Predictors of short- and long-term avoidance in completers of inpatient group interventions for...

Elsevier Editorial System(tm) for Journal of Affective Disorders Manuscript Draft Manuscript Number: JAD-D-14-01515R1 Title: Predictors of short- and long-term avoidance in completers of inpatient group interventions for agoraphobia Article Type: Research Paper Keywords: agoraphobia, psychological treatment, latent growth curve modeling, long-term follow-up Corresponding Author: Prof. Asle Hoffart, PhD Corresponding Author's Institution: Modum Bad First Author: Asle Hoffart, PhD Order of Authors: Asle Hoffart, PhD; Tuva Øktedalen, Cand.Psychol.; Karol Svanoe, MSW; Liv M Hedley, Ph.D.; Harold Sexton, MD Abstract: Background: Little is currently known about predictors of follow-up outcome of psychological treatment of agoraphobia. In this study, we wished to examine predictors of short- and long-term avoidance of inpatient group interventions for agoraphobia. Methods: Ninety-six (68%) of 141 agoraphobic patients (74% women) who had completed treatment in two open and one randomized controlled trial (RCT) were followed up 13 to 21 years after start of treatment. Results: Major depression at pre-treatment predicted less short-term (up to one year after end of treatment) improvement in agoraphobic avoidance. Working and being married/cohabiting at pre-treatment predicted greater long-term (across one-year, two-year, and 13 to 21 year follow-up) improvement. In contrast, the duration of agoraphobia, amount of Axis I and II co-morbidity, being diagnosed with avoidant, dependent, and obsessive-compulsive personality disorder, and the use of antidepressants and benzodiazepines the month before intake to treatment, were unrelated to short-term as well as long-term outcome. Limitations: As many as 31.9% of the included patients did not attend long-term follow-up and the power of the study was limited. The long time period between the two and 13-21 year follow-ups is a limitation, in which it is difficult to assess what actually happened. Although all the patients received some form of CBT, there was variability among the treatments. Conclusions: The only short-term predictor identified represented a clinical feature, whereas the long-term predictors represented features of the patients' life situation. The limited power of the study precludes the inference that non-significant predictors actually are unrelated to follow-up outcome.

Vikersund, March 14. 2015

Editor-in-Chief

Cornelius Katona

University College London

Research Dept. Of Mental Health Sciences

Charles Bell House, 2nd

Floor

67-73 Riding House Street

London W1W 7EJ

UK

Dear professor Katona,

Please find enclosed a revision of the ms. no. JAD-D-14-01515 now entitled “Predictors of

short- and long-term avoidance in completers of inpatient group interventions for

agoraphobia”, which we hope you will re-consider for publication in the Journal of Affective

Disorders.

Sincerely,

Asle Hoffart, Professor

Research Institute, Modum Bad, N-3370 Vikersund, Norway and Department of

Psychology, University of Oslo, PB 1094, Blindern, N-0317 Oslo, Norway

Phone: +47 32 74 98 61

E-mail: [email protected]

*Cover Letter

mailto:[email protected]

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Response to comments from the Reviewers: WE WISH TO THANK THE REVIEWERS FOR CONSTRUCTIVE AND HELPFUL COMMENTS. Reviewer #1: My suggestions for possible amendment are listed below. Abstract 1.The abstract reads well apart from the second sentence of the conclusion. Given the relatively small sample size and the relatively restricted range of clinical severity in the sample studied the implied assertion that personality disorder and high co-morbidity are unrelated to long-term outcome seems unjustified. WE HAVE DELETED THE SENTENCE AND INSTEAD INSERTED: “The limited power of the study precludes the inference that non-significant predictors actually are unrelated to follow-up outcome.” Highlights 2. The first point of the highlights - 'there were few baseline predictors of follow-up outcome' - is most probably a function primarily of sample size and the relatively restricted range of severity of the sample. It is unlikely that more than one or two reliable predictors would emerge from the analysis. As indicated above I don't think the fourth point is really justified. WE HAVE DELETED THE FIRST AND THE LAST POINT AND INSTEAD PUT IN TWO POINTS ABOUT DIAGNOSTIC CHANGE Introduction 3. On the whole this is clear and concise and reads well. However, although I appreciate this is an empirical investigation of pre-treatment outcome predictors of a clinical and demographic nature, it would be appropriate to comment on treatment response predictors of long-term outcome. Degree of compliance with treatment, quality of the therapeutic alliance, degree of improvement post-treatment may also play an important part in building a conceptual model of the influences on short and long term outcome of moderate to severe agoraphobia. There is an investigation of this set of predictors with a sample of GAD patients that might be worth looking at in this connection (Durham et al, 2009, International Journal of Cognitive Therapy, 2(4), 383-399). WE FIND THIS TO BE AN IMPORTANT EXTENSION OF OUR PREDICTION MODEL AND HAVE ADDED ON PAGE 4: “Also treatment response variables such as degree of compliance with treatment, quality of therapeutic alliance, and immediate treatment response may influence follow-up outcome, but their ability to predict such outcome in agoraphobia has hardly been studied (for generalized anxiety disorder, however, see Durham et al., 2009).” Method

*Response to Reviewers

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4. The participants are clearly defined. Table 1 provides the reader with a useful overview of attenders and non-attenders. This appears to be a moderate to severe sample of agoraphobic patients with longstanding problems, a poor response to previous treatment and a complex clinical presentation with what appears to be a significant bias towards social disadvantage. It would be of interest to know how representative the sample is of the population demographic in Norway if this data is available. ACTUALLY, WE FOUND RELEVANT POPULATION DATA ON MARRIED/COHABITING AND OCCUPATIONAL LEVEL FOR COMPARISON, PAGE 7: “The proportion married/cohabiting at pre-treatment, 68.8% in the total sample, was similar to the one of the Norwegian population at the time, 67% (Norwegian Social Science Data Services, 1995). However, the proportions having a lower occupational level, 72.9% of the attending and 86.7% of the non-attending patients, were higher than the 63% estimated in the population (Norwegian Social Science Data Services, 1995). This suggests that the sample had a bias toward social disadvantage.” 5. The non-attenders look to have a tendency to a higher rate of depression, a lower occupational level and a lower level of married/cohabiting and this is likely to lead to an overestimate of improvement levels at long-term outcome and this might be worth commenting on.

WE HAVE COMMENTED THE PROBABILITY OF OVERESTIMATION OF IMPROVEMENT ON PAGE 16: “In any event, these figures are likely to represent an overestimation of improvement as non-attenders at follow-up could be expected to improve less. Moreover, more of the non-attenders were not working at pre-treatment, which turned out to be a predictor of poorer long term course.”

