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Cognitive Restructuring and Interoceptive Exposure in the Treatment of Panic Disorder: a Crossover Study

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Cognitive Restructuring and Interoceptive Exposure in the Treatment of Panic Disorder: a Crossover Study Behavioural and Cognitive Psychotherapy, 1998, 26, 115±131 Cambridge University Press. Printed in the United Kingdom COGNITIVE RESTRUCTURING AND INTEROCEPTIVE EXPOSURE IN THE TREATMENT OF PANIC DISORDER: A CROSSOVER STUDY Jeffrey E. Hecker University of Maine, U.S.A. Christine M. Fink Maine Head Trauma Center, U.S.A. Nancy D. Vogeltanz University of North Dakota, U.S.A. Geoffrey L. Thorpe and Sandra T. Sigmon University of Maine, U.S.A. Abstract. The relative ef®cacy of cognitive restructuring and interoceptive exposure procedures for the treatment of panic disorder, as well as the differential effects of the order of these interventions, was studied. Eighteen clients with panic disorder were seen for four sessions of exposure therapy and four sessions of cognitive therapy in a cross- over design study. Half of the participants received exposure therapy followed by cogni- tive therapy and for half the order was reversed. There was a 1-month follow-up period between the two interventions and after the second intervention. Questionnaire meas- ures and independent clinician ratings were used to assess outcome. Participants expected greater bene®t from cognitive therapy, but tended to improve to a similar degree with either intervention. The order in which treatments were presented did not in¯uence outcome. Participants tended to improve with the ®rst intervention and main- tain improvement across the follow-up periods and subsequent intervention. Several methodological limitations qualify the conclusions that can be drawn from this study. These limitations, as well as some conceptual and methodological challenges of con- ducting this type of research, are discussed. Keywords: Panic disorder, cognitive-behavior therapy, cognitive restructuring, exposure therapy, interoceptive exposure. Reprint requests to Jeffrey E. Hecker, Department of Psychology, University of Maine, 5717 Corbett Hall, Orono, ME 04469, U.S.A. 1998 British Association for Behavioural and Cognitive Psychotherapies 116 J. E. Hecker et al. Introduction The 1980s witnessed the development of psychological treatments of panic disorder that directly target panic attacks and the anxiety associated with them. These treatments are based upon cognitive-behavioral principles (Barlow & Cerny, 1988; Hecker & Thorpe, 1992). Typically, treatment includes some combination of four components: education about the phenomena of panic and panic disorder which emphasizes the role of cogni- tive variables and learning experiences, a physiological control strategy (usually relax- ation training or controlled breathing), cognitive restructuring, and exposure to internal and external panic cues. Case studies and uncontrolled clinical trials provided the ®rst evidence for the ef®cacy of cognitive-behavioral treatment of panic disorder (Barlow et al., 1984; Clark, Salkovskis, & Chalkley, 1985; Gitlin et al., 1985). The late 1980s and early 1990s saw the publication of controlled studies of panic disorder treatment from clinical research centers in the United States and Europe (Beck, Sokol, Clark, Berchick, & Wright, 1992; Barlow, Craske, Cerny, & Klosko, 1989; Clark et al., 1994; Klosko, Barlow, Tassinari, & Cerny, 1990; Margraf, Barlow, Clark, & Telch, 1993; Ost, 1988; Ost & Westling, 1995). These studies consistently reported strong and clinically mean- ingful improvement in general anxiety, phobic avoidance, depression and panic attacks. Findings of 80% or more of panic disorder clients achieving panic-free status by the end of treatment were consistently reported. Follow-up studies indicate maintenance of improvement one to two years post-treatment (Clark, Salkovskis, Hackmann, & Gelder, 1991; Craske, Brown, & Barlow, 1991). Establishment of general treatment ef®cacy has led to questions about the relative contributions of components of cognitive-behavioral intervention. Two studies have compared relaxation training with cognitive therapy and exposure to panic cues alone or in combination. Barlow et al. (1989) found that while relaxation training, cognitive restructuring plus exposure to physiological panic cues, and a combination treatment were superior to a wait-list control on a variety of measures, the treatment conditions that included cognitive and exposure strategies led to signi®cantly more panic-free clients post-treatment than relaxation training alone. This advantage for cognitive restructuring plus exposure was still evident at two-year follow-up (Craske et al., 1991). Beck, Stanley, Baldwin, Deagle, and Averill (1994) compared cognitive therapy to relaxation training in the treatment of panic disorder. The interventions were