title: 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.
  
  
  METHODS
  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.
authors.affiliation: Institute for Clinical Psychology and Psychotherapy, Technische Universität Dresden, Chemnitzer Strasse 46, Dresden, Germany. gloster@psychologie.tu-dresden.de
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Gloster
authors.forename: Hans-Ulrich
authors.initials: HU
authors.lastname: Wittchen
authors.forename: Franziska
authors.initials: F
authors.lastname: Einsle
authors.forename: Thomas
authors.initials: T
authors.lastname: Lang
authors.forename: Sylvia
authors.initials: S
authors.lastname: Helbig-Lang
authors.forename: Thomas
authors.initials: T
authors.lastname: Fydrich
authors.forename: Lydia
authors.initials: L
authors.lastname: Fehm
authors.forename: Alfons O
authors.initials: AO
authors.lastname: Hamm
authors.forename: Jan
authors.initials: J
authors.lastname: Richter
authors.forename: Georg W
authors.initials: GW
authors.lastname: Alpers
authors.forename: George W
authors.initials: GW
authors.lastname: Alpers
authors.forename: Alexander L
authors.initials: AL
authors.lastname: Gerlach
authors.forename: Andreas
authors.initials: A
authors.lastname: Ströhle
authors.forename: Tilo
authors.initials: T
authors.lastname: Kircher
authors.forename: Jürgen
authors.initials: J
authors.lastname: Deckert
authors.forename: Peter
authors.initials: P
authors.lastname: Zwanzger
authors.forename: Michael
authors.initials: M
authors.lastname: Höfler
authors.forename: Volker
authors.initials: V
authors.lastname: Arolt
mesh_terms: D000328:Adult; D000379:Agoraphobia / Q000150:complications / Q000523:psychology / Q000628:therapy*; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D005260:Female; D006801:Humans; D007171:Implosive Therapy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D016584:Panic Disorder / Q000150:complications / Q000523:psychology / Q000628:therapy*; D011369:Professional-Patient Relations; D016896:Treatment Outcome