Professional Documents
Culture Documents
Jacques P. Barber
Adelphi University
Objective: To identify variables predicting psychotherapy outcome for panic disorder or indicating which of
2 very different forms of psychotherapy—panic-focused psychodynamic psychotherapy (PFPP) or cognitive-
behavioral therapy (CBT)—would be more effective for particular patients. Method: Data were from 161
adults participating in a randomized controlled trial (RCT) including these psychotherapies. Patients included
104 women; 118 patients were White, 33 were Black, and 10 were of other races; 24 were Latino(a).
Predictors/moderators measured at baseline or by Session 2 of treatment were used to predict change on the
Panic Disorder Severity Scale (PDSS). Results: Higher expectancy for treatment gains (Credibility/
Expectancy Questionnaire d ⫽ ⫺1.05, CI95% [⫺1.50, ⫺0.60]), and later age of onset (d ⫽ ⫺0.65, CI95%
[⫺0.98, ⫺0.32]) were predictive of greater change. Both variables were also significant moderators: patients
with low expectancy of improvement improved significantly less in PFPP than their counterparts in CBT,
whereas this was not the case for patients with average or high levels of expectancy. When patients had an
onset of panic disorder later in life (ⱖ27.5 years old), they fared as well in PFPP as CBT. In contrast, at low
and mean levels of onset age, CBT was the more effective treatment. Conclusions: Predictive variables
suggest possibly fruitful foci for improvement of treatment outcome. In terms of moderation, CBT was the
more consistently effective treatment, but moderators identified some patients who would do as well in PFPP
as in CBT, thereby widening empirically supported options for treatment of this disorder.
This article was published Online First June 26, 2017. University, Northern Virginia; Jacques P. Barber, Derner Institute of Ad-
Dianne L. Chambless, Department of Psychology, University of Penn- vanced Psychological Studies, Adelphi University.
sylvania; Barbara Milrod, Department of Psychiatry, Weill Cornell Med- This research was supported by National Institute of Mental Health
ical College; Eliora Porter, Department of Psychology, University of grants to Barbara Milrod (Grant R01 MH70918) and to Jacques P. Barber
Pennsylvania; Robert Gallop, Department of Mathematics, West Chester and Dianne L. Chambless (Grant R01 MH 070664).
University; Kevin S. McCarthy, Department of Psychology, Chestnut Hill Correspondence concerning this article should be addressed to Dianne L.
College; Elizabeth Graf, Independent Practice, New York, New York; Chambless, Department of Psychology, University of Pennsylvania, 425 South
Marie Rudden, Department of Psychiatry, Weill Cornell Medical College; University Avenue, Philadelphia, PA 19104-6018. E-mail: chambless@
Brian A. Sharpless, American School of Professional Psychology, Argosy psych.upenn.edu
803
804 CHAMBLESS ET AL.
Panic disorder is associated with substantial societal and eco- change, and greater pretreatment functional impairment consis-
nomic costs, including high rates of health service utilization and tently predicted worse response to CBT in this population. There
absenteeism from work (Batelaan et al., 2007; de Graaf, Tuithof, was also some indication in this review that individuals with a later
van Dorsselaer, & ten Have, 2012), poor physical health, de- age of onset and a shorter duration of disorder fared better in CBT,
creased quality of life, and impairments in social and occupational but these variables were conceptualized somewhat differently
functioning (e.g., Markowitz, Weissman, Ouellette, Lish, & Kler- across studies, making the literature difficult to synthesize. Finally,
man, 1989). Fortunately, effective treatments for this condition this meta-analysis indicated that the presence of a comorbid Clus-
exist. A wealth of evidence supports the efficacy of CBT in the ter C personality disorder was predictive of decreased improve-
treatment of panic disorder (see Mitte, 2005, for a meta-analysis ment in CBT for panic disorder and/or agoraphobia. However,
and review). More recently, Milrod, Busch, Cooper, and Shapiro results from the individual studies included in the meta-analysis
(1997) developed PFPP, a time-limited, manualized psychody- were mixed, with one study finding that patients with Cluster C
namic treatment that specifically targets panic symptoms. In a disorders fared worse, and two studies finding no significant
small RCT, PFPP outperformed applied relaxation training (ART) effects. Despite exhaustive search procedures, we located no study
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
in the reduction of panic symptoms and improvement in psycho- that examined moderators of response to a CBT treatment as
This document is copyrighted by the American Psychological Association or one of its allied publishers.
