درمان شناختی در مقابل مواجهه کالبد شناسی به عنوان درمان اختلال پانیک بدون موقعیت هراسی

Cognitive therapy (CT) and interoceptive exposure (IE) as treatments of panic disorder without agoraphobia were compared in a sample of 69 patients, randomly allocated to condition. There were no significant differences between treatments as to reductions in panic frequency, daily anxiety levels and a composite questionnaire score, at posttest after the 12-session treatment, and at both follow-ups (4 weeks, 6 months). In both conditions, high percentages of patients were panic free at post and follow-up tests (range 75–92%). Although the reduction in idiosyncratic beliefs about the catastrophic nature of bodily sensations was equally strong in both conditions, post-treatment beliefs correlated strongly with symptoms at post and follow-up tests in the CT condition, but not in the IE condition. Reduction of beliefs may be essential in CT, but not in IE. This suggests that the two treatments utilize different change mechanisms.

In the last decades various cognitive behavioral therapies (CBT) for panic disorder without agoraphobia have been developed. The treatments that seem to be the most effective aim at reducing both the perceived danger and the fear of symptoms associated with panic attacks. These approaches generally reach very high success percentages in the treatment of panic disorder without agoraphobia. In a recent overview, Clark (1999) presented 7 controlled studies in 6 different countries comparing Clark and Salkovskis' version of cognitive therapy (CT) for panic (Clark, 1986 and Clark & Salkovskis, 1986) with other treatments. In all of these studies (Arntz & van den Hout, 1996, Beck, Sokol, Clark, Berchick & Wright, 1992, Clark et al., 1994, Clark et al., 1999, Hoffart, 1995, Hoffart, 1998, Margraf & Schneider, 1991 and Öst & Westling, 1995), the specific CT was superior to the wait list, and to other treatments, including supportive therapy, applied relaxation (2 out of 3 studies), and imipramine. At the end of treatment an average of 84% of the patients was panic free (range 74–94%) and results were well maintained at follow up (an average of 78% panic free). Other CBT approaches, of which Barlow and Craske's (1994) version is the best known, have comparable success rates (e.g., Barlow, Craske, Cerny & Klosko, 1989, Beck, Stanley, Deagle & Averill, 1994, Klosko, Barlow, Tassinari & Cerny, 1990 and Michelson et al., 1990). Many of these CBT packages incorporate at least two procedures. First, cognitive therapeutic procedures to change catastrophic misinterpretations of bodily sensations, mainly by challenging automatic thoughts representing these misinterpretations, and gathering potentially corrective information. Second, exposure procedures to let the patient habituate to the fear evoked by experiencing certain bodily sensations. Barlow and Craske's package explicitly involves both types of procedures. In contrast, Clark and Salkovskis' package seems more cognitive, though the extensive use of behavioral experiments does not preclude that exposure to bodily sensations is an important ingredient of this treatment. The success of these packages raises the question of what the most effective, or even essential, ingredient is. A direct comparison of cognitive procedures with exposure to feared bodily sensations seems therefore relevant. For clinical reasons, it is important to compare the effects of exposure to bodily sensations to cognitive procedures, to get an idea of what the most effective procedure is. For more theoretical reasons, a direct comparison seems relevant to test the hypothesis that treatment, of any type, only works if the belief in catastrophic misinterpretations reduces during treatment (Clark, 1986 and Clark et al., 1994). There are, globally speaking, two schools of thought about psychological processes underlying pathological anxiety and successful treatment. According to the first school, psychological processes which are (mainly) automatic and nonreflective (or even nonconscious) are responsible for the maintenance of pathological anxiety. Treatment is based on procedures that involve information processing at these levels, for instance prolonged exposure in vivo. Conscious thoughts about danger are not supposed to play an important role in the maintenance of the disorder, and conscious and deliberate attempts to change ideas about the dangerousness of the feared stimuli are not believed to lead to any change. Öhman's theory of phobias (Öhman, 1997 and Öhman & Soares, 1994) and Marks' ideas about the acquisition of fear and the role of habituation in the reduction of