East Asian Arch Psychiatry 2017;27:150-5

ORIGINAL ARTICLE

Fear of Fear and Broad Dimensions of Psychopathology over the Course of Cognitive Behavioural Therapy for Panic Disorder with Agoraphobia in Japan
S Ogawa, M Kondo, K Ino, T Ii, R Imai, T A Furukawa, T Akechi

Dr Sei Ogawa, MD, PhD, Department of Psychiatry and Cognitive-Behavioural Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
Dr Masaki Kondo, MD, PhD, Department of Psychiatry and Cognitive- Behavioural Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
Dr Keiko Ino, MD, Department of Psychiatry and Cognitive-Behavioural Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
Dr Toshitaka Ii, MD, Department of Psychiatry and Cognitive-Behavioural Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
Dr Risa Imai, MD, Department of Psychiatry and Cognitive-Behavioural Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
Dr Tatsuo Akechi, MD, PhD, Department of Psychiatry and Cognitive- Behavioural Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
Dr Toshi A. Furukawa, MD, PhD, Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan.

Address for correspondence: Dr Sei Ogawa, Department of Psychiatry and Cognitive-Behavioural Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan. Tel: (81) 528538271; Fax: (81) 528520837; 

Email: seiogawa1964@nifty.com

Submitted: 20 February 2017; Accepted: 14 August 2017


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Abstract

Objective: To examine the relationship of fear of fear and broad dimensions of psychopathology in panic disorder with agoraphobia over the course of cognitive behavioural therapy in Japan.

Methods: A total of 177 Japanese patients with panic disorder with agoraphobia were treated with group cognitive behavioural therapy between 2001 and 2015. We examined associations between the change scores in Agoraphobic Cognitions Questionnaire or Body Sensations Questionnaire and the changes in subscales of Symptom Checklist–90 Revised during cognitive behavioural therapy controlling the change in panic disorder severity using multiple regression analysis.

Results: Reduction in Agoraphobic Cognitions Questionnaire score was related to a decrease in all Symptom Checklist–90 Revised (SCL-90-R) subscale scores. Reduction in Body Sensations Questionnaire score was associated with a decrease in anxiety. Reduction in Panic Disorder Severity Scale score was not related to any SCL-90-R subscale changes.

Conclusions: Changes in fear of fear, especially maladaptive cognitions, may predict broad dimensions of psychopathology reductions in patients of panic disorder with agoraphobia over the course of cognitive behavioural therapy. For the sake of improving a broader range of psychiatric symptoms in patients of panic disorder with agoraphobia, more attention to maladaptive cognition changes during cognitive behavioural therapy is warranted.

Key words: Agoraphobia; Fear; Panic disorder

Introduction

Panic disorder (PD) is a common mental disorder with a lifetime prevalence of approximately 3%.1 It is associated with significant disability and diminished quality of life.Patients with PD commonly have a broad psychopathology. In all, 50% to 80% of PD patients meet the criteria for at least one other diagnosis, most typically other anxiety or mood disorders.3,4 Panic disorder with co-morbid psychiatric disorders is thought to be a severe condition. For example, the co-morbidity of PD with depressive disorder is thought to be associated with greater symptom severity5 and poorer treatment response.6 Successful treatment of PD is related to improvement in co-morbid psychiatric symptoms.

In particular, PD with agoraphobia (PDA) is common and being one of the most handicapping anxiety disorders. Approximately two-thirds of PD patients alsohave agoraphobia.8 Patients with PDA have many clinical problems. Their remission rates are lower and their relapse rates are higher than those with PD alone.9 Moreover, PDA is associated with greater functional impairment and greater disability.10

Panic disorder with agoraphobia can be conceptualised as fear of fear (FOF), or a tendency to respond fearfully to benign bodily sensations, and figures remarkably in several theoretical accounts of PDA.11,12 Fear of fear comprises 2 elements: maladaptive thoughts about the consequences of becoming anxious and a fear of bodily sensations associated with a panic attack.13 In a number of studies, FOF was associated with agoraphobic severity.13 Moreover, FOF is related to avoidance behaviour after treatment.14

The efficacy of cognitive behavioural therapy (CBT) for PDA is well established.15 There is now evidence that CBT for a targeted anxiety disorder causes positive outcomes in a broad range of psychopathologies.3,16 Although many researchers have performed mediation analyses to investigate the specific mechanism of changes during CBT, there is limited evidence about how CBT works for PDA.17 Improvement of FOF may mediate the acute-phase treatment effect on PDA symptoms in CBT.18 As mentioned above, successful CBT for PDA is associated with changes in co-morbid psychiatric symptoms, although it is unclear whether changes in FOF are also related to changes in broader psychiatric symptoms during CBT for PDA.