social functioning (Milrod, Leon, Busch, et al., 2007). Other compared with another form of psychotherapy.
supportive evidence of PFPP’s efficacy comes from a study of its It seems highly likely that some of the identified predictors may
effectiveness in clinical practice (Beutel et al., 2013). not be specific to CBT, but instead might predict response to
No single psychotherapy is effective for all patients with panic psychotherapy more broadly. For example, individuals who expect
disorder. For example, in a recent large clinical trial of three more benefit from therapy at the outset of treatment are likely to
psychotherapies (Milrod et al., 2016), 54% of patients failed to make greater gains in any form of psychotherapy (Constantino,
respond to ART, 41% to PFPP, and 37% to CBT. Thus, research- Glass, Arnkoff, Ametrano, & Smith, 2011). Similarly, we might
ers have sought to identify which factors explain this variability in expect individuals with an earlier age of onset, longer duration of
treatment response. A key question is whether there are individual disorder, greater agoraphobic avoidance, and greater functional
differences that reliably predict better response to one treatment disability to do more poorly in any form of psychotherapy than
over another. These variables are referred to as moderators and, patients without these pretreatment characteristics in light of the
once identified, they can be used to guide treatment selection. A chronicity and severity of their condition. Although the literature
related question is whether there are certain types of patients who on Cluster C diagnosis as a predictor of outcome for anxiety
do not fare well in any existing treatment. Predictor variables disorders is scant and mixed, in a 2003 review Reich concluded
predict treatment outcome irrespective of the type of treatment, that, overall, personality disorders (including but not limited to
and the identification of such variables is an important first step Cluster C) are a predictor of poor outcome for anxiety treatments
toward developing more effective treatments for individuals who across the board, with the possible exception of selective seroto-
do not benefit from existing interventions. nergic reuptake inhibitors (Reich, 2003).
In the present study, we use data from the Milrod et al. (2016)
trial to examine predictors and moderators of response to CBT and
Predictors and Moderators of Response to
PFPP. Although both treatments are symptom-focused, they rep-
resent two very different approaches to treatment in theory and in Psychodynamic Therapy for Panic Disorder
execution. CBT is a very directive treatment involving psychoe- There is little research on predictors of response to psychody-
ducation, cognitive restructuring, and interoceptive and in vivo namic treatments for panic disorder. Beutel et al. (2013) found that
exposure, with copious homework designed to help the patient higher emotional awareness and lower global illness ratings at
become less fearful by changing catastrophic thinking about panic baseline predicted more change in treatment for patients with panic
and relinquishing avoidance behaviors. In contrast, PFPP is a disorder receiving either PFPP or CBT. The preponderance of
short-term, transference-based psychodynamic treatment that es- patients their study received PFPP, but the sample sizes were too
chews homework assignments and focuses on helping patients to small to test prediction of PFPP alone. Existing papers on moder-
uncover the unconscious meanings of their panic symptoms and to ation of response to psychodynamic treatments for panic disorder
resolve core unconscious conflicts leading to panic. Frequent foci have all investigated moderators of PFPP versus ART in a single
are recognizing, managing, and expressing anger and guilt and small, exploratory study (Milrod, Leon, Busch, et al., 2007), which
conflicts over separation and autonomy. The stark contrast be- found that PFPP was superior to ART. No statistically significant
tween these treatments suggests it should be possible to identify moderators were identified, which is unsurprising given the small
patients who would benefit more from one than the other.1 sample size in this trial. In several other papers Milrod and
colleagues sought to examine moderators in their study, but in light
Predictors and Moderators of Response to CBT for of their small sample appropriately did not employ statistical tests
Panic Disorder of their hypotheses (Kraemer, Wilson, Fairburn, & Agras, 2002).
However, there is some suggestion from the prepost effect sizes for
We began variable selection for this study by conducting a
systematic review and meta-analysis of the literature on predictors
1
and moderators of response to CBT for panic disorder and/or Milrod et al. (2016) included a third treatment group, ART. Because
this condition was, by design, randomized only half the number of patients
agoraphobia (Porter & Chambless, 2015). Although the number of as the other two conditions, and because the drop-out rate was very high in
studies for any single variable was small, we found that higher ART (41%), we judged the ART group too small to include in these
levels of pretreatment agoraphobic avoidance, lower expectancy of analyses.