6. It is of interest that the drop-out rates are low but I am not sure that the detail in Figure 2 is necessary in an article of this kind. IT SEEMS THAT YOU MEAN FIGURE 1 HERE? FIGURE 1 IS UNCHANGED BUT WE WOULD DELETE OR SHORTEN IT IF REQUESTED. FIGURE 2 IS SIMPLIFIED (SEE BELOW). 7. The very lengthy description of treatment methods could be condensed to a paragraph or two with the reader referred to the original articles. I am surprised that there is no mention of discharge treatment planning and liaison with local services as this might be expected to have a significant impact on outcome over the long term. THERE WAS DISCHARGE TREATMENT PLANNING, BUT THIS WAS UNFORTUNATELY NOT MENTIONED. IN ANY EVENT, WE HAVE FOLLOWED THE REVIEWER’S SUGGESTION AND CONDENSED THE DESCRIPTION OF TREATMENT METHODS (PAGE 7). 8. The outcome measures used seem appropriate but I wondered why the only self-report measure concerned agoraphobic avoidance. Were other self-report

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measures administered but not reported in this paper? This requires clarification. A broad measure of psychiatric symptomatology and depression in particular would have been helpful. WE HAVE ADDED SCORES FOR TRAIT ANXIETY AND DEPRESSION IN TABLE 2. 9. In the diagnostics section it is reported that diagnostic status at long-term follow-up was largely confined to panic and phobic anxiety with few other diagnoses assigned. This is a curious finding given the level of depression in the sample at the start of treatment and merits some comment. WE HAVE REPORTED THE PREVALENCE OF CO-MORBID DIAGNOSES ON PAGE 13, COMMENTED THIS IN THE DISCUSSION (PAGE 16) AND IN THE HIGHLIGHTS. The procedure and statistics sections read clearly. Results 10. While I appreciate that the primary outcome measure is degree of agoraphobic avoidance it would be helpful to have a clearer description of the overall outcome of the sample in terms of diagnostic status and level of symptomatology. We are told about the rates of patients no longer fulfilling a panic disorder/agoraphobia diagnosis but not the rates for any diagnosis. Surely this information is important given the high level of comorbidity of the sample. From a clinical and theoretical perspective Table 2 would be more informative if a broader range of outcome data was clearly described. SEE RESPONSES TO POINT 8 AND 9 ABOVE. 11. The results for outcome prediction in relation to avoidance are reasonably clear but I wonder if the authors have any information in regard to outcome prediction for overall clinical status? WE HAVE THE POSSIBILITY TO COMPUTE HIGH ENDSTATE FUNCTIONING BASED ON THE CRITERIA OF CLARK ET AL. 1994, BRITISH JOURNAL OF PSYCHIATRY, FOR PANIC DISORDER. HOWEVER,THIS WOULD EMPHASIZE PANIC ATTAKCS INSTEAD OF AVOIDANCE AND THE PREDICTIVE ANALYSES WOULD NOT INCLUDE FOLLOW-UP NON-ATTENDERS. THEREFORE, WE HAVE CONCENTRATED ON AGORAPHOBIC AVOIDANCE SO FAR. BUT WE ARE OF COURSE WILLING TO CONSIDER FURTHER REVISIONS. Discussion 12. My main concern with this section follows from the comments above. While the findings for agoraphobic avoidance are most definitely of interest they tell only part of the story in terms of overall clinical outcome. The term 'Outcome' is used sometimes to refer to 'agoraphobic avoidance' and sometime to refer to 'overall clinical improvement'. It would be helpful in terms of placing this research in a broader context of outcome prediction studies to either add additional analyses of overall clinical outcome or limit the paper to a more restricted focus on agoraphobic avoidance. If the latter course is chosen the title of the study might reasonably be changed to "Predictors of short and long-term

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avoidance in completes of inpatient psychological treatment for agoraphobia'. WE HAVE CHOSEN TO FOCUS ON AVOIDANCE BASED ON THE REASONS MENTIONED UNDER POINT 11 AND CHANGED THE TITLE OF THE PAPER ACCORDINGLY. Reviewer #2: The idea of determining very distant long term outcome (here, 13-21 years later) of a fairly brief intervention (here, 5-11 weeks) for moderate to severe agoraphobia is interesting. Even though the authors combine 3 separate samples, this seems a worthy enough endeavor. However, a number of serious flaws dim enthusiasm for this paper as presented. Specifically: 1. Please present the "acute intervention" more clearly, ie by labeling it in the abstract and throughout the paper as GROUP INPATIENT interventions. This is important, because such interventions likely have limited generalizability. WE HAVE LABELED THE INTERVENTIONS AS SUGGESTED IN THE TITLE AND THE ABSTRACT. 2. While initial medications at presentation were noted, and patients on meds were withdrawn from their meds for the acute interventions, no interval tracking of medications or psychotherapies are tracked, nor is clear interval history obtained. This is an enormous omission, as the work itself is presented as though the "follow-up" bears a direct relationship with the brief, very distant largely CT interventions. Surely, we know that patients with panic with/without agoraphobia seek multiple forms of treatment. It may well be that the "long term" results presented here bear almost no relationship to the original distant intervention. Without this information, this paper is not terribly interesting or useful to the field. USE OF PSYCHOSOCIAL TREATMENT AND MEDICATIONS WERE TRACKED AT EVERY FOLLOW-UP, BUT ONLY FOR THE LAST YEAR AND MONTH, RESPECTIVELY. THIS INFORMATION IS NOW INCLUDED IN THE RESULTS (PAGE 13) AND ADDRESSED IN THE DISCUSSION (PAGE 18). 3. The question of whether these "outcomes" are simply the natural course of illness vs. any type of outcome data is crucial. I do not know the answer having read the paper. Nonetheless, the authors do not entertain this question, which is an omission. THE POSSIBILITY OF NATURAL COURSE IS NOW ADDRESSED ON PAGE 17-18: “Although these long term results suggest that the treatments were effective in the long term, we do not know what the patients’ course would have been without treatment. However, the use of a no-treatment control group in such a very long term follow-up study would be both unethical and unfeasible. We must instead rely on longitudinal community studies, which suggest that agoraphobia is a chronic disorder and few attain natural remission (Wittchen et al., 2008).”

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4. Because of points 2 and 3, this is a very fuzzy dataset. Please do not report "trend" data. WE HAVE RETAINED THE ONE TREND REPORT ON PAGE 14 BECAUSE IT IS NOT A RESULT IN THIS STUDY BUT MORE A PRELIMINARY FINDING FOR EVALUATING THE RESULTS. IT SAYS THAT THE VARIATION IN THE LONG-TERM SLOPES ARE LIMITED AND THEREFORE ALSO THE POSSIBILITY OF FINDING PREDICTORS ARE RESTRICTED, ALTHOUGH NOT NON-EXISTENT. 5. Figure 2 contains a lot of information that is not presented clearly. Please re-draw in a manner that adds clarity. It is likely that the authors will need several figures to convey the data they are trying to present. WE HAVE TRIED TO SIMPLIFY THE FIGURE 2 BY MOVING SOME INFORMATION TO THE FIGURE LEGEND AND SOME TO THE TEXT (PAGE 11, ABOUT LOADINGS ON THE TWO LATENT TIME TERMS). 6p. 16 "There was a treatment condition effect on the short term growth curve, not on long term growth". This of course is entirely unsurprising given the brief intervention at such a distant time point. The authors should at least note this. SEE NEXT RESPONSE. 7. later in the same paragraph: "The inclusion of treatment condition resulted in a worse model fit relative to the unconditional model". Again, really no surprise. But given these findings, it is somewhat misleading to frame the entire paper/data analytic project as "long term outcome of CBT". It may well be that the original brief treatments had little to do with the patients' current state. In any case, all of this calls into question the original premise of the study, which should be noted and presented differently. WE HAVE NOTED WHAT IS POINTED OUT IN 6. AND 7. ON PAGE 18: “Nevertheless, the findings that long-term predictors were limited to environmental variables and that there was no treatment condition effect on long-term avoidance are consistent with that long-term avoidance is unrelated to the original treatments.” 8. In the last paragraph on p. 16 too little is made of untracked ongoing or interval treatments. Please be clear. THE ISSUE OF FOLLOW-UP TREATMENTS IS NOTED ON PAGE 18: “It is also difficult to evaluate the influence of treatment received in the follow-period. The utilization of psychosocial treatments was reduced from 52.1% during the last year at one-year follow-up to only 10.4% at long term follow-up. The use of BZs was reduced from before treatment to all the follow-ups, whereas the use of antidepressants remained stable. There was a rather prevalent use of BZs (39.6%) and antidepressants (36.5%) at long term follow-up, although the BZs use was mostly on an intermittent per-as-needed basis. The use of BZs but not of antidepressants was associated with more avoidance at long-term follow-up.”