The present study aimed to examine the relationship of changes in FOF and changes in broader psychopathology over the course of CBT for PDA.

Methods

Participants

A total of 205 Japanese patients with PDA who attended the group CBT programme participated in the present study between October 2001 and February 2015. All of the patients met the following inclusion criteria: (i) principal Axis I diagnosis of PDA according to the DSM-IV criteria, as assessed by the Structured Clinical Interview for DSM-IV (SCID)19; (ii) free from benzodiazepine use prior to CBT entry, since these drugs may interact negatively with exposure treatments.20 Use of benzodiazepine to control anxiety was not permitted during the course of CBT; and (iii) highly motivated to undergo CBT. Exclusion criteria were current psychosis, bipolar disorder, and substance use disorder. Use of antidepressants to control anxiety or depression was permitted throughout the CBT period because these drugs do not interfere with CBT treatments.21 The patients provided written informed consent after receiving a full explanation of the purpose and procedures of the study.

The study was performed in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of the Nagoya City University Graduate School of Medical Sciences, Japan.

Treatments

We followed the established CBT treatment manual for PDA.9 Treatments were conducted in groups of 3 to 4 patients led by a principal therapist and a co- therapist. The 2 therapists were psychiatrists or clinical psychologists with at least 2 years of clinical experience. A total of 8 male and 6 female therapists conducted the CBT. The treatment consisted of 10 sessions, each lasting approximately 2 hours. The first through ninth sessions were held weekly, and the tenth session was conducted 4 weeks after the ninth session. The first 2 sessions included psycho-education about the nature of anxiety, panic and agoraphobia and provided a rationale for training in breathing retraining. From the third session on, cognitive restructuring, situational and interoceptive exposure were introduced, and patients were asked to try to formulate rational thoughts and to perform self-exposure tasks without therapists to reproduce both situational and interoceptive phobic cues during and between sessions.

Assessment

All patients completed the SCID at baseline, including the anxiety and mood disorder sections. This interview was conducted by one of the therapists in charge of the programme. All researchers were trained in carrying out the SCID and completing the Panic Disorder Severity Scale (PDSS). All subjects were assessed with the following instruments pre- and post-treatment.

Symptom Checklist–90 Revised

The Symptom Checklist–90 Revised (SCL-90-R) is widely used to assess general psychopathology.22 It contains 90 items, subdivided into 9 subscales of somatisation, obsessive-compulsive disorder, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Each item was scored between 0 (not at all) and 4 (extremely), and the average of the relevant items was taken as the subscale score. The reliability and validity of the Japanese version have been reported.23,24

Agoraphobic Cognitions Questionnaire

The Agoraphobic Cognitions Questionnaire (ACQ) is a 14-item self-report instrument to assess maladaptive thoughts concerning catastrophic consequences of experiencing anxiety in FOF. Frequency of each item is rated on a 5-point scale ranging from 1 (thought never occurs) to 5 (thought always occurs). Good reliability and validity have been shown for both original and Japanese versions of this questionnaire.13,25

Body Sensations Questionnaire

The Body Sensations Questionnaire (BSQ) is a 17-item self-report instrument to assess the fear evoked by panic- related bodily sensations in FOF. Degree of each item is rated on a 5-point scale ranging from 1 (not frightened or worried by this sensation) to 5 (extremely frightened by this sensation). Reliability and validity of original and Japanese versions of this questionnaire have been established.13,26

Panic Disorder Severity Scale

The PDSS is an interview-based, 7-item scale to assess overall severity of PD in which the clinician rates the severity of 7 features of PD on a scale ranging from 0 (none) to 4 (extreme). The 7 areas include the frequency of panic attacks; distress during the panic attacks; anticipatory anxiety; agoraphobic fear / avoidance; interoceptive fear / avoidance; work impairment / distress; and impairment of social functioning. The reliability and validity have been reported for both original and Japanese versions.27,28