PSYCHOTHERAPY FOR PANIC DISORDER 805
different subgroups of patients that although PFPP was superior to outcome across both types of psychotherapy or a moderator of
ART overall, the difference in favor of PFPP was even greater for treatment response.
patients whose panic disorder onset was not precipitated by a We also suspected that patients’ personalities might moderate
recent interpersonal loss (Klass et al., 2009) and for those with a response to CBT and PFPP, specifically that patients with comor-
comorbid Cluster C diagnosis (Milrod, Leon, Barber, Markowitz, bid Cluster C personality disorders would fare better in PFPP than
& Graf, 2007). Patients with and without a comorbid Cluster B in CBT. Such a finding would be consistent with results from our
diagnosis appeared to fare similarly well in each treatment, but the meta-analysis (Porter & Chambless, 2015), in which we found that
number of Cluster B patients was so small as to limit any conclu- a comorbid Cluster C diagnosis was predictive of less improve-
sions (Milrod, Leon, Barber, et al., 2007). ment in CBT, and Milrod, Leon, Barber et al.’s (2007) paper,
which suggested that patients with a comorbid Cluster C diagnosis
did especially well in PFPP as compared with ART. Some research
Theorized Moderators of Response to CBT and PFPP suggests that the impact of Cluster C comorbidity on response to
Because the empirical literature provides little guidance about treatment may depend on the specific Cluster C disorder involved.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
panic disorder with or without agoraphobia were compared (Mil- provided written informed consent; the Institutional Review
rod et al., 2016). Boards of Weill Cornell Medical College and University of Penn-
For the reasons described above, we hypothesized that, in this sylvania approved the research.
trial, greater expectancy for change, later age of onset, shorter
duration of disorder, lower functional impairment, lower agora-
Procedure
phobic avoidance, and absence of a Cluster C diagnosis would be
predictive of greater pre- to posttreatment improvement across the Patients at each site were stratified on diagnosis of agoraphobia
sample of patients who received CBT or PFPP. Thus, we seek to and of major depression before randomization. Subsequent to
replicate prior results in the CBT literature but extend these for the baseline assessment and completion of 3 weeks of a panic diary,
first time to a psychodynamic treatment. With regard to modera- they were assigned according to availability to one of eight CBT
tion, we predicted that patients with higher levels of agoraphobic therapists or 16 PFPP therapists for twice-weekly 45-min sessions
avoidance, longer duration of disorder, greater disability, and for 19 –24 sessions. Therapists were trained for this study or had
lower RF would improve more in CBT as compared with PFPP, been trained in a prior trial to deliver one of the two treatments.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
even though within the CBT condition such patients might do Therapists treated patients in a single protocol and were supervised
This document is copyrighted by the American Psychological Association or one of its allied publishers.
worse than patients without these characteristics. Conversely, we by an expert in their treatment modality throughout the trial.
expected patients who had experienced a childhood loss and those Assessment of the primary outcome variable, the PDSS (Shear
with Cluster C personality disorders to fare better in PFPP as et al., 1997), was conducted by trained diagnosticians kept unin-
compared with CBT. Our design allows us (a) to test not only formed as to treatment assignment and was carried out at roughly
whether prior findings for predictors of CBT outcome will repli- monthly intervals: baseline, Weeks 1, 5, and 9 of treatment, and
cate in this trial but also whether they extend to a symptom- termination. Predictor and moderator variables were assessed at
focused psychodynamic therapy, and (b) to perform the first test of baseline, with the exception of treatment expectancy, which was
moderation of these two very different forms of psychotherapy for assessed prior to or immediately after Session 2. For additional
panic disorder. Moreover, given that we have two sites in our details of the procedure, see Milrod et al. (2016).
study, our design allows us an internal test of replication of the Interview measures.
findings across sites. This permits us to rectify what Schneider, Anxiety Disorders Interview Schedule for DSM–IV (ADIS).
Arch, and Wolitzky-Taylor (2015) identified as a major limitation Trained masters or doctoral level interviewers used the ADIS
to the moderation literature in treatment of anxiety disorders—the (Brown, Di Nardo, & Barlow, 2004) for diagnosis of panic disor-
absence of two studies that explore the same treatments with the der, agoraphobia, and possible comorbid conditions. ADIS reli-
same populations and use the same variables to define the mod- ability was excellent for panic disorder ( ⫽ 1.0) and agoraphobia
erators. ( ⫽ .94). The diagnostician also collected information about
duration of the current episode of panic disorder and about the
Method patient’s age at the time of the first episode of panic disorder.