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9. p.17 "Presence of MDD may inhibit engagement in therapy through symptoms of loss of interest, etc..." This view is fairly narrow. These group treatments may simply not have been terribly good for these patients. This deserved a note at least. A NOTE IS ADDED ON PAGE 16: “The studied inpatient group treatment may be less suited for patients who suffer from the combination of agoraphobia and major depression.” 10. p.17 A very narrow, exposure focused discussion is presented about why being in a close relationship may have resulted in better function at 13-21 years. Please re-write this discussion taking into account more global understandings of attachments on mental health and specific mood and anxiety disorders. THE IMPORTANCE OF ATTACHMENT FOR MENTAL HEALTH WITH A REFERENCE TO SCHORE IS ADDED ON PAGE 17: “This is consistent with all the literature on the importance of stable attachment relationships for mental health (Schore, 2001).” 11. p. 18. Please do not draw conclusions about very long term outcomes from very brief interventions for chronic disorders here. This does patients a general disservice. WE HAVE SUBSTITUTED “OUTCOME” WITH THE MORE EFFECT-NEUTRAL EXPRESSION

“AVOIDANCE” IN THE DISCUSSIONS ON PAGE 18 AND 19.

THE AUTHORS

PREDICTORS LONG-TERM OUTCOME AGORAPHOBIA 1

Predictors of short- and long-term avoidance in completers of inpatient group interventions for

agoraphobia

Asle Hoffart

Research Institute, Modum Bad, N-3370 Vikersund, Norway and Department of Psychology,

University of Oslo, PB 1094, Blindern, N-0317 Oslo, Norway

Tuva Øktedalen

Research Institute, Modum Bad, N-3370 Vikersund, Norway and Department of Psychology,

University of Oslo, PB 1094, Blindern, N-0317 Oslo, Norway

Karol Svanøe

Buskerud and Vestfold University College, PB 2243, N-3103 Tønsberg, Norway

Liv M. Hedley

Research Institute, Modum Bad, N-3370 Vikersund, Norway

Harold Sexton

Research Institute, Modum Bad, N-3370 Vikersund, Norway

Address correspondence to Asle Hoffart, Research Institute, Modum Bad, N-3370 Vikersund,

Norway. Tel. + 47 32 74 98 61. Fax +47 32 74 98 68; e-mail: [email protected]

*ManuscriptClick here to view linked References

mailto:[email protected]

http://ees.elsevier.com/jad/viewRCResults.aspx?pdf=1&docID=12065&rev=1&fileID=304220&msid=76B77DEC-69D9-4CA7-983A-5BC2F7AAEA3B


ABSTRACT

Background: Little is currently known about predictors of follow-up outcome of psychological

treatment of agoraphobia. In this study, we wished to examine predictors of short- and long-term

avoidance after inpatient group interventions for agoraphobia.

Methods: Ninety-six (68%) of 141 agoraphobic patients (74% women) who had completed

treatment in two open and one randomized controlled trial (RCT) were followed up 13 to 21 years

after start of treatment.

Results: Major depression at pre-treatment predicted less short-term (up to one year after end of

treatment) improvement in agoraphobic avoidance. Working and being married/cohabiting at pre-

treatment predicted greater long-term (across one-year, two-year, and 13 to 21 year follow-up)

improvement. In contrast, the duration of agoraphobia, amount of Axis I and II co-morbidity,

being diagnosed with avoidant, dependent, and obsessive-compulsive personality disorder, and the

use of antidepressants and benzodiazepines the month before intake to treatment, were unrelated

to short-term as well as long-term outcome.

Limitations: As many as 31.9% of the included patients did not attend long-term follow-up and the

power of the study was limited. The long time period between the two and 13-21 year follow-ups

is a limitation, in which it is difficult to assess what actually happened. Although all the patients

received some form of CBT, there was variability among the treatments.

Conclusions: The only short-term predictor identified represented a clinical feature, whereas the

long-term predictors represented features of the patients’ life situation. The limited power of the

study precludes the inference that non-significant predictors actually are unrelated to follow-up

outcome.

Keywords: agoraphobia, psychological treatment, latent growth curve modeling, long term follow-

up


1. Introduction

Agoraphobia – with or without panic disorder – has a lifetime prevalence rate of 5 to 6

percent (Kessler et al., 2005). It is associated with an increased risk of suicide, severe social

impairment, and significant comorbidity with other mental and medical disorders (Milrod and

Busch, 1995). Recent meta-analyses suggest that both cognitive therapy and exposure therapy are

efficacious (Norton and Price, 2007; Stewart and Chambless, 2009) appearing to be equally

effective (Norton and Price, 2007). Some evidence also supports the efficacy of psychodynamic

therapy for panic disorder (Milrod et al., 2007).

However, it is important to know to what degree initial treatment gains are maintained over

time. Furthermore, knowledge of pre-treatment predictors of long-term outcome may inform

theory and assist in treatment planning (Brown and Barlow, 1995). No predictor studies of

psychological therapies for panic disorder/agoraphobia have extended beyond a two-year follow-

up. Durham et al. (2005) examined a wider sample of anxiety disorder patients (including 189

panic disorder patients, 116 generalized anxiety disorder patients, and 31 post-traumatic stress

disorder patients) at 2 to 14 years follow-up. These patients had participated in eight trials

comparing cognitive-behavioral treatment (CBT) and non-CBT. Unemployment and severity of

functional impairment predicted poorer outcome in terms of clinical significant change.

Marriage/cohabiting correlated negatively with a dimensional long-term symptom factor. In short-

term follow-up studies, no variables have consistently been found to predict follow-up outcome.

However, at least some studies have provided support for the following clinical and demographic

predictors of poorer outcome in panic disorder/agoraphobia patients: duration (Faravelli et al.,

1995), co-morbid major depression (Cowley et al., 1996), benzodiazepine use (Brown and

Barlow, 1995), antidepressant use (Barlow et al., 2000), and the presence of DSM Cluster C


personality disorders (avoidant, dependent, obsessive-compulsive; Hoffart and Hedley, 1997).