Statistical Analyses

All data were examined using the SPSS (Windows version 18.0; SPSS Inc., Chicago [IL], US). The pre- and post- treatment data were used to calculate change scores (Δ) for each variable. First, we used an independent-samples t test and χ2 tests to compare the demographic and clinical data among the patients who completed the programme and those who did not. Second, we used paired t tests to compare the pre- and post-therapy scores. Third, simple correlations among change scores of independent variables were examined. Generally, if the correlation between 2 variables (including those in multiple linear regression analysis) is high, it may cause multicollinearity that influences interpretation of the findings. If 2 independent variables had a correlation of > 0.7, we could omit one in multiple regression analysis. Last, to examine the predictors of changes in co-morbid psychiatric symptoms, we performed multiple linear regression analysis. We used the changes in 9 subscales of SCL-90-R as dependent variables, and the changes in the total scores of ACQ and BSQ as independent variables controlling the changes in the PDSS total score. All statistical tests were 2-tailed. Except for multiple linear regression analysis, an alpha value of < 0.05 was considered statistically significant. In order to counteract the problem of multiple comparisons, we used the Bonferroni correction. In multiple linear regression analysis, an alpha value of < 0.005 was considered statistically significant.

Results

Of 205 patients, 28 (13.0%) who started CBT treatment dropped out prematurely from the programme: 16 were lost to follow-up, 4 discontinued because of clinical relapse, 4 because of personal choice, and 4 for other reasons. Table 1 shows their baseline demographic and clinical characteristics. No statistically significant differences were found between the subgroups. Of 102 patients who completed the trial and had used an antidepressant at baseline, 21 tapered or stopped usage at the endpoint.

Table 2 shows that all SCL-90-R subscale scores at baseline were higher than those of Japanese community sample,24 and all post-treatment scores were significantly lower than the pre-treatment scores (p < 0.001).

Table 3 shows that all bivariate correlations of change scores of PDSS, ACQ, and BSQ were < 0.6 implying that the correlation was relatively low and might not cause multicollinearity.

In regression analysis (Table 4), the reduction in ACQ score was related to the decrease in all SCL-90-R subscale scores. Reduction in BSQ score was significantly associated with decrease in anxiety only (p < 0.01). Reduction in PDSS score was not related to any SCL-90-R subscale changes.

Discussion

This study investigated the relationship of FOF and broad areas of psychopathology in PDA patients over the course of CBT in Japan using multiple regression analysis. The results show that changes in maladaptive thoughts concerning catastrophic consequences of experiencing anxiety predicted broad dimensions of psychopathological changes, whereas changes in the fear evoked by panic- related bodily sensations predicted anxiety only, in patients

Table 1. Baseline characteristics of the patients.*

150 T1

Abbreviations: ACQ = Agoraphobic Cognitions Questionnaire; BSQ = Body Sensations Questionnaire; PDSS = Panic Disorder
Severity Scale.

* Data are shown as No. (%) of subjects or mean ± standard deviation.

Table 2. Pretreatment and post-treatment rating scale scores (n = 177).*

150 T2

Abbreviations: ACQ = Agoraphobic Cognitions Questionnaire; BSQ = Body Sensations Questionnaire; PDSS = Panic Disorder
Severity Scale; SCL-90-R = Symptom Checklist–90 Revised.

* Data are shown as mean ± standard deviation.

Table 3. Correlations among changes in PDSS, ACQ, and BSQ (n = 177).

150 T3

Abbreviations: ACQ = Agoraphobic Cognitions Questionnaire; BSQ = Body Sensations Questionnaire; N/A = not applicable; PDSS = Panic Disorder Severity Scale.

* p < 0.01.

 

with PDA during CBT. On the contrary, reduction in PD severity was not related to changes in co-morbid psychiatric symptoms over the course of CBT for PDA.

These results are consistent with the findings that cognitive factors are an important transdiagnostic target of treatment.29 Improvement in FOF, especially disorder- specific maladaptive cognitions, may mediate treatment effects on co-morbid psychiatric symptoms beyond those of PDA during CBT.

Furthermore, our results suggest that the changes in PD severity may not contribute to improvement in broad areas of psychopathology. Changes in maladaptive cognitions may be superior to changes in PDA symptoms in predicting improvements in co-morbid psychiatric symptoms during CBT. This work emphasises the importance of considering cognitive factors in CBT for PDA.