PDSS. The PDSS (Shear et al., 1997) was used to assess
Participants change with treatment. Ratings on the seven PDSS questions range
from 0 (none) to 4 (extreme). Questions tap frequency and severity
Participants were 161 patients with a primary diagnosis of panic of panic attacks; distress associated with attacks; severity of in-
disorder with (n ⫽ 127, 79%) or without (n ⫽ 34, 21%) agora- teroceptive and situational avoidance and of anticipatory anxiety;
phobia drawn from the Cornell-Penn Psychotherapies for Panic and social, familial, and vocational impairment, and form a uni-
Disorder trial (Milrod et al., 2016). Patients in that trial were factorial scale (Shear et al., 2001). Internal consistency of the
randomly assigned to one of three forms of psychotherapy, and the measure is acceptable (␣ ⫽ .695 in the present sample). Prior
present sample comprises those in two of those conditions: CBT research has demonstrated the interrater and test–retest reliability
(n ⫽ 81) and PFPP (n ⫽ 80). Of these, 104 (65%) were female; and construct validity of this measure (Shear et al., 1997, 2001). In
118 (76%) patients were White, 31 (19%) were Black, 8 (5%) were the present study, the ADIS diagnostician, who was uninformed as
Asian or Asian American, 1 (⬍1%) were Native American, and 3 to treatment assignment, completed the PDSS as well. Interrater
(2%) were other or missing. Twenty-four (15%) were Latino(a). PDSS reliability, calculated across sites with an intraclass corre-
Participants ranged in age from 18 – 69 (M ⫽ 39.40, SD ⫽ 13.25); lation coefficient, proved excellent, rI (2,1) ⫽ .95.
the duration of their current panic episode ranged from 1 to 444 Childhood Trauma Scale: Loss. Using the Childhood Trauma
months (Mdn ⫽ 15). Scale (Lizardi et al., 1995; Nemeroff et al., 2003), diagnosticians
Inclusion criteria included a primary diagnosis of panic disorder interviewed patients about their experiences prior to age 15 of loss
and at least one spontaneous panic attack weekly for the month of or prolonged separation from a parent (coded as present/absent)
before entry. Psychotropic medication was permitted if stable Loss was coded when the patient reported that before the age of 15
for ⱖ2 months at intake and if the patient was willing for it to she or he experienced the death of a parent, separation from a
remain constant across the trial. Exclusion criteria included active parent for more than 6 months, or parental divorce or separation of
substance dependence (⬍6 months’ remission), history of psycho- more than 6 months. Seventy-two patients (45%) reported such a
sis or bipolar disorder, acute suicidality, organic mental syndrome, loss.
evidence of medical conditions that might cause the patient’s RF. Originally designed to be used with the Adult Attachment
symptoms, involvement in legal or disability proceedings involv- Interview and derived from its demand questions, RF ratings
ing the patient’s mental state, and unwillingness to forego non- (Fonagy et al., 1998) in the present study were based on material
study psychotherapy for the duration of the protocol. All patients collected via the Brief RF Interview-Revised (Rudden, 2009)
PSYCHOTHERAPY FOR PANIC DISORDER 807
Reliability was assessed by having pairs of coders independently equated CBT and PFPP in length and duration of sessions. The
This document is copyrighted by the American Psychological Association or one of its allied publishers.
code the same transcript (n ⫽ 62). Intraclass reliability coefficients protocol included psychoeducation about anxiety and panic; iden-
among the three coders ranged from acceptable to excellent, rI tification and correction of maladaptive thoughts about anxiety and
(1,1) ⫽ .63–.91. panic; training in slow, diaphragmatic breathing; and exposure to
Structured Clinical Interview for DSM–IV Axis II Personality bodily sensations designed to mimic those experienced during
Disorders (SCID-II, Version 2.0. The SCID-II (First, Spitzer, panic. All sessions were followed by homework assignments and
Gibbon, Williams, & Benjamin, 1997) was administered by the readings. In vivo exposure via homework assignments was intro-
same diagnosticians as the ADIS. Cluster A (n ⫽ 24, 17%) and B duced at Session 17 for those patients with significant agoraphobic
diagnoses (n ⫽ 18, 11%) and traits were too infrequent for analysis avoidance. Session 24 focused on review and relapse prevention.
