Elsevier

Clinical Psychology Review

Volume 42, December 2015, Pages 179-192
Clinical Psychology Review

A systematic review of predictors and moderators of improvement in cognitive-behavioral therapy for panic disorder and agoraphobia

https://doi.org/10.1016/j.cpr.2015.09.004Get rights and content

Highlights

  • Agoraphobic avoidance predicted less improvement from pre- to post-treatment.

  • Functional impairment and low expectancy for change predicted less improvement.

  • Comorbid depression and medication use consistently did not predict improvement.

  • Few studies examined moderators of improvement in CBT vs. other treatments.

Abstract

Background: Despite the considerable efficacy of cognitive-behavioral therapy (CBT) for panic disorder (PD) and agoraphobia, a substantial minority of patients fail to improve for reasons that are poorly understood.

Objective: The aim of this study was to identify consistent predictors and moderators of improvement in CBT for PD and agoraphobia.

Data sources: A systematic review and meta-analysis of articles was conducted using PsycInfo and PubMed. Search terms included panic, agoraphobi*, cognitive behavio*, CBT, cognitive therapy, behavio* therapy, CT, BT, exposure, and cognitive restructuring.

Study selection: Studies were limited to those employing semi-structured diagnostic interviews and examining change on panic- or agoraphobia-specific measures.

Data extraction: The first author extracted data on study characteristics, prediction analyses, effect sizes, and indicators of study quality. Interrater reliability was confirmed.

Synthesis: 52 papers met inclusion criteria. Agoraphobic avoidance was the most consistent predictor of decreased improvement, followed by low expectancy for change, high levels of functional impairment, and Cluster C personality pathology. Other variables were consistently unrelated to improvement in CBT, understudied, or inconsistently related to improvement.

Limitations: Many studies were underpowered and failed to report effect sizes. Tests of moderation were rare.

Conclusions: Apart from agoraphobic avoidance, few variables consistently predict improvement in CBT for PD and/or agoraphobia across studies.

Section snippets

Identification and selection of studies

Relevant studies were primarily identified though literature searches conducted in January 2014 using the PsycInfo and PubMed databases. The search required that at least one of two key terms related to diagnosis (panic or agoraphobi*) and one of eight key terms related to treatment (cognitive behavio*, CBT, cognitive therapy, behavio* therapy, CT, BT, exposure, or cognitive restructuring) appear in the abstract. Databases were searched from the beginning of the database through January 2014.

Characteristics of included studies

Characteristics of the 52 papers included in the present review are displayed in Table A1. Fifty-one papers were published, peer-reviewed journal articles, and one paper was an unpublished dissertation. These papers encompass 39 studies and include a total of 3466 participants. The vast majority of studies (n = 28; 71.7%) included patients with PD with or without agoraphobia. Of these 28 studies, four excluded individuals with severe agoraphobia, and two of these also excluded individuals with

Discussion

We identified several pre-treatment variables that appear to predict improvement in CBT for panic disorder and/or agoraphobia. Specifically, greater pre-treatment severity of agoraphobic avoidance appears to consistently predict decreased improvement in CBT according to the meta-analysis, the narrative review, and the box score analysis. Additionally, our meta-analysis also indicated that diagnosis of a Cluster C PD is associated with less improvement in CBT, and the two studies examining

Role of funding sources

This study was not funded by an external organization.

Contributors

The first author (Eliora Porter) designed the study with input from the second author (Dianne Chambless). The first author also conducted literature searches, screened potentially eligible studies for inclusion, extracted data on study characteristics, prediction analyses, and indicators of study quality, conducted statistical analyses, and wrote the first draft of the manuscript. Both authors have contributed to and have approved the final manuscript.

Conflicts of interest

Both authors declare that they have no conflicts of interest.

Acknowledgments

The authors thank Kelly Allred, Lorenzo Lorenzo-Luaces, Jack Keefe, and Hana Zickgraf for their assistance in coding studies and extracting data. We also thank the following individuals for providing us with additional details regarding the methods and results of their original papers on predictors of improvement in CBT for PD and/or agoraphobia: Cindy Aaronson, Per Carlbring, David Clark, David Dozois, Raymond Goetz, Gert-Jan. Hendriks, Michael Höfler, Mirjam Kampman, Ger Keijsers, Justin

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    Note: Papers included in the systematic review are marked with an *. Papers included in the systematic review but discussed in appendices only are listed in Appendix F.

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