As mentioned above, PD patients commonly have broad psychiatric symptoms. From the clinical point of view, it may be useful to focus on achieving cognitive changes in preference to PDA symptom changes during CBT for the purpose of improving broader psychopathology.

The present study had several limitations. First, the study did not involve a control group. It is not certain whether the significant reduction in the symptomatology or maladaptive cognitions were due to CBT treatment rather than the passage of time. A randomised controlled trial with an appropriate control group is needed to investigate the efficacy of CBT for PDA. Second, because independent and dependent variables were measured at the same time point, we were not able to assess whether changes in maladaptive cognitions preceded changes in broader areas of psychopathology. It is necessary to use a design with temporal delay between assessments of maladaptive thoughts and broader psychiatric symptoms in future studies. Third, our multiple regression analysis used only 2 elements of FOF as independent variables, therefore our results accounted for less than half of the variance in changes in broader areas of psychopathology. Lastly, we used a standardised CBT manual, and did not record the interviews or performances to ensure the accuracy of materials provided to patients in the course of CBT.

Conclusions

We examined the relationship of FOF and broad areas of psychopathology in PDA patients during CBT using multiple regression analysis in Japan. Changes in maladaptive cognitions concerning potential harm of a panic attack may predict changes in broad areas of psychopathology in PDA patients over the course of CBT. For the purpose of improving a broad range of psychiatric symptoms in patients with PDA, more attention to maladaptive cognition changes during CBT is warranted.

Table 4. Unique predictors of changes in co-morbid psychiatric symptoms (n = 177).*

150 T4

Abbreviations: ACQ = Agoraphobic Cognitions Questionnaire; ANX = anxiety; BSQ = Body Sensations Questionnaire; DEP = depression; HOS = hostility; I-S = interpersonal sensitivity; O-C = obsessive-compulsive disorder; PAR = paranoid ideation; PDSS = Panic Disorder Severity Scale; PHOB = phobic anxiety; PSY = psychoticism; SCL-90-R = Symptom Checklist–90 Revised; SOM = somatisation.

* Data are shown as standardised beta coefficients.

p < 0.01.

p < 0.001.

Acknowledgements

This study was supported by the Grants-in-Aid from the Ministry of Education, Culture, Sports, Science, and Technology from Japan (23530910).

Declaration

All authors have disclosed no conflicts of interest.