of moderation. However, Cluster C diagnoses were sufficiently Muscle relaxation was omitted to reduce overlap with ART.
common for analysis (n ⫽ 54, 33.5%). Interrater reliability for PFPP. PFPP is a manual-based treatment (Milrod et al., 1997)
presence/absence of any Cluster C personality disorder was very rooted in the assumption that panic symptoms have a psycholog-
good, ⫽ .83. ical meaning and that uncovering these unconscious meanings will
Questionnaire measures. lead to relief. The therapist explores the circumstances and feelings
Avoidance Alone Scale of the Mobility Inventory for surrounding panic onset, the personal meaning of panic symptoms,
Agoraphobia. The Avoidance Alone Scale of the Mobility In- and the feelings and content of panic episodes. PFPP aims to lessen
vulnerability to panic by helping patients understand and alter core
ventory for Agoraphobia (Chambless, Caputo, Jasin, Gracely, &
unconscious conflicts, which are often identified and understood
Williams, 1985) was used to assess agoraphobic avoidance. Pa-
through their emergence in the transference. Frequent themes
tients are asked to rate 26 items reflecting situations patients with
include conflicts over separation and autonomy; recognizing, man-
agoraphobia may avoid on 1 (never avoid) to 5 (always avoid)
aging, and expressing anger; and guilt. Termination, addressed
scales. Item scores are averaged to yield the total score. The
prominently in the last third of treatment, permits patients to
internal consistency, test–retest reliability, and convergent and reexperience conflicts directly with the therapist so that underlying
discriminant validity of this measure have been repeatedly sup- feelings can be articulated and rendered less frightening.
ported (Chambless et al., 2011). Adherence. Adherence to the therapy manuals was assessed
Credibility/Expectancy Questionnaire. The three expectancy by teams of coders for each of the three treatments. As reported in
items from this measure (Devilly & Borkovec, 2000) yielded the the main outcome paper (Milrod et al., 2016), we confirmed that
expectancy score. Patients are asked to indicate on 0 –100% scales adherence was acceptable for both treatments, and that therapists
how much they think and feel they will improve by the end of did not mix interventions from the other two protocols with their
therapy and on a 1 (not at all) to 9 (very much) scale how helpful assigned protocol.
they feel therapy will be in reducing their symptoms. Item scores
are standardized and averaged for analysis. The factor analytically
derived expectancy scale is internally consistent, has good test– Statistical Analyses
retest reliability, and has proved useful in predicting treatment Change during treatment. Standard approaches to the lon-
outcomes (Devilly & Borkovec, 2000). gitudinal analysis of treatment data assume that missing data are
The Sheehan Disability Scale. The Sheehan Disability Scale missing at random, but this was not the case with these data. For
(Sheehan, 1983) is a three-item measure of social, family, and this reason, we analyzed change in treatment over time with a
vocational impairment. Each item is rated on a 0 (not at all) to shared parameters approach (ten Have, Pulkstenis, Kunselman, &
10 (extremely) scale indicating the degree to which the patient’s Landis, 1998), rather than the typical multilevel modeling (MLM)
disorder disrupted functioning in that domain in the last month. approach, which ignores the missing data mechanism. Each patient
Expressed as a sum, total scores range from 0 –30. Leon, Shear, was simultaneously modeled with (a) MLM for change over time
Portera, and Klerman (1992) have demonstrated the reliability
and validity of this measure for panic disorder patients, which 4
In rare cases where the patients had planned an extensive absence for
evinced good internal consistency in the present sample, work or vacation toward the end of their treatment and did not have
␣ ⫽ .83. extensive agoraphobia avoidance, 21-session treatments were planned.
