title: Timing matters: change depends on the stage of treatment in cognitive behavioral therapy for panic disorder with agoraphobia.
abstract: OBJECTIVE
  The mechanisms of action underlying treatment are inadequately understood. This study examined 5 variables implicated in the treatment of panic disorder with agoraphobia (PD/AG): catastrophic agoraphobic cognitions, anxiety about bodily sensations, agoraphobic avoidance, anxiety sensitivity, and psychological flexibility. The relative importance of these process variables was examined across treatment phases: (a) psychoeducation/interoceptive exposure, (b) in situ exposure, and (c) generalization/follow-up.
  
  
  METHODS
  Data came from a randomized controlled trial of cognitive behavioral therapy for PD/AG (n = 301). Outcomes were the Panic and Agoraphobia Scale (Bandelow, 1995) and functioning as measured in the Clinical Global Impression scale (Guy, 1976). The effect of process variables on subsequent change in outcome variables was calculated using bivariate latent difference score modeling.
  
  
  RESULTS
  Change in panic symptomatology was preceded by catastrophic appraisal and agoraphobic avoidance across all phases of treatment, by anxiety sensitivity during generalization/follow-up, and by psychological flexibility during exposure in situ. Change in functioning was preceded by agoraphobic avoidance and psychological flexibility across all phases of treatment, by fear of bodily symptoms during generalization/follow-up, and by anxiety sensitivity during exposure.
  
  
  CONCLUSIONS
  The effects of process variables on outcomes differ across treatment phases and outcomes (i.e., symptomatology vs. functioning). Agoraphobic avoidance and psychological flexibility should be investigated and therapeutically targeted in addition to cognitive variables.
authors.affiliation: Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden.
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Gloster
authors.affiliation: Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden.
authors.forename: Jens
authors.initials: J
authors.lastname: Klotsche
authors.affiliation: Department of Psychology, Clinical Psychology, and Psychotherapy, University of Cologne.
authors.forename: Alexander L
authors.initials: AL
authors.lastname: Gerlach
authors.affiliation: Institute for Psychology, Physiological and Clinical Psychology/Psychotherapy, Ernst Moritz Arndt University of Greifswald.
authors.forename: Alfons
authors.initials: A
authors.lastname: Hamm
authors.affiliation: Department of Psychiatry, Charité- Universitätsmedizin Berlin.
authors.forename: Andreas
authors.initials: A
authors.lastname: Ströhle
authors.affiliation: Institute for Medical Psychology and Medical Sociology, University of Aachen.
authors.forename: Siegfried
authors.initials: S
authors.lastname: Gauggel
authors.affiliation: Clinic for Psychiatry and Psychotherapy, Philipps- University Marburg.
authors.forename: Tilo
authors.initials: T
authors.lastname: Kircher
authors.affiliation: Clinical and Biological Psychology and Psychotherapy, University of Mannheim.
authors.forename: Georg W
authors.initials: GW
authors.lastname: Alpers
authors.affiliation: Department of Psychiatry, Psychosomatics, and Psychotherapy, University of Würzburg.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Deckert
authors.affiliation: Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden.
authors.forename: Hans-Ulrich
authors.initials: HU
authors.lastname: Wittchen
mesh_terms: D000328:Adult; D000379:Agoraphobia / Q000150:complications / Q000523:psychology / Q000628:therapy*; D001007:Anxiety / Q000150:complications / Q000523:psychology / Q000628:therapy; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016584:Panic Disorder / Q000150:complications / Q000523:psychology / Q000628:therapy*; D016896:Treatment Outcome