Also treatment response variables such as degree of compliance with treatment, quality of

therapeutic alliance, and immediate treatment response may influence follow-up outcome, but

their ability to predict such outcome in agoraphobia has hardly been studied (for generalized

anxiety disorder, however, see Durham et al., 2009). Thus, little is currently known about

predictors of follow-up outcome of psychological treatment of agoraphobia. Studies of more

short-term follow-up have yielded inconsistent results and no study has examined predictors of

long-term outcome in a purely agoraphobic sample.

In the present study, we wished to contribute to amending this lack of knowledge by

examining pre-treatment clinical and demographic predictors of short- and long-term (13-21

years) avoidance in agoraphobic patients who had previously participated in one of three trials at

our site. These were the randomized controlled trial (RCT) of 5-weeks with cognitive therapy or

guided mastery therapy for agoraphobia (Hoffart, 1998) and two open trials. One of the open trials

utilized exposure in a first 5-week phase and psychodynamic therapy in a second 6-week phase

(Hoffart et al., 1995) while the other utilized cognitive therapy in a first 5-week phase and schema

therapy in a second 6-week phase (Hoffart et al., 2002). Psychodynamic and schema therapy

addressed potential vulnerabilities for developing agoraphobia and co-morbid disorders and were

intended to protect against relapse. A report on the long-term outcome in the RCT has been

published elsewhere, showing that 56.5% of those attending follow-up no longer had a panic

disorder/agoraphobia diagnosis (Hoffart, Hedley, Svanøe, & Sexton, in press). In this study, our

focus was the combined sample of agoraphobic patients from all the three trials. Common to these

patients was that they had received standardized medication-free group-based and agoraphobia-

focused CBT. We examined predictors that had received some support in previous studies. Our

research questions included the following: Will not working, not being married or cohabiting, a

longer duration of the disorder, more Axis I and II co-morbidity, major depression, avoidant,


dependent, obsessive-compulsive personality disorder, using benzodiazepines, and/or using

antidepressants at pre-treatment predict poorer short-term (up to one year after end of treatment)

and/or long-term (from one to 13-21 years after end of treatment) course of avoidance?

2. Method

2.1 Participants

Participants were selected among patients who had been treated in a specialized program for

agoraphobia at an inpatient clinic. Due to scattered settlement in Norway, such residential adaptations

of programs developed in an outpatient setting assist in providing specialized and intensive treatment

opportunities for the entire Norwegian population. Thus, the patients were referred due to lack of

specialized local treatment or because outpatient treatment attempts had failed. Patients from three

different trials, two open and one RCT, were included in the present study of long-term outcome.

In the first open trial, participants were allocated from January 1989 to November 1990

according to following inclusion criteria: (a) DSM-III-R criteria for panic disorder with agoraphobia or

agoraphobia without history of panic disorder, (b) symptoms of agoraphobia were considered to be the

main problem, and (c) age 20 to 65 years. These patients received exposure (E) in a first 5-week phase

and psychodynamic therapy (PT) in a second 6-week phase.

In the RCT (allocation from April 1992 to April 1993), the participant inclusion criteria were:

(a) DSM-III-R criteria for panic disorder with agoraphobia, (b) degree of agoraphobia was moderate or

severe, (c) the symptoms of agoraphobia were considered to be the main problem, and (d) age 20 to 65

years. These patients were randomly allocated to five weeks of either cognitive therapy (CT) or guided

mastery therapy (GMT). Six groups were admitted sequentially, alternating between cognitive or

guided mastery therapy.


In the second open trial (allocation from January 1996 to February 1997), the participant

inclusion criteria were: (a) DSM-IV criteria for panic disorder with or without agoraphobia or

agoraphobia without history of panic disorder, (b) 22 to 65 years old, and (c) they presented at least

one problem related to DSM-IV Cluster C personality disorder, i.e., they described chronic problems

independent of their Axis I disorders and that expressed the core content of the Cluster C personality

disorders. These patients received CT in a first 5-week phase and schema therapy (ST) in a second 6-

week phase.

As a majority of the participants had tried medication previously without satisfactory effect and

the use of medication could potentially interfere with cognitive and behavioral learning, psychotropic

medication was not utilized during the inpatient treatment period. Medications were tapered and

discontinued prior to admission.

Patients completing treatment were eligible for the present study. The chart of patient flow in

Figure 1 shows that the dropout rates from the treatments were low (13 of 154, on average 8.4%) and

that a total of 141 patients from the three trials were included. After their two-year follow-up, these

patients were contacted and asked to give informed consent to allow for subsequent follow-up. The

patients were fully informed and the follow-up was conducted in compliance with the Regional Ethical

Committee. Forty-five (31.9%) of the 141 included patients did not attend this follow-up. Reasons for

non-attendance, listed in Figure 1, indicate that 17 (12.1%) withdrew, while 28 (19.9%) did not attend

for other reasons (death, sickness, unavailability). The 96 patients who attended the long-term follow-

up were compared on pre-treatment characteristics to the 45 non-attending patients to determine the

representativeness of the attenders in relation to the original sample (see Table 1). The two groups of

patients were similar, with the exception that relatively more attenders were working (42.7% vs.

24.4%), X²(1) = 4.58, p < .05; and initially had dysthymia (18.8% vs. 4.4%), X²(1) = 5.15, p < .05.

The attendance rates were similar across the subsamples, 38 of the 53 (71.7%) patients who

received E + PT, 16 of the 23 (69.6%) patients who received CT, 15 of the 23 (65.2%) patients who


received GMT, and 27 of the 42 (64.3%) patients who received CT + ST; X²(3) = 0.61, ns. Thirteen

(34.2%) of the 38 E + PT and 3 (11.1%) of the 27 CT + ST patients had agoraphobia without a history

of panic disorder at pre-treatment. The original inclusion criteria of the RCT excluded this diagnosis.

The proportion married/cohabiting at pre-treatment, 68.8% in the total sample, was similar to

the one of the Norwegian population at the time, 67% (Norwegian Social Science Data Services,

1995). However, the proportions having a lower occupational level, 72.9% of the attending and 86.7%

of the non-attending patients, were higher than the 63% estimated in the population (Norwegian Social

Science Data Services, 1995). This suggests that the sample had a bias toward social disadvantage.

2. 2 Treatments

The patients were admitted to closed treatment groups with 8 members in each. Except for the

intake session, patients had no individual sessions during the treatments that focused on panic disorder

and agoraphobia. The first week consisted of education concerning the treatment model with patients

setting specific goals for their treatment. Also, within this first week, any remaining psychotropic

medication was discontinued. In weeks 2 to 4 agoraphobia was focused upon according to the specific

therapy model applied (E, CT or GMT). In the fifth week, patients returned home to test their newly

acquired skills. Subsequently, the E + PT and CT + ST patients attended 6-week of PT or ST,

respectively, while the CT and GMT patients returned simply for 2 days, discussing experiences and

setting personal goals for the next year. More information about the therapies, therapists, training,

supervision, and independent ratings of the therapists’ skill levels are available (Hoffart et al., 1995;

Hoffart, 1998; Hoffart et al., 2002).