References

  1. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:593-602.
  2. Ettigi P, Meyerhoff AS, Chirban JT, Jacobs RJ, Wilson RR. The quality of life and employment in panic disorder. J Nerv Ment Dis 1997;185:368-72.
  3. Tsao JC, Lewin MR, Craske MG. The effects of cognitive-behavior therapy for panic disorder on comorbid conditions. J Anxiety Disord 1998;12:357-71.
  4. Brown TA, Antony MM, Barlow DH. Diagnostic comorbidity in panic disorder: effect on treatment outcome and course of comorbid diagnoses following treatment. J Consult Clin Psychol 1995;63:408- 18.
  5. Noyes R Jr, Reich J, Christiansen J, Suelzer M, Pfohl B, Coryell WA. Outcome of panic disorder. Relationship to diagnostic subtypes and comorbidity. Arch Gen Psychiatry 1990;47:809-18.
  6. Keller MB, Lavori PW, Goldenberg IM, Baker LA, Pollack MH, Sachs GS, et al. Influence of depression on the treatment of panic disorder with imipramine, alprazolam and placebo. J Affect Disord 1993;28:27- 38.
  7. Barlow DH. Anxiety and its disorders: the nature and treatment of anxiety and panic. 2nd ed. New York, NY: Guilford Press; 2002.
  8. Eaton WW, Anthony JC, Romanoski A, Tien A, Gallo J, Cai G, et al. Onset and recovery from panic disorder in the Baltimore Epidemiologic Catchment Area follow-up. Br J Psychiatry 1998;173:501-7.
  9. Andrews G, Creamer M, Crino R, Hunt C, Lampe L, Page A. The treatment of anxiety disorders: clinician guides and patient manuals. 2nd ed. New York, NY: Cambridge University Press; 2003.
  10. Grant BF, Hasin DS, Stinson FS, Dawson DA, Goldstein RB, Smith S, et al. The epidemiology of DSM-IV panic disorder and agoraphobia in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2006;67:363- 74.
  11. 1 Clark DM, Salkovskis PM, Hackmann A, Middleton H, Anastasiades P, Gelder M. A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. Br J Psychiatry 1994;164:759-69.
  12. Bouton ME, Mineka S, Barlow DH. A modern learning theory perspective on the etiology of panic disorder. Psychol Rev 2001;108:4- 32.
  13. Chambless DL, Caputo GC, Bright P, Gallagher R. Assessment of fear of fear in agoraphobics: the body sensations questionnaire and the agoraphobic cognitions questionnaire. J Consult Clin Psychol 1984;52:1090-7.
  14. Chambless DL, Gracely EJ. Fear of fear and the anxiety disorders. Cognit Ther Res 1989;13:9-20.
  15. Otto MW, Deveney C. Cognitive-behavioral therapy and the treatment of panic disorder: efficacy and strategies. J Clin Psychiatry 2005;66 Suppl 4:28-32.
  16. Craske MG, Farchione TJ, Allen LB, Barrios V, Stoyanova M, Rose R. Cognitive behavioral therapy for panic disorder and comorbidity: more of the same or less of more? Behav Res Ther 2007;45:1095-109.
  17. Oei TP, McAlinden NM, Cruwys T. Exploring mechanisms of change: the relationships between cognitions, symptoms, and quality of life over the course of group cognitive-behaviour therapy. J Affect Disord 2014;168:72-7.
  18. Smits JA, Powers MB, Cho Y, Telch MJ. Mechanism of change in cognitive-behavioral treatment of panic disorder: evidence for the fear of fear mediational hypothesis. J Consult Clin Psychol 2004;72:646- 52.
  19. First MB. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), clinician version, administration booklet. Washington, D.C.: American Psychiatric Press; 1997.
  20. Watanabe N, Churchill R, Furukawa TA. Combined psychotherapy plus benzodiazepines for panic disorder. Cochrane Database Syst Rev 2009;(1):CD005335.
  21. Furukawa TA, Watanabe N, Churchill R. Psychotherapy plus antidepressant for panic disorder with or without agoraphobia: systematic review. Br J Psychiatry 2006;188:305-12.
  22. Derogatis LR. SCL-90-R: Administration, scoring and procedures manual–II for the R (evised) version and other instruments of the psychopathology rating scale series. 2nd ed. Towson, MD: Clinical Psychometric Research; 1992.
  23. Furukawa TA, Nakanishi M, Sakurai A, Suzuki A, Suzuki-Moor A, Hamanaka T. Effects of ethyl loflazepate in mood and neurosis-related disorders (ICD-10 JCM): Changes in SCL-90-R subscale scores. Rinsho Seisinigaku (Jpn J Clin Psychiatry) 1996;25:233-40.
  24. Tomioka M, Shimura M, Hidaka M, Kubo C. The reliability and validity of a Japanese version of symptom checklist 90 revised. Biopsychosoc Med 2008;2:19.
  25. Noda Y, Nakano Y, Lee K, Ogawa S, Kinoshita Y, Funayama T, et al. Sensitization of catastrophic cognition in cognitive-behavioral therapy for panic disorder. BMC Psychiatry 2007;7:70.
  26. Lee K, Noda Y, Nakano Y, Ogawa S, Kinoshita Y, Funayama T, et al. Interoceptive hypersensitivity and interoceptive exposure in patients with panic disorder: specificity and effectiveness. BMC Psychiatry 2006;6:32.
  27. Shear MK, Brown TA, Barlow DH, Money R, Sholomskas DE, Woods SW, et al. Multicenter collaborative panic disorder severity scale. Am J Psychiatry 1997;154:1571-5.
  28. Yamamoto I, Nakano Y, Watanabe N, Noda Y, Furukawa TA, Kanai T, et al. Cross-cultural evaluation of the Panic Disorder Severity Scale in Japan. Depress Anxiety 2004;20:17-22.
  29. Boswell JF, Farchione TJ, Sauer-Zavala S, Murray HW, Fortune MR, Barlow DH. Anxiety sensitivity and interoceptive exposure: a transdiagnostic construct and change strategy. Behav Ther 2013;44:417-31.
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