808 CHAMBLESS ET AL.
on the PDSS, and (b) a survival model for attrition. The two moderation depends on the form of any interaction obtained (or-
processes share a common random effect, creating a quantifiable dinal vs. disordinal), the relative within-treatment condition effect
correlation between change in the PDSS outcome and dropout sizes, and the sample sizes of each treatment condition. Based on
processes. In this sample this correlation was substantial, hypotheses, we assumed any interactions would be ordinal, indi-
r ⫽ ⫺.44, p ⫽ .03, demonstrating outcome-missing data depen- cating the effect was in the same direction across the intervention
dency: Patients who were improving at a slower rate were more arms but of different magnitudes, and calculated power under a
likely to drop out of treatment more quickly. number of scenarios of larger and smaller effect sizes across the
At Level 1 of the MLM, PDSS scores varied within patients two treatment conditions. Sample size for our study was deter-
over time, expressed as weeks from baseline. Level 2 captured mined on the basis of power for our randomized test of treatment
between person variability as a function of treatment assignment.5 outcome differences and not for moderation. Thus, we only had
The attrition process was assessed with a discrete time survival
adequate power (⬎.80) when we assumed large differences (e.g.,
model: At each evaluation point, an individual was classified a
d of 0.9) in the efficacy of one of the treatments at low and high
dropout, treatment completer, or continuing in treatment. By
levels of the moderator and very small effects for the second.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Contrary to hypothesis, duration of present episode (log trans- Childhood Trauma Scale: Loss
This document is copyrighted by the American Psychological Association or one of its allied publishers.
sample for both treatments with a medium-large effect size. We younger onset patients, such as higher neuroticism. We do not
assessed expectancy after the patient had one or two meetings with have measures of neuroticism but note that Cluster C diagnosis
the therapist to learn the rationale for the treatment. Thus, it is was not related to worse outcome in the present study. In our
conceivable that the expectancy measure could reflect not only the clinical experience the younger the onset the more normal devel-
treatment rationale but also the patient’s initial reaction to the opment is disrupted by panic disorder, and the less patients have a
therapist, that is, not only will this treatment help me, but also will compelling image of the life they could have if they confronted
this person help me? Research on why expectancy is related to their fears in treatment. Progress may seem punishing in that it
outcome is not extensive, but findings to date (Constantino et al., may confront the patient with the challenge of delayed develop-
2011) suggest that expectancy may affect outcome through its mental experiences, for example, seeking further education or
effects on completion of homework and on the therapeutic alli- employment or establishing an independent residence. Longer
ance. Huppert et al. (2014) have demonstrated the positive rela- term treatment with support to develop life skills may be required.
tionship of working alliance at Session 3 with treatment outcome PFPP may fare worse than CBT with patients of younger onset
on panic disorder symptoms. Thus, examining whether the work- because CB therapists are more likely to provide such concrete
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
would be a worthwhile pursuit. Moreover, in studies of CBT for Cluster C was not a predictor of poor treatment outcome overall,
various disorders, both the quantity and quality of homework thus adding another negative study to the column of those reported
completion is associated with better outcome (see the meta- by Porter and Chambless (2015) and making it less likely that this
analysis by Kazantzis et al., 2016). It seems likely that expectancy is a negative prognostic sign for CBT. In light of the high prepon-
might also affect the level of engagement in challenging activities derance of patients with OCPD in our Cluster C patients (74% of
in session such as interoceptive exposure in CBT and interpreta- those with a Cluster C diagnosis), we predicted that Cluster C
tion of intrapsychic conflict and the transference in PFPP. Why patients would improve more if in PFPP than in CBT (cf., Barber
low expectancy predicted worse outcome for PFPP than CBT is & Muenz, 1996). We found no statistically significant moderation
not clear. However, this might be the result of CB therapists’ use by Cluster C diagnosis. However, in analyses conducted for heu-
of cognitive restructuring for low expectations of change—an ristic purposes, we found that, contrary to prediction, CBT was
approach readily available in their armamentarium. That is, had we superior to PFPP for patients with OCPD. Thus, these results are
had measures of expectancy at later sessions, we might have found inconsistent with Milrod, Leon, Barber, et al.’s (2007) small study
that in CBT initially low expectancy patients had a more positive in which the pattern of results suggested PFPP was particularly
view of their prospects for improvement later in therapy. Unfor- more effective than ART for Cluster C patients (albeit that ART is
tunately, such measures are lacking in our sample. a different form of cognitive-behavioral treatment than panic con-
Constantino et al. (2011) noted the poor methodological quality trol therapy). Under these circumstances, no clear statement can be
of many of the 46 studies they included in their meta-analysis. made about moderation other than to say that the findings do not
Thus, the present study makes a meaningful contribution to the suggest that a psychodynamic therapy should be selected over
literature by assessing expectancy in a reliable and valid fashion CBT when a panic disorder patient has a Cluster C diagnosis.