2.3 Self-report measures


The self-report Mobility Inventory for Agoraphobia (MI; Chambless et al., 1985) measures

agoraphobic avoidance of a range of situations, both when the patients are alone (MI-AAL) and

when they are accompanied (MI-ACC), on a 1 to 5 scale. The reliability and the concurrent and

construct validity of the MI has been supported (Chambless et al., 1985), particularly for the MI-

AAL subscale (Chambless et al., 2011) that was used as the primary outcome measure in the

present study. In the present sample, Cronbach’s alpha ranged from .95 to .97 across the five

assessments. The self-report State-Trait Anxiety Inventory-Y2 (STAI-Y2; Spielberger, 1983)

provides scores for trait anxiety. The self-report Beck Depression Inventory (BDI; Beck et al.,

1988) measures degree of depressive symptoms. Alpha ranged from .91 to .96 on these two

measures across assessments.

2.4. Interview-based measure

The interview-based Phobic Avoidance Rating Scale – Separation subscale (PARS-Sep; Hoffart

et al., 1989) measures avoidance of situations involving separation from safe persons (e.g., walk away

from home alone, travel by bus or train alone) on a 0 to 4 scale. The two long-term follow-up

interviewers (third and fourth author) independently rated tapes of 10 of each others’ randomly

selected PARS-Sep interviews. The intraclass correlation (ICC (3,1); Shrout and Fleiss, 1979) was .97.

2.5. Diagnostics

The Structural Clinical Interview for DSM-III-R (Spitzer et al., 1988) or DSM-IV (First et al.,

1995; First et al., 1994) (SCID-I and II) was used for the assessment of Axis I and II disorders. The

DSM-III-R interview was used in the E + PT, CT, and GMT samples and the DSM-IV interview was


used in the CT + ST sample. There was satisfactory inter-rater reliability for the baseline interviews

(Hoffart et al., 1995; Hoffart, 1998; Hoffart et al., 2002).

The diagnostic interviews at the long-term follow-up focused upon the period since the two-

year follow-up and were conducted by the third and fourth author. Twenty videotaped interviews - 10

from each interviewer - were randomly drawn for a reliability check. The kappa values were .98 for

panic disorder with agoraphobia, social phobia, and specific phobia, and .75 for agoraphobia without

panic disorder. As very few other diagnoses were assigned in the 20 interviews, kappa values were not

calculated for these.

A measure of co-morbidity was computed by summing the number of co-morbid Axis I and II

diagnoses. The mean number of such diagnoses was 3.17 (SD = 2.12, range = 0-8) and this variable

was fairly normally distributed. Level of co-morbidity did not differ among the four

subsamples/treatment groups, F(3, 92) = 1.10, ns.

2.6. Procedure

Patients had been assessed at evaluation, at admission to hospital/treatment start (pre-

treatment, on average two months after the evaluation), and immediately after the agoraphobia-

focused treatment (5 weeks). The patients were invited as a group to short (2-4 days) follow-up

stays at the hospital and assessed one and two years after completing treatment. One exception to

this was that patients of the RCT received mailed questionnaires to complete at two-year follow-

up. At long-term follow-up, patients were approached by mail, inviting them to contact the

researcher for an appointment. If no response occurred within two weeks, the patients were

contacted by phone. Participants could come to the clinic or meet at another place of their choice.

Travel expenses and any loss of income incurred as a result of their participation were refunded.

No incitements were given for participation. If it seemed apparent that a participant had a current


need for treatment, the interviewer assisted with a referral. The long-term follow-up interviews

occurred on average 17.55 (SD = 2.73, range 12.8 to 21.2) years post-treatment, were conducted

individually and videotaped. A comprehensive interview was conducted in addition to the

administration of the MI and other self-report measures. It included the SCID-I and –II (DSM-III-

R or DSM-IV, depending on which DSM version was used at inclusion), targeting the period since

the previous SCID interview (one-/two-year follow-up), the PARS-Sep (administered only at

long-term follow-up), and assessment of the frequency of panic attacks for the two last weeks and

for the last month. As for the one- and two-year follow-up, psychosocial treatments in the

previous year and use of medication the previous month were tracked. The one interviewer (the

fourth author) is a PhD psychologist experienced in performing diagnostic interviews and follow-

investigations. She was blind to the results of diagnostic assessments at baseline, but not always

blind to treatment conditions of the patients, as she had participated in the treatment and

supervision related to some patients. The other interviewer (the third author) is a Clinical Social

Worker (MSW), who had been trained in conducting DSM diagnostic interviews in previous

studies at another site. She was blind to all previous results of this study and had not been

involved in the treatments.

2. 7. Statistical analysis

Latent growth curve modeling with piecewise functions for repeated measurement data

was used to investigate the trends for both short-term and long-term outcomes and predictors of

these trends. Parameter estimates were derived through maximum likelihood using m-plus version

7.3. Full information maximum likelihood (FIML) was used to handle missing data. The Little’s

test of missing completely at random (MCAR) (Little, 1988) indicated that data were missing at

random (Little’s MCAR test: χ2 (4) = 14.161, p = .224), and this was therefore assumed.


Individuals were allowed to have different intercepts (initial status) and linear slopes (growth) in

the analysis, known as the unconditional model if predictors are not included in the model. If the

unconditional models fit the data well and the variances of the initial status and linear slopes were

statistically significant, we included covariates to predict the two linear slopes in the piecewise

model, known as the conditional model.

To assess the appropriateness of the growth models, we used the comparative fit index

(CFI), Tucker-Lewis index (TLI), standardized root-mean-square residual (SRMR), and the root-

mean-square error of approximation (RMSEA). A model is judged as reasonably fitting the data

when CFI and TLI is larger than .95 and RMSEA is .06 or smaller (Hu and Bentler, 1999).

Different degrees of change were expected for short-term and long-term follow-up and the

time intervals between assessments varied greatly. To find the model that best captured the non-

linear rate of change in avoidance, we tested three models for the primary outcome measure, the

MI-AAL. In the first model, time was represented with a piecewise latent curve model consisting

of two latent growth curves with a knot point at one-year follow-up. In this piecewise model, the

first latent growth curve represents pre-treatment, post-treatment and 1 year follow-up MI-AAL

scores (loadings set to 1,2 and 3 on this first latent time term), while the second latent growth

curve represents the follow-ups (1 year, 2 years, 13-21 years; loadings set to 1,2,3 on this second

latent time term). In the second model, a quadratic term (time2) was added to a linear elapsed time

term. In the third model, the initial loading on the time factor was set to 0 and the final loading to

1, whereas the intermediate loadings were freely estimated. The second model with the quadratic

effects of time showed poor fit to the data (26 (N = 140) = 19.078, p < .001 with CFI = .96, TLI =

.96, SRMR = .052 and RMSEA = .125 with 90% confidence interval from .064 to .190). The third

model with freely estimated loadings showed somewhat better fit (27 (N = 140) = 14.890, p <

.001 with CFI = .98, TLI = .97, SRMR = .129 and RMSEA = .090 with 90% confidence interval

from .021 to .153). The piecewise model with two latent growth curves fitted best (29 (N = 140) =


9.208, p < .162; CFI = .99, TLI = .99, SRMR = .050, RMSEA = .062 with 90% confidence

interval from .000 to .136) and was utilized in the further analyses. Thus, this study used a

piecewise function for describing segmented change of a latent construct over time.

