title: Facing the fear--clinical and neural effects of cognitive behavioural and pharmacotherapy in panic disorder with agoraphobia.
abstract: BACKGROUND
  Cognitive behavioural therapy (CBT) and pharmacological treatment with selective serotonin or serotonin-noradrenalin reuptake inhibitors (SSRI/SSNRI) are regarded as efficacious treatments for panic disorder with agoraphobia (PD/AG). However, little is known about treatment-specific effects on symptoms and neurofunctional correlates.
  
  
  METHODS
  We used a comparative design with PD/AG patients receiving either two types of CBT (therapist-guided (n=29) or non-guided exposure (n=22)) or pharmacological treatment (SSRI/SSNRI; n=28) as well as a wait-list control group (WL; n=15) to investigate differential treatment effects in general aspects of fear and depression (Hamilton Anxiety Rating Scale HAM-A and Beck Depression Inventory BDI), disorder-specific symptoms (Mobility Inventory MI, Panic and Agoraphobia Scale subscale panic attacks PAS-panic, Anxiety Sensitivity Index ASI, rating of agoraphobic stimuli) and neurofunctional substrates during symptom provocation (Westphal-Paradigm) using functional magnetic resonance imaging (fMRI). Comparisons of neural activation patterns also included healthy controls (n=29).
  
  
  RESULTS
  Both treatments led to a significantly greater reduction in panic attacks, depression and general anxiety than the WL group. The CBT groups, in particular, the therapist-guided arm, had a significantly greater decrease in avoidance, fear of phobic situations and anxiety symptoms and reduction in bilateral amygdala activation while the processing of agoraphobia-related pictures compared to the SSRI/SSNRI and WL groups.
  
  
  CONCLUSIONS
  This study demonstrates that therapist-guided CBT leads to a more pronounced short-term impact on agoraphobic psychopathology and supports the assumption of the amygdala as a central structure in a complex fear processing system as well as the amygdala's involvement in the fear system's sensitivity to treatment.
authors.affiliation: Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany. Electronic address: carolin.liebscher@charite.de.
authors.forename: Carolin
authors.initials: C
authors.lastname: Liebscher
authors.affiliation: Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: André
authors.initials: A
authors.lastname: Wittmann
authors.affiliation: Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Johanna
authors.initials: J
authors.lastname: Gechter
authors.affiliation: Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany; Max Planck Institute for Human Cognitive and Brain Science, Leipzig, Germany.
authors.forename: Florian
authors.initials: F
authors.lastname: Schlagenhauf
authors.affiliation: Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital Würzburg, Würzburg, Germany.
authors.forename: Ulrike
authors.initials: U
authors.lastname: Lueken
authors.affiliation: Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Jens
authors.initials: J
authors.lastname: Plag
authors.affiliation: Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Straube
authors.affiliation: Department of Clinical Radiology, University of Münster, Münster, Germany.
authors.forename: Bettina
authors.initials: B
authors.lastname: Pfleiderer
authors.affiliation: Institute of Psychology, Psychotherapy and Somatopsychology - Humboldt University at Berlin, Berlin, Germany.
authors.forename: Lydia
authors.initials: L
authors.lastname: Fehm
authors.affiliation: Department of Psychology, University of Cologne, Cologne, Germany.
authors.forename: Alexander L
authors.initials: AL
authors.lastname: Gerlach
authors.affiliation: Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Marburg, Germany.
authors.forename: Tilo
authors.initials: T
authors.lastname: Kircher
authors.affiliation: Institute of Psychology, Psychotherapy and Somatopsychology - Humboldt University at Berlin, Berlin, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Fydrich
authors.affiliation: Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital Würzburg, Würzburg, Germany.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Deckert
authors.affiliation: Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany.
authors.forename: Hans-Ulrich
authors.initials: HU
authors.lastname: Wittchen
authors.affiliation: Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Heinz
authors.affiliation: Department of Psychiatry, University of Münster, Münster, Germany.
authors.forename: Volker
authors.initials: V
authors.lastname: Arolt
authors.affiliation: Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Ströhle
mesh_terms: D000379:Agoraphobia / Q000150:complications / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000534:rehabilitation*; D001921:Brain / Q000000981:diagnostic imaging / Q000187:drug effects / Q000502:physiology*; D015928:Cognitive Behavioral Therapy; D005239:Fear / Q000523:psychology; D005260:Female; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008279:Magnetic Resonance Imaging; D008297:Male; D010100:Oxygen / Q000097:blood; D016584:Panic Disorder / Q000150:complications / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000534:rehabilitation*; D010555:Personality Inventory; D011569:Psychiatric Status Rating Scales; D057566:Self Report; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use*; D013223:Statistics as Topic; D016896:Treatment Outcome
chemical_list: D010100:Oxygen; D017367:Selective Serotonin Reuptake Inhibitors
keywords: Agoraphobia; CBT; Panic; SSRI; Westphal-Paradigm; fMRI