A comparative outcome and follow-up investigation of panic disorder with agoraphohia: The relative and combined efficacy of cognitive therapy, relaxation training, and therapist-assisted exposure

The primary objective of this investigation was to examine the relative efficacy of Cognitive Therapy + Graded Exposure (CT + GE) vs. Relaxation Training + Graded Exposure (RT + GE) vs. Graded Exposure alone for subjects with moderate-severe panic disorder with agoraphobia (PDA). PDA is one of the most prevalent, severe, and clinically debilitating psychiatric disorders and shows high levels of Axis-I and Axis-II comorbidity. PDA is a complex disorder that leads to significant impairment in psychiatric, psychological, medical, social, occupational, interpersonal, and economic spheres. Hence, the impact of PDA mandates development of effective treatments. In the present study, 92 patients with panic disorder with agoraphobia (PDAs) entered and 74 completed a 16-session protocol of the above treatments. Significant within-group improvements were noted across treatments and most domains. CT + GE generated the most rapid, effective, and stable effects both at posttreatment and throughout the one-year follow-up. Analyses revealed: (a) both outcome and follow-up were mediated by changes on critical cognition measures during therapy; and, (b) the presence of residual panic attacks, which was noted in 30%-60% of the PDAs following therapy, was significantly associated with reemergence, relapse, or worsening of PDA over the course of the follow-up. Normative controls were also used to examine the clinical significance of the treatments. Overall, findings indicated that cognitive therapy paired with exposure appears to be a relatively effective treatment for PDA. Yet, a significant proportion of subjects did not achieve remission and/or high endstate functioning and were left with residual panic attacks or nonnormative outcome. These findings indicate that CT will need to be combined with other modalities that specifically target panic, such as the Cognitive Model of Panic or similar panic-control treatments to enhance both outcome and longitudinal adjustment. Our results are reviewed and recommendations offered for future research.