Elsevier

Behavior Therapy

Volume 43, Issue 2, June 2012, Pages 271-284
Behavior Therapy

Coping Skills and Exposure Therapy in Panic Disorder and Agoraphobia: Latest Advances and Future Directions

https://doi.org/10.1016/j.beth.2011.08.002Get rights and content

Abstract

Although cognitive-behavioral treatments for panic disorder have demonstrated efficacy, a considerable number of patients terminate treatment prematurely or remain symtpomatic. Cognitive and biobehavioral coping skills are taught to improve exposure therapy outcomes but evidence for an additive effect is largely lacking. Current methodologies used to study the augmenting effects of coping skills test the degree to which the delivery of coping skills enhances outcomes. However, they do not assess the degree to which acquisition of coping skills and their application during exposure therapy augment outcomes. We examine the extant evidence on the role of traditional coping skills in augmenting exposure for panic disorder, discuss the limitations of existing research, and offer recommendations for methodological advances.

Highlights

► Identification of strategies to augment the efficacy of exposure. ► Review of additive effect of common coping skills over exposure alone. ► Review of new coping strategies to enhance exposure. ► Recommendations to examine mechanisms of change during exposure.

Section snippets

Evidence for Additive Effects of Traditional Coping Skills

Coping skills traditionally included in CBT for PD/A are cognitive restructuring and either breathing retraining and/or relaxation. Presumably, the effects of exposure are augmented by applying the skills (e.g., disputing the probability of a harmful outcome while being exposed to a feared situation and showing that dysregulated physiology can be partially regulated). In the following, we review the evidence for the augmenting effects of traditionally taught cognitive and behavioral skills on

Exploring Mechanism of Therapy Success in PD

Kazdin (2007) cogently outlined the importance of mechanism research, including the potential to optimize the way in which treatment is delivered and thereby enhance outcomes. However, despite the invocation for mechanism research, less than a handful of psychosocial intervention studies have tested mediation properly. In the following we examine the meditational evidence for traditional coping skills in PD.

Future Directions in the Implementation, Assessment, and Evaluation of Current and Novel Coping Skills in Augmenting Exposure

There is a pressing need for both objective and online measurement of purported mediators, and evaluation of the degree to which change in those indices are predictive of change in subsequent symptom outcomes. Below we illustrate the implementation of online assessments using examples of two recently developed therapeutic approaches. The first exemplifies the direct manipulation and assessment of dysfunctional respiration, and the second illustrates a novel approach of assessing online thought

Assessment of Cognitive Appraisal/Acceptance Skills: Think-Aloud Paradigm

In a recent pilot study, we tested the feasibility of a modified and extended version of the think-aloud paradigm (Davison et al., 1991, Davison et al., 1997, Williams et al., 1997). The paradigm is aimed at assessing concurrent, situation-specific, and participant representative thoughts both during skill acquisition and application. This online method of recording verbalizations provides a sample of thinking that differs from the constraints of forced-choice formats and retrospective

Conclusion

Empirical support for an augmenting effect of traditional coping skills (cognitive and biobehavioral) on exposure is lacking. However, the extant reliance on delivery of coping skills detracts from examining the degree to which acquisition of coping skills and their application during exposure therapy enhance outcomes. At present, implementation of appraisal techniques (as taught in CT) are largely assessed retrospectively; likewise the assessment of core physiological processes (i.e., PCO2 in

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    The pilot study mentioned is in part funded by the generous support of the Beth and Russell Siegelman Foundation (Meuret).

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