and by measuring change with treatment subsequent to expectancy Given the small number of patients with Cluster A and B disorders
assessment, thus avoiding confounding the effects of early panic in our study, our results do not speak to treatment selection where
disorder improvement and expectancy on outcome. Although cor- other personality disorder types are concerned.
relational, these findings argue for the importance of therapists’ We tested whether RF would predict better treatment outcome
efforts to increase early treatment expectancy. Constantino et al. across therapies, as was the case in treatment of depressed patients
(2011) suggested a number of strategies including explicit discus- with very low RF (Ekeblad et al., 2015), or would moderate
sions of patients’ expectancies during which the therapist is re- outcome such that those low in RF would do better in CBT than in
spectful of any doubts patients hold, providing information on the PFPP due to their low capacity for reflection on mental states. The
known efficacy of an intervention plus reasons the therapist be- effects for prediction and moderation both failed to reach signifi-
lieves the intervention will be beneficial for this particular person, cance. For heuristic purposes we probed the moderation effect and
and the like. found that, consistent with the hypothesis, CBT was superior to
Age of onset of the first episode of panic disorder was both a PFPP at low and average levels of RF but not at high levels. We
predictor of poorer treatment outcome and a moderator of out- note that average RF scores were substantially higher in our study
come, in that regardless of treatment condition patients did worse than in that of Ekeblad et al. (2015), and this may have made it less
when they had an earlier age of onset, but this was especially likely that we would find this variable to be a predictor of outcome
marked for PFPP. For roughly 63% of the sample, CBT was likely in our sample.
to be more effective than PFPP, but for patients in the upper 37% Contrary to hypothesis, we did not find that patients who had
of the distribution (ⱖ27.5 years old at first onset), there was no suffered a significant loss in childhood benefited more from PFPP
advantage to CBT over PFPP. These data solidify the uncertain than from CBT. This is not to say that a panic disorder patient who
findings reported in Porter and Chambless (2015) as to age of is suffering from such a loss and needs to talk about it might not
onset’s predictive utility and are consistent with reports that age of do better in a treatment that has space for such a discussion (which
onset is related to worse outcome in psychotherapy for social would have been difficult in our highly structured CBT unless
anxiety disorder as well (e.g., Borge, Hoffart, & Sexton, 2010). therapists went off protocol). However, the mere fact of such a loss
Interpreting why socially anxious patients with earlier onset did does not indicate that the patient needs to focus on this in treat-
worse in both CBT and IPT, Borge et al. (2010 hypothesized that ment: childhood loss neither predicted poorer outcome nor mod-
their findings might reflect greater personality problems in the erated results of treatment.
PSYCHOTHERAPY FOR PANIC DISORDER 811
Limitations were significant. These were RF and OCPD. Noting the difficulty
of amassing sufficient statistical power to test medium but none-
There are several limitations to our tests of moderation: The theless potentially meaningful moderators in a single study, Sch-
obtained moderation effects, although replicated across sites, were neider et al. (2015) advocated reporting such results to make them
not those we predicted, our study had adequate power only for available for meta-analysis, and in that spirit we highlight them as
large moderation effects thus risking Type II error, and to maintain potential targets for future research.
power we conducted a number of tests without correcting for Type Finally, we have identified two predictors of poor treatment
I error. Moreover, we acknowledge that the substantial majority of outcome (again, expectancy and age of onset) and have suggested
our patients were White and non-Latino. Whether our results how these might guide therapists’ efforts to improve outcomes for
would generalize to a more racially and ethnically diverse sample patients with these characteristics. An important next step is to
remains to be determined. In addition, we conducted CBT on a elucidate the mechanisms behind these prediction effects, and we
slower schedule than is often the case, spreading a treatment often plan both qualitative and quantitative studies to test such mecha-
delivered in 11–12 sessions (e.g., Barlow, Gorman, Shear, & nisms. Such research, along with the present study, will provide
Woods, 2000) over 19 –24 sessions. It is impossible to assess how
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
panic disorder.
tency of our three predictors of outcome with the prior literature.
CBT does not work for all patients (e.g., Milrod et al., 2016),
and we had hoped to detect moderators identifying patients who References
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