We then examined the pre-treatment predictors in the piecewise model with two latent

growth curves representing short-term and long-term change, respectively. The predictors were

included in separate models as time-invariant covariates for both latent growth curves and the

latent intercept. As this is a first exploratory study of predictors of long-term outcome in

agoraphobia after CBT treatment, a significance level of .05, two-tailed, was selected and no

adjustment for family-wise error rate was made. Groups were compared at a single assessment

point using a one-way ANOVA or independent samples t-test for continuous data and chi-square

(Fisher’s Exact Test when an expected cell number was below 5) for categorical data. McNemar

test was used for dependent (longitudinal) categorical data.Effect sizes (ESs) were computed as

Hedges’ g for dependent samples (Borenstein et al., 2009).

3. Results

3. 1. Improvements and end states

The means (SDs) and the effect sizes on the MI-AAL, the STAI-Y2, and the BDI across

assessments for each treatment condition and the overall sample are provided in Table 2. The 96

attending patients had improved from 3.56 (SD = 0.90) at pre-treatment to 2.07 (SD = 1.00) at

long term follow-up, an ES of -1.55, 95% confidence interval [-1.92, -1.18]. The number of

patients free of panic attacks the last two weeks before long-term follow-up examination was 68

(70.8%) and the number of patients not having a panic disorder and/or agoraphobia diagnosis

was 60 (62.5%). The rates of patients no longer fulfilling a panic disorder/agoraphobia diagnosis


were 27 (71.1%) of the 38 E + PT patients, 9 (56.3%) of the 16 CT patients, 10 (66.7%) of the 15

GMT patients and 16 (59.3%) of the 27 CT + ST patients, X² (3) = 1.54, ns. The frequency of

co-morbid diagnoses exceeding a number of 1 was 12 (12.5%) for social phobia, 4 (4.2%) for

generalized anxiety disorder, 4 (4.2%) for obsessive compulsive disorder, 15 (15.6%) for simple

phobia, 2 (2.1%) for hypochondriasis, 5 (5.2%) for somatoform pain disorder, 14 (14.6%) for

major depression, 4 (4.2%) for non-alcohol dependence/abuse, 12 (12.5%) for avoidant and 2

(2.1%) for obsessive compulsive personality disorder. Thus, most of these diagnoses were

reduced by more than two third compared to pre-treatment (see Table 1). The mean level on the

PARS was 1.02 (SD = 1.13). There was less use of psychosocial treatments at the follow-ups

than before intake, and only 10 patients (10.4%) had received psychosocial treatment during the

year prior to follow-up. Also the use of benzodiazepines (BZs) was reduced from before

treatment to all the follow-ups, whereas the use of antidepressants was unchanged. There was a

rather prevalent use of BZs (n = 38, 39.6%) and antidepressants (n = 35, 36.5%) at long term

follow-up. Of those 38 using BZs, 14 were on stable doses, whereas the other 24 used them on

an intermittent basis, 8 of these more seldom than monthly. There were no between-condition

differences on these variables. At long-term follow-up, those who used psychosocial treatment

and those who used BZs had increased MI-AAL scores, t(95) = 3.62 and t(95) = 3.40,

respectively, whereas those who used antidepressants did not differ from those who did not, t(95)

= 0.89.

3.2. The unconditional latent growth curve model

The unconditional piecewise model with two latent growth curves showed reasonable fit to

the data (26 (N = 140) = 9.208, p < .162 with CFI = .99, TLI = .98, SRMR = .050 and RMSEA =

.062 with 90% confidence interval from .000 to .136). The MI-AAL scores changed differently in


the two latent growth curves representing short term improvement and improvement in the long-

term follow-up period (from one-year to 13-21 year after end of treatment). The factor means for

the first latent growth curve was -.599 (SE = .07, p < .001), and -.055 (SE = .04, p = .182) for the

second latent growth curve. The variances of the initial statuses and first slope were significant at

= .01, indicating individual variation in initial statuses and trajectory of change, while the

second slope displayed a trend towards individual variation (p < .10). No significant relationship

was found between the initial level and the rate of change in agoraphobic avoidance. That is, the

initial level of agoraphobic avoidance was unrelated to the rate of change. The R square statistics

indicate the proportion of variance in the observed measures that is explained by the latent growth

curve factors. Small R-square indicates that most of the observed change is not related to change

over time. In the unconditional model, all obtained R-squares are large, meaning that the growth

curve factors explain 86%, 79%, 94%, 76%, and 48 % of the observed variance in agoraphobic

avoidance at pre-treatment, post-treatment, 1-year, 2-year, and 13 or 21 year follow-up,

respectively.

3.3. Predictive analyses

We included the covariates for both short-term and long-term growth curves in separate

models and compared the improvement of fit relative to the unconditional model. The time-

invariant pre-treatment covariates were working, being married/cohabiting, duration of

agoraphobia, Axis I and II co-morbidity, major depression, and avoidant, dependent, and

obsessive-compulsive personality disorder. In addition, use of benzodiazepines and of

antidepressants during the month before start of treatment and treatment condition were

examined as covariates.

Table 3 shows the fit indices and the standardized parameters for the conditional


piecewise growth models. Only statistical significant effects on the MI-AAL in models with

satisfactory fit are provided. Also Figure 2 depicts the significant relationships. Major depression

at pre-treatment was positively related to the short-term rate of change, but unrelated to long-

term improvement. Also duration of agoraphobia was negatively related to short-term but not to

long-term rate of change. However, the model including this covariate showed poor fit to the

data (28 (N = 140) = 19.558, p < .012 with CFI = .97, TLI= .94, SRMR = .055 and RMSEA =

.101 with 90% confidence interval from .044 to .159). Likewise, there was a treatment condition

effect on the short-term growth curve, but not on the long-term growth curve. However, also the

model including treatment condition as a covariate showed poor fit to the data (28 (N = 140) =

32.489, p < .001 with CFI = .94, TLI = .88, SRMR = .061 and RMSEA = .148 with 90%

confidence interval from .097 to .203). The inclusion of treatment condition resulted in

significantly worse model fit relative to the unconditional model (2 (2) = 23.3, p < .001).

Accordingly, the models that included duration of agoraphobia and treatment condition were

evaluated to not fit the data.

The only significant effects for the long-term follow-up were working and being

married/cohabiting. Being married/cohabiting was related to the latent intercept (start level) of

MI-AAL scores. Both working and being married/cohabiting were negatively related to the slope

of MI-AAL scores across the follow-ups (see Figure 2), indicating greater reduction of MI-AAL

scores over time among those who were working or living with a partner.

Co-morbidity, being diagnosed with avoidant, dependent, and obsessive-compulsive

personality disorder, use of antidepressants and/or benzodiazepines were unrelated both to short-

term and long-term improvement.

