Competitive Memory Training (COMET) for Panic and Applied Relaxation (AR) Are Equally Effective in the Treatment of Panic in Panic-Disordered Patients Kees Korrelboom, Sjef Peeters, Sacha Blom & Irma Huijbrechts
Journal of Contemporary Psychotherapy On the Cutting Edge of Modern Developments in Psychotherapy ISSN 0022-0116 Volume 44 Number 3 J Contemp Psychother (2014) 44:183-190 DOI 10.1007/s10879-013-9259-3
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Author's personal copy J Contemp Psychother (2014) 44:183–190 DOI 10.1007/s10879-013-9259-3
ORIGINAL PAPER
Competitive Memory Training (COMET) for Panic and Applied Relaxation (AR) Are Equally Effective in the Treatment of Panic in Panic-Disordered Patients Kees Korrelboom • Sjef Peeters • Sacha Blom Irma Huijbrechts
•
Published online: 31 December 2013 Ó Springer Science+Business Media New York 2013
Abstract While various psychological interventions, among them Applied Relaxation (AR), are effective in treating patients with panic disorder, there is still room for improvement. Competitive Memory Training (COMET) is a transdiagnostic intervention, slightly different variants of which have proven to be successful in several psychopathological conditions in different patient populations. The objective of this study is to compare the effectiveness of COMET for panic disorder with AR in a group of panicdisordered patients (with or without agoraphobia) in a routine clinical setting. A total of 143 panic-disordered patients were randomized over two (group) treatment conditions: seven sessions of AR, or seven sessions of COMET. Measurements were made at pre- and post intervention. Both treatments resulted in significant amelioration of panic and phobic symptoms; this beneficial effect was relatively large for the primary outcome measure. However, there were no significant differences between the two treatments for any of the outcome measures. COMET and AR appear to be equally effective in treating panic in panic-disordered patients. Keywords Panic disorder Agoraphobia Coping Applied relaxation COMET
K. Korrelboom (&) Research & Innovation of PsyQ, Parnassia Psychiatric Centre, Lijnbaan 4, 2512 VA The Hague, The Netherlands e-mail:
[email protected];
[email protected] S. Peeters S. Blom Department of Anxiety Disorders of PsyQ, Parnassia Psychiatric Centre, Lijnbaan 4, 2512 VA The Hague, The Netherlands I. Huijbrechts Research & Innovation of PsyQ Nederland, Denemarkenlaan 2, 2711 EL Zoetermeer, The Netherlands
Introduction According to the Dutch Multidisciplinary Guidelines for Anxiety Disorders (MGAD: Landelijke Stuurgroep Multidisciplinaire Richtlijnontwikkeling in de GGZ, LSMR 2003), three psychological interventions are considered to be evidence-based for treating panic in patients with panic disorder, with or without agoraphobia. These are Applied ¨ st 1987), Cognitive Therapy (CT: SalRelaxation (AR: O kovskis and Clark 1991) and Interoceptive Exposure (IE: Barlow et al. 1989). All three share a number of common elements: (1) cognitive restructuring, (2) interoceptive exposure, and (3) learning how to cope with panic sensations and cognitions. CT, AR and IE mainly differ in the ways these three latter elements are emphasized and combined in each of the procedures. Whereas some studies found more or less equivalent ¨ st et al. efficacy between AR and CT (Beck et al. 1994; O ¨ st and Westling 1995) others found better effects 1993; O for CT compared to AR (Clark et al. 1994; Arntz and van den Hout (1996). Despite the reported success of these three methods, there seems to be room for further improvement (Craske 1999). Recently, several variants of a series of interventions known as Competitive Memory Training (COMET) appeared to be successful in treating different kinds of psychopathology in different patient populations. Therefore, COMET is considered to be a transdiagnostic intervention. All of these COMET protocols are based on Brewin’s notion of competitive memory retrieval hierarchies (Brewin 2006). According to Brewin most concepts have different meanings, all stored in long-term memory, competing with each other to be retrieved and activated. However, some of these meanings might be dysfunctional. Psychopathology develops when a dysfunctional meaning
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is too high in the retrieval hierarchy of a concept and is, therefore, too easily retrievable. Therapeutic change is not acquired by directly changing the dysfunctional meaning of the concept, but by making its functional meanings more competitive, thus placing these alternative ‘healthy meanings’ higher up in the retrieval hierarchy. All COMET protocols are targeted at (1) identifying the dysfunctional meaning of the target concept that is too high in the retrieval hierarchy, (2) identifying a credible alternative interpretation that is too low in that same hierarchy, and (3) making that alternative interpretation more competitive and better retrievable by frequent activation, enhanced emotional saliency and stronger associations with the target concept. Although all COMET protocols can be applied in both an individual and a group setting, no comparisons have yet been made between these two formats. Competitive Memory Training can be considered an ‘experiential cognitive intervention’. It is cognitive since it aims to change the patient’s cognitions and interpretations. It is experiential since it stimulates the patient not only to (intellectually) know these changes but, above all, to become aware of these changes at an experiential level. Starting from these general ideas, one variant of COMET (COMET-self-esteem) proved efficacious in enhancing self-esteem and reducing depression in