and supervised exposure in situ exercises outside the therapy room; in the T- group (n = 138), therapists planned and discussed patients' in situ exposure exercises but did not accompany them. Primary outcome measures were (a) Hamilton Anxiety Scale, (b) Clinical Global Impression, (c) number of panic attacks, and (d) agoraphobic avoidance (Mobility Inventory). RESULTS: For T+ and T- compared with WL, all outcome measures improved significantly with large effect sizes from baseline to post (range = -0.5 to -2.5) and from post to follow-up (range = -0.02 to -1.0). T+ improved more than T- on the Clinical Global Impression and Mobility Inventory at post and follow-up and had greater reduction in panic attacks during the follow-up period. Reduction in agoraphobic avoidance accelerated after exposure was introduced. A dose-response relation was found for Time × Frequency of Exposure and reduction in agoraphobic avoidance. CONCLUSIONS: Therapist-guided exposure is more effective for agoraphobic avoidance, overall functioning, and panic attacks in the follow-up period than is CBT without therapist-guided exposure. Therapist-guided exposure promotes additional therapeutic improvement--possibly mediated by increased physical engagement in feared situations--beyond the effects of a CBT treatment in which exposure is simply instructed.
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Traditionally, guidelines for in vivo exposure sessions have included the support of a co-therapist during exposure, or the presence of the therapist outside the therapy office.
“Traditionally, guidelines for IVE sessions have included the support of a co-therapist during the exposure, or even the presence of the therapist outside of the therapy office (Gloster et al., 2011).”
From Enhancing In Vivo Exposure in the Treatment of Panic Disorder and Agoraphobia Using Location-Based Technologies: A Case Study (2020) · cites this paper as Gloster et al., 2011
Some measures used to support in vivo exposure can have potential costs in time and interference, whereby patients turn the measures into safety signals.
“However, some of these measures can have potential costs in terms of time and interference, whereby patients turn the measures into safety signals (Gloster et al., 2011).”
From Enhancing In Vivo Exposure in the Treatment of Panic Disorder and Agoraphobia Using Location-Based Technologies: A Case Study (2020) · cites this paper as Gloster et al., 2011
Mobile components might assist patients in overcoming limitations of traditional desktop- and laptop-based interventions, such as needing to leave the computer during in vivo exposure exercises.
“Mobile components might assist patients in overcoming several limitations of traditional desktop- and laptop-based interventions.”
From Efficacy of a hybrid online training for panic symptoms and agoraphobia: study protocol for a randomized controlled trial. (2014) · cites this paper as [19]
Two large studies of traditional CBT for panic disorder and agoraphobia reported dropout rates ranging between 19.6% and 28%.
“two large studies of traditional CBT for panic disorder and agoraphobia reported dropout rates ranging between 19.6% [11] and 28% [1]”
From Treating Treatment-Resistant Patients with Panic Disorder and Agoraphobia Using Psychotherapy: A Randomized Controlled Switching Trial. (2015) · cites this paper as [11]
The dropout rate in this study was 9%, which was much lower than dropout rates in other treatment outcome studies.
“Of clinical importance, the dropout rate in this study (9%) was much lower than that in other treatment outcome studies.”
From Treating Treatment-Resistant Patients with Panic Disorder and Agoraphobia Using Psychotherapy: A Randomized Controlled Switching Trial. (2015) · cites this paper as [11]
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- Authors
- Gloster, A. T., Wittchen, H.-U., Einsle, F., Lang, T., Helbig-Lang, S., Fydrich, T., Fehm, L., Hamm, A. O., Richter, J., Alpers, G. W., Gerlach, A. L., Ströhle, A., Kircher, T., Deckert, J., Zwanzger, P., Höfler, M., & Arolt, V.
- Affiliations
- Technische Universität Dresden (DE)
- Humboldt-Universität zu Berlin (DE)
- Universität Greifswald (DE)
- University of Würzburg (DE)
- University of Münster (DE)
- Charité – Universitätsmedizin Berlin (DE)
- Philipps University of Marburg (DE)
- ORCID
- Venue
- Journal of Consulting and Clinical Psychology
- Published
- 2011
- Volume
- 79
- Issue
- 3
- Pages
- 406-420
- ISSN
- 0022-006X (ISSN-L)
- 1939-2117
- OpenAlex
- W1965222801
- Cited by
- 203
- References
- 57
- Citations by year
- 2026: 6 · 2025: 4 · 2024: 8 · 2023: 3 · 2022: 4 · 2021: 14 · 2020: 7 · 2019: 23 · 2018: 19 · 2017: 18 · 2016: 17 · 2015: 16 · 2014: 23 · 2013: 23 · 2012: 13
- FWCI
- 26.04
- Type
- journal article
- Language
- en
- Update notices
- correction (2011-09-26)
- Open access
- closed
- Locations
- Journal of Consulting and Clinical Psychology (publishedVersion)
- PubMed (publishedVersion)
- MADOC (University of Mannheim) (submittedVersion)
- Funders
- German Federal Ministry for Education and Research (01GV0615)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Keywords
- panic disorder with agoraphobia, cognitive behavioral therapy, in situ exposure, agoraphobic avoidance, panic attacks, therapeutic mechanisms, dose-response relationship
- MeSH terms
- Adult, Agoraphobia, Female, Humans, Implosive Therapy, Male, Middle Aged, Professional-Patient Relations, Cognitive Behavioral Therapy, Panic Disorder, Treatment Outcome
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