4. Discussion


This is the first study of predictors of a long-term (13 to 21 years) outcome study after

standardized medication-free psychological treatment for agoraphobia of which we are aware. We

assessed and predicted short- and long-term agoraphobic avoidance by using latent growth curve

modeling. Participants in two open trials and one RCT were combined and studied. For those who

attended long-term follow-up, there was a large effect size of -1.55 on the primary self-report

avoidance measure in the total sample. Large effect sizes were observed also on measures of trait

anxiety (-1.40) and depression (-1.12). The primary interview-based outcome measure (mean 1.02

at long term follow-up) indicates that on the whole patients were not avoiding separation

situations – those that are most feared by agoraphobic patients (e.g., walk away from home alone,

travel by bus or train alone). However, they still had avoidant tendencies (e.g. hurrying through

them) (Hoffart et al., 1989). Nearly two-third (62.5%) lost their panic disorder/agoraphobia

diagnosis. The prevalence of most co-morbid diagnoses was reduced by even more than two-third.

The interviewers were stuck by how many of those retaining a diagnosis of panic

disorder/agoraphobia spontaneously reported that they lived better with the disorder. One may

speculate that the extra reduction of co-morbid diagnoses reflects this process. In any event, these

figures are likely to represent an overestimation of improvement as non-attenders at follow-up

could be expected to improve less. Moreover, more of the non-attenders were not working at pre-

treatment, which turned out to be a predictor of poorer long term course.

Variables previously found to predict response to psychological treatment among

agoraphobic patients in at least some studies were examined. Consistent with Cowley et al.

(1996), pre-treatment major depression was related to reduced short-term improvement. The

studied inpatient group treatment may be less suited for patients who suffer from the combination

of agoraphobia and major depression. In particular, the presence of major depression may inhibit

engagement in treatment through the symptoms of loss of interest, lack of energy and/or

pessimistic thinking.


Pre-treatment working predicted greater long-term improvement, that is, across the follow-

ups. This is consistent with the findings of Durham et al. (2005) among anxiety patients.

Employment may indicate a greater capacity to function and/or it may help patients overcome

agoraphobia by providing regular exposure to feared situations.

Also consistent with Durham et al. (2005), being married/cohabiting predicted long-term

improvement. In addition, being married/cohabiting was related to a lower initial level of

avoidance scores. This is consistent with all the literature on the importance of stable attachment

relationships for mental health (Schore, 2001). Being in a close relationship to another person may

also be beneficial for reducing symptoms of agoraphobia in several ways: by providing social

support, reducing the risk for isolation, and encouraging the agoraphobic person not to avoid

feared stimuli.

Use of antidepressants and benzodiazepines the month before intake to treatment was not

related to levels of or improvements in agoraphobic avoidance. As the treatments were

medication-free, we could not study the influence of concurrent use of medication on long-term

outcome. Although the frequency of co-morbid DSM-III-R and DSM-IV Axis I and II disorders

was high on average (mean > 3) and varied among the patients, co-morbidity predicted neither

short-term nor long-term avoidance.

Overall, it is noteworthy that a person-related clinical feature (major depression) was

predictive of short-term change, whereas external situation variables were related to long-term

change. Thus, it appears that environmental variables are increasingly influential on agoraphobic

avoidance over time.

Several limitations of the present study are worth noticing. Although these long term results

suggest that the treatments were effective in the long term, we do not know what the patients’

course would have been without treatment. However, the use of a no-treatment control group in

such a very long term follow-up study would be both unethical and unfeasible. We must instead


rely on longitudinal community studies, which suggest that agoraphobia is a chronic disorder and

few attain natural remission (Wittchen et al., 2008). Nevertheless, the findings that long-term

predictors were limited to environmental variables and that there was no treatment condition effect

on long-term avoidance are consistent with that long-term avoidance is unrelated to the original

treatments.

It is also difficult to evaluate the influence of treatment received in the follow-period. The

utilization of psychosocial treatments was reduced from 52.1% during the last year at one-year

follow-up to only 10.4% at long term follow-up. The use of BZs was reduced from before

treatment to all the follow-ups, whereas the use of antidepressants remained stable. There was a

rather prevalent use of BZs (39.6%) and antidepressants (36.5%) at long term follow-up, although

the BZs use was mostly on an intermittent per-as-needed basis. The use of BZs but not of

antidepressants was associated with more avoidance at long-term follow-up.

Another limitation of this study is that 31.9% of the included patients did not complete

long-term follow-up, leading to reduced power and threat to the internal representativity of the

sample of respondents. Only 12.1% actually withdrew from the study while 19.9% did not

complete because they were deceased, physically ill, or not possible to contact. However, there

were few differences in baseline characteristics between those we could and those we could not

follow up long term. Moreover, in the predictive analyses, missing data were handled by the FIML

procedure, which is supposed to lead to unbiased estimates of the parameters.

The long time gap between the two and 13-21 year follow-ups is a limitation, in which it is

difficult to assess what actually happened during this period. Another shortcoming is that the

length of the follow-up period varied between the patient cohorts.

There were significant individual variations in initial statuses and trajectory of change for

short-term avoidance, while the trajectories of change in long-term avoidance displayed only a

trend towards individual variation. However, despite less individual variation for long-term


outcome of treatment, the variables employment and living with a partner/spouse still predicted

long-term effects of treatment.

Although all the patients received some form of CBT, there was variability among these. It

appears that this variability did not influence avoidance as the model including treatment

condition led to a poorer fit. Furthermore, some of the treatments had additional vulnerability-

focused parts. It remains uncertain whether these parts influenced short-term and/or long-term

avoidance.

With regard to external validity, these patients had a relatively long duration of their

disorder, a high frequency of co-morbid disorders, and most of them had previously not responded

to treatment. Therefore, they were probably more severely affected and more treatment resistant

than the average patient seeking anxiety treatment. Moreover, the inpatient context of the

treatments is unusual for anxiety disorder patients. Compared to the Norwegian population, their

demographics suggested a tendency toward social disadvantage.

5. Conclusions

Nearly two-third of those attending follow-up had lost their panic disorder/agoraphobia

diagnosis, and the prevalence of most co-morbid diagnoses was reduced by even more than two

third. The only short-term predictor of avoidance identified represented a clinical feature (i.e.

major depression), whereas the long-term predictors represented features of the patients’ life

situation, that is, working and being married/cohabiting.


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Table 1

Participants characteristics at pre-treatment.

Attenders

(n = 96)

Non-attenders

(n = 45)

Variable M SD M SD

Age at intake 39.3 (9.0) 40.3 (9.5)

Duration of agoraphobia 13.0 (10.1) 13.1 (11.1)

n (%)

n (%)

Female 68 (70.8) 36 (80.0)

Married/cohabiting 70 (72.9) 27 (60.0)

Lower occupational levela

70 (72.9) 39 (86.7)

Working last year (> 50%) 41 (42.7) 11 (24.4)

Previous psychiatric treatment 83 (86.5) 40 (88.9)

Use of benzodiazepines last month 60 (62.5) 29 (64.4)

Use of antidepressants last month 25 (26.0) 18 (40.0)

Axis I disorders:

Panic disorder with agoraphobia 80 (83.3) 40 (88.9)

Agoraphobia without panic disorder 16 (16.7) 5 (11.1)

Social phobia 37 (38.5) 18 (40.0)

Generalized anxiety disorder 22 (22.9) 8 (17.8)

Obsessive compulsive disorder 25 (26.0) 11 (24.4)

Simple phobia 25 (26.0) 14 (31.1)

Hypochondriasis 14 (14.6) 5 (11.1)

Somatoform pain disorder 8 (8.3) 6 (13.3)

Table(s)

Undifferentiated somatoform

disorder

5 (5.2) 0 (0.0)

Major depression, current 40 (41.7) 23 (51.1)

Major depression, lifetime 59 (61.5) 30 (66.7)

Dysthymia 18 (18.8) 2 (4.4)

Alcohol dependence/ abuse 10 (10.4) 8 (17.8)

Non-alcohol dependence/ abuse 23 (24.0) 10 (22.2)

Axis II disorders:

Paranoid 4 (4.2) 3 (6.7)

Schizoid 0 (0.0) 1 (2.2)

Schizotypal 0 (0.0) 1 (2.2)

Antisocial 1 (1.0) 0 (0.0)

Borderline 3 (3.1) 4 (8.9)

Histronic 4 (4.2) 2 (4.4)

Narcissistic 1 (1.0) 1 (2.2)

Avoidant 40 (42.7) 19 (42.2)

Dependent 12 (12.5) 8 (17.8)

Obsessive compulsive 11 (11.5) 6 (13.0)

a Unemployed, skilled/unskilled worker, uneducated functionaries.