delivered without exposure instructions or practice in this study. Both treatments were moder- ately effective with no clear differences appearing. Three studies have compared cognitive therapy (Clark, 1986) and applied relaxation (Ost, 1987). The latter intervention involves mastering a rapid relaxation technique and utilizing relaxation while gradually exposing oneself to feared conditions. Clark et al. (1994) found cognitive therapy to be more effective than applied relaxation on ques- tionnaire measures and panic frequency, while Ost & Westling (1995) did not ®nd consistent differences between the two procedures. Arntz and van den Hout (1996) found a clear advantage for cognitive therapy over applied relaxation on the percentage of panic-free patients and questionnaire measures at post-treatment and one month follow-up. The two interventions were no different at six-months post-treatment on questionnaire measures, but an advantage for cognitive therapy was still present based upon percentage of panic free patients. Cognitive and exposure therapies for panic disorder 117 Three studies have compared cognitive restructuring to exposure-based treatment of panic disorder. Margraf and Schneider (1991) treated a group of German panic dis- order clients in one of four conditions: ``pure'' cognitive therapy (no exposure to internal or external panic cues); ``pure'' exposure treatment (no reattribution of anxiety symptons); a combined cognitive and exposure therapy; and a wait-list control. Analy- sis of outcome measures including panic diaries, questionnaire measures, psycho- physiological monitoring, client and therapist ratings, and response to a panic- induction procedure indicated positive effects across the three treatment conditions with no improvement in the wait-list group. There were no outcome differences between the three treatment conditions, but fewer clients dropped out of the combined treatment condition. Bouchard et al. (1996) treated 28 individuals with panic disorder with agoraphobia over 14 sessions of exposure or cognitive restructuring. Exposure therapy was conduc- ted in groups and involved exposure to interoceptive panic cues (e.g., voluntary hyper- ventilation, spinning) in sessions 1±7 and group discussion of individualized in vivo exposure exercises, practiced individually between sessions, in sessions 7±14. Cognitive restructuring was also conducted in groups and was based upon standard practitioner guides (Barlow & Cerny, 1988; Beck & Emery, 1985; Clark & Salkovskis, 1987). These researchers hypothesized that, while both interventions would be effective, exposure therapy would result in more rapid therapeutic gains. Results indicated no differences in rate of change and the interventions were equally effective. In a third study comparing cognitive therapy with an exposure treatment, Williams and Falbo (1996) treated 48 individuals with panic disorder. Many of their subjects also met criteria for other axis I disorders (i.e., 26 with social phobia, 25 with major depression). There were four treatment conditions: cognitive therapy (Barlow & Cerny, 1988; Beck & Emery, 1985); performance-based treatment (Williams, 1990; Williams & Zane, 1989); combined treatment; or delayed treatment control. In performance-based treatment, therapists assisted subjects in developing plans for approaching activities that tended to provoke panic attacks. Subjects would practice these activities for three hours each week between sessions. Therapists used a variety of guided mastery aids, as described by Williams (1990), to help subjects succeed at mastering challenging situ- ations. No cognitive restructuring techniques were used. Results indicated that all three interventions were effective in helping subjects master panic. Performance-based treat- ment was signi®cantly superior to cognitive therapy on one measure of generalized phobic avoidance and two measures of panic-related cognitions. In summary, controlled trials have demonstrated cognitive-behavior therapy to be an effective treatment for panic disorder. Research to date on the components of cogni- tive-behavior therapy suggest that cognitive therapy by iteslf can be effective (Arntz & van den Hout, 1996; Margraf & Schneider, 1991; Salkovskis, Clark, & Hackmann, 1991) and may be more effective than relaxation training (Arntz & van den Hout, 1996; Clark et al., 1994), although ®ndings are inconsistent (Beck et al., 1994; Ost & Westling, 1995). Three studies comparing cognitive therapy to an intervention based only on exposure have found no differences among the two treatments and their combination (Bouchard et al. 1996; Margraf & Schneider, 1991; Williams & Falbo, 1996). 118 J. E. Hecker et al. The present paper describes a fourth comparison between an intervention focussed exclusively upon cognitive restructuring and a pure exposure treatment of panic dis- order. However, the present
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