Elsevier

Biological Psychiatry

Volume 73, Issue 11, 1 June 2013, Pages 1064-1070
Biological Psychiatry

Archival Report
Changes in Automatic Threat Processing Precede and Predict Clinical Changes with Exposure-Based Cognitive-Behavior Therapy for Panic Disorder

https://doi.org/10.1016/j.biopsych.2013.02.005Get rights and content

Background

Cognitive behavioral therapy (CBT) is an effective treatment for emotional disorders such as anxiety or depression, but the mechanisms underlying successful intervention are far from understood. Although it has been a long-held view that psychopharmacological approaches work by directly targeting automatic emotional information processing in the brain, it is usually postulated that psychological treatments affect these processes only over time, through changes in more conscious thought cycles. This study explored the role of early changes in emotional information processing in CBT action.

Methods

Twenty-eight untreated patients with panic disorder were randomized to a single session of exposure-based CBT or waiting group. Emotional information processing was measured on the day after intervention with an attentional visual probe task, and clinical symptoms were assessed on the day after intervention and at 4-week follow-up.

Results

Vigilance for threat information was decreased in the treated group, compared with the waiting group, the day after intervention, before reductions in clinical symptoms. The magnitude of this early effect on threat vigilance predicted therapeutic response after 4 weeks.

Conclusions

Cognitive behavioral therapy rapidly affects automatic processing, and these early effects are predictive of later therapeutic change. Such results suggest very fast action on automatic processes mediating threat sensitivity, and they provide an early marker of treatment response. Furthermore, these findings challenge the notion that psychological treatments work directly on conscious thought processes before automatic information processing and imply a greater similarity between early effects of pharmacological and psychological treatments for anxiety than previously thought.

Section snippets

Participants

Twenty-eight patients with DSM-IV PD with or without agoraphobia, naïve to exposure-based CBT, were recruited. They were randomly assigned to one of two experimental conditions, either receiving a single session of exposure-based CBT (treatment group [TG]) or no intervention (until after the study procedures and assessments; waiting group [WG]). Diagnoses were assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders Clinician Version (20). Patients had to present with at

Group Matching

The two groups were not different with respect to gender [χ21 = .70, p = .68], age, years of education, and verbal intelligence; and they experienced similar degrees of panic severity and panic attack frequency at baseline [all t26<1.04, all p>.31] (Table 1). Furthermore, they were well-matched in terms of primary diagnosis [panic disorder with agoraphobia: 14 TG, 12 WG; panic disorder without agoraphobia: 0 TG, 2 WG; χ21 = 2.15, p = .48] or comorbid diagnoses (depression: 1 TG, 1 WG; anxiety

Discussion

This study shows that a single session of exposure-based CBT has rapid effects on automatic emotional processing. Although on the day after treatment symptoms of panic and anxiety were still unaffected, TG patients already showed significantly reduced hyper-vigilance for fear faces compared with the WG. Moreover, greater reduction in fear bias in TG patients on the day after treatment was associated with greater improvement in agoraphobic avoidance during the 4-week follow-up period, with over

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