Table 2

The means (SDs)a and effect sizes

b on symptom measures across assessments and treatment conditions.

Pre-treatment

5 weeks

1 year

2 years

13-21 years

Measure

Mean (SD) n

Mean (SD) n d

Mean (SD) n d

Mean (SD) n d

Mean (SD) n d

MI-AALg

E + PTc

3.73 (0.85) 53

2.70 (0.86) 53 -1.19

2.20 (1.04) 53 -1.58

2.21 (1.03) 49 -1.59

1.86 (0.90) 38 -2.15

CTd

3.59 (0.64) 23

2.76 (0.73) 23 -1.15

2.28 (0.82) 23 -1.70

2.38 (0.82) 20 -1.77

2.05 (0.99) 16 -1.60

GMTe

3.62 (0.88) 23

2.90 (0.87) 23 -0.79

2.40 (0.87) 23 -1.35

2.42 (0.84) 19 -1.28

2.04 (1.02) 15 -1.53

CT + STf

3.34 (1.06) 42

3.15 (1.14) 42 -0.17

2.60 (1.16) 42 -0.65

2.44 (1.18) 42 -0.78

2.41 (1.07) 27 -0.81

Total

3.57 (0.90) 141

2.88 (0.95) 141 -0.74

2.36 (1.02) 141 -1.25

2.34 (1.02) 130 -1.28

2.07 (1.00) 96 -1.55

STAI-Y2g

E + PTc

CTd

GMTe

CT + STf

Total

57.8 (10.5) 53

60.0 (13.5) 23

65.1 (9.5) 23

62.9 (12.0) 42

60.9 (12.0) 141

52.8 (12.2) 53 -0.43

51.7 (14.1) 23 -0.58

53.0 (15.0) 23 -0.89

62.0 (12.9) 42 -0.07

55.4 (13.8) 141 -0.42

45.0 (12.8) 53 -1.07

47.7 (17.1) 23 -0.76

51.5 (16.7) 23 -0.90

51.1 (15.9) 42 -0.82

48.3 (15.3) 141 -0.90

41.4 (12.5) 49 -1.39

45.7 (14.6) 20 -0.98

47.3 (16.3) 19 -1.24

46.9 (15.5) 42 -1.13

44.8 (15.0) 130 -1.17

38.0 (12.1) 38 -1.78

44.6 (16.6) 16 -0.92

46.9 (16.1) 15 -1.45

46.4 (13.4) 27 -1.29

42.8 (14.3) 96 -1.40

Table(s)

BDIg

E + PTc

17.1 (9.4) 53 9.3 (9.0) 49 -0.83 7.1 (6.5) 38 -1.24

CTd

GMTe

19.5 (10.3) 23

24.5 (10.7) 23

11.4 (10.4) 20 -0.75

14.7 (11.7) 19 -0.83

12.6 (11.2) 16 -0.52

10.7 (12.5) 15 -1.21

CT + STf

Total

26.0 (11.3) 42

21.4 (11.0) 141

15.6 (13.3) 42 -0.82

12.4 (11.4) 130 -0.80

11.2 (9.3) 27 -1.32

9.8 (9.4) 130 -1.12

a Computed for those attending each assessment.

b Effect sizes computed as Hedges’ g using pre-treatment as baseline.

c E + PT = Exposure and Psychodynamic Therapy.

d CT = Cognitive Therapy.

e GMT = Guided Mastery Therapy.

f ST = Schema Therapy.

g MI-AAL = Mobility Inventory-Avoidance Alone; STAI-Y2 = State-Trait Anxiety Inventory-Y2 (trait version); BDI = Beck Depression

Inventory.

Table 3

Model fit indices for the conditional piecewise linear growth curve models.

Model Standardized values p-value 2 df RMSEA

a SRMR

b CFI

c TLI

d

Major depression .277 .002 9.398 8 .035 .043 .996 .993

Working -.358 .026 13.246 8 .068 .043 .986 .974

Married/cohabiting -.376 .023 12.609 8 .064 .049 .988 .977

aRMSEA = root mean squared error of approximation.

bSRMR = standardized root mean residuals.

cCFI = comparative fit index.

dTLI = Tucker Lewis index.

Table(s)

Figure(s)Click here to download high resolution image

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Figure caption

Fig. 1. Patient enrollment, randomization, and treatment

Figure(s)

Intercept

Short-term

latent slope

Long-term

latent slope

Major

depression

Working

Married/coh

abiting

-.36 (.161)

Figure(s)

Fig. 2. Significant pre-treatment predictors of the initial level and the rate of change in

agoraphobic avoidance. The short-term latent slope represents the pre-treatment, post-

treatment, and 1 year follow-up Mobility Inventory – Avoidance Alone scores whereas the

long-term latent slope represents the 1 year, 2 years and 13-21 years follow-up scores.

Figure(s)


Role of funding source

This research was funded by the South-Eastern Norway Regional Health Authority (Project

no. 2009045), who had no role in conducting the research or in writing and submitting the report.

*Role of the Funding Source


Conflict of interest

All the authors declare that they have no conflicts of interest.

*Conflict of Interest


Acknowledgements

*Acknowledgement


Contributors

Asle Hoffart has initiated and contributed to the planning of the project, has supervised the

interviewers, and has been the primary writer of the ms.

Tuva Øktedalen has contributed to the writing of the ms. and has done and described the latent

growth curve analyses.

Karol Svanøe has contributed as one of the interviewers and in the writing of the ms.

Liv M. Hedley has contributed to the planning, has been an interviewer, and has contributed to the

writing of the ms.

Harold Sexton has contributed to the planning of the project, to some of the analyses, and to the

writing of the ms.

*Contributors

At follow-up, nearly two-third lost their panic disorder/agoraphobia diagnosis

The prevalence of most co-morbid disorders was reduced by more than two

third

The only short-term predictor identified represented a clinical feature

The long-term predictors represented features of the patients’ life situation

*Highlights (for review)Click here to view linked References

http://ees.elsevier.com/jad/viewRCResults.aspx?pdf=1&docID=12065&rev=1&fileID=304219&msid=76B77DEC-69D9-4CA7-983A-5BC2F7AAEA3B

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