fear (Marks, 1987) are examples of this school of thought. In the second school of thought, conscious ideas that people have about the dangerousness of the feared stimuli are given the most prominent role. These ideas are, according to this school, accessible for consciousness, and changing them by deliberate considerations is essential for reduction of fear to take place. Beck's (Beck, Emery, & Greenberg, 1985) and Clark's (1986) and Clark (1986) models of anxiety disorders are examples of theories that fit in this school of thought. The Oxford group has formulated an explicit prediction in this respect: “The cognitive theory of panic predicts that sustained improvement after the end of any treatment (whether psychological or pharmacological) will depend on cognitive change having occurred during the course of therapy” (Clark et al., 1994 and Clark, 1986). To summarize, the first school of thought assumes that nonconscious processes play the essential role in pathological anxiety and its reduction. Lower level learning processes, such as habituation, trial and error learning, and processes of an associative nature, are the prominent processes in acquisition and reduction of fear. The second school of thought assumes that conscious and deliberate processes are essential. Higher level learning processes, such as logical reasoning and explicit hypothesis formulation and testing are assumed to be essential. The question of which of these theories is true, is in the present author's view an empirical issue. It is also possible that both “higher level” and “lower level” psychological processes play a role in pathological anxiety, or that in some disorders one of the type of processes is the most prominent, whereas in other forms of psychopathology the other processes dominate. Recently, theories have been proposed that incorporate both types of processes, e.g. the SPAARS model (Power & Dalgleish, 1997 and Power & Dalgleish, 1999) proposes that both interpretational processes and associative processes are involved in emotional disorders. The present study, comparing exposure to feared bodily sensations with cognitive procedures as treatment of panic disorder gives an opportunity to investigate this issue in a clinical context. Clark et al. (1994) used a standardized belief measure and found in the whole sample positive associations with symptom levels at posttest and at follow-up. But, the association was not assessed within each treatment modality (CT, applied relaxation and imipramine). To test the hypothesis that reduction of danger beliefs accessible for consciousness is essential to reduce the pathological anxiety, idiosyncratic beliefs about the dangerousness of specific bodily sensations were formulated and repeatedly rated by the patients during therapy. Both treatment modalities were compared as to the reduction of these beliefs, and the strength of the beliefs immediately after treatment was within each condition correlated with symptom measures assessed immediately after treatment, and at follow-up. There are, to the best of the present author's knowledge, 3 studies that addressed the issue whether purely cognitive procedures can reduce the fear of panic attacks and the frequency of panic attacks. Margraf and Schneider (1991) compared pure cognitive therapy (without exposure), pure exposure (with minimal cognitive therapeutic elements), a combined treatment and a wait list control condition. Unfortunately, the study is still not published, but reports on conferences and in overview articles (Clark, 1999 and Margraf, Barlow, Clark & Telch, 1993) indicate that all active conditions were successful, compared to wait list. As to proportion of panic free patients after treatment, the combined treatment seemed to be the most successful (91%), the pure exposure treatment the least (52%), and the pure cognitive treatment in between (73%) (cf. Clark, 1999). Salkovskis, Clark, and Hackman (1991) and Arntz, Krol, and van Rijsoort (1993) and Arntz, Krol & van Rijsoort (1993) both demonstrated with a case series design that a purely cognitive intervention, concentrated in a short time (in the case of Arntz et al.'s study even on one day) was successful in reducing panic frequency. To summarize, there is ample evidence that purely cognitive procedures, not involving direct exposure to bodily sensations, are capable of reducing panic frequency. Much less is known about the relative efficacy of the two types of procedures, and about the involvement of conscious considerations about the dangerousness of bodily sensations in non-cognitive treatments. The present study aimed to investigate these two issues.