patients with eating disorders (Korrelboom et al. 2009), personality disorders (Korrelboom et al. 2011) and depressive disorders (Korrelboom et al. 2012). Another COMET protocol (COMETworry and rumination) was successful in reducing rumination and depression in a group of elderly depressed patients (Ekkers et al. 2011). Finally, another slightly different COMET protocol (COMET-auditory hallucinations) succeeded in reducing depression in persistently hallucinating patients with schizophrenia-spectrum disorders by enhancing self-esteem and stimulating a more distant attitude towards the attributed power of the voices (van der Gaag et al. 2012). In all these studies, therapy as usual (TAU) was the treatment condition that COMET was compared with. These successes stimulated the development of yet another COMET protocol, COMET-panic. In panic-disordered patients, panic sensations such as dizziness, palpitations, or sweating are hypothesized to activate the dysfunctional expectation of physical, mental and/or social catastrophe. In IE and CT this expectation is challenged by exposing the patient to these sensations in such a way that he experiences that, in reality, the expected catastrophe will not happen. Both AR and COMET-panic also falsify this erroneous expectation by interoceptive exposure but, at the same time, provide the patient with an adequate coping response to handle the frightening bodily sensations. In AR this coping response is relaxation, in COMET the patient is taught to make a ‘mental switch’ to a sense of control and mastery.
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The rationale behind this ‘mental switching’ is connected to a second dysfunctional meaning that is hypothesized to be activated in panic-disordered patients. Specific physical symptoms are supposed to activate the experience of powerlessness and uncontrollability (Mineka and Sutton 2006) in addition to the already mentioned expectation of oncoming catastrophe. In COMET this second ‘thinking error’ is addressed by strengthening the patient’s sense of mastery and control. This is achieved by the repeated activation of memories of personal instances where control and the sense of mastery were at hand. As in the other COMET protocols, these memories are made more emotionally salient with the help of imagery, body posture, facial expression and self-verbalizations. Thereafter, these enhanced ‘having control experiences’ are more firmly associated with the triggering bodily sensations with the aid of counter-conditioning procedures. Since this COMET-panic protocol appeared to be effective in two pilot studies in routine clinical settings (Korrelboom et al. 2008; Peeters et al. 2005), it was decided to put the new protocol to the test in a randomized controlled trial versus an evidence-based anti-panic procedure, in this case AR. It was expected that COMETpanic, being a more comprehensive coping technique in handling panic sensations by addressing self-confidence instead of bodily sensations directly, would outperform AR, specifically on the different panic measures.
Methods Overview of the Study The current study was performed at the Department of Anxiety Disorders (DAD) of PsyQ, one of the largest mental health institutions in the Netherlands for the treatment of psychiatric outpatients. Newly referred patients with a diagnosis of panic disorder, or panic disorder with agoraphobia, were eligible. After inclusion, patients were randomized over two treatment procedures, i.e. COMET-panic or AR. After this first stage of therapy, patients could either discontinue their treatment and stop or, if considered necessary by the therapist and patient, they could continue their treatment in a second stage with exposure in vivo. However, since randomization was neutralized after the first stage of treatment, the current study is limited to the first part of the treatment: COMET-panic versus AR. Patients All patients were regularly referred to the DAD and had initially been assessed according to the regular procedures
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Fig. 1 Flow chart of the study participants. COMET competitive memory training, AR applied relaxation, PD only panic disorder, PDA panic disorder with agoraphobia
of the department. During this initial clinical interview the primary diagnosis was established by a regular assessor of the DAD according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR: American Psychiatric Association 2000). Whenever a clinical diagnosis of panic disorder (with or without agoraphobia) was established, the patient was asked to participate in the study. When affirmative, patients were assessed again. In this second assessment, the diagnosis was verified formally by one of six trained assessors by applying a Dutch translation of the Mini International Neuropsychiatric Interview (MINI: Sheehan et al., 1998; van Vliet et al. 2000). Then, the second author (SP) discussed the results of the MINI with the patient and checked the other inclusion/exclusion criteria. Apart from the diagnosis, other inclusion criteria were: age 18–65 years, and being able to read, speak and understand Dutch well enough to participate in the treatment groups and to fill in all assessments. Criteria for exclusion were: severe co-morbid psychopathology, such as psychosis; addiction; being suicidal; mental retardation; concurrent psychological treatments, or cognitive-behavioral treatments in the past 6 months. Use of psychotropic medication was permitted only if the medication dose was stable during the study and had been stable for at least 2 months prior to study inclusion. Patients who changed their medication during treatment
were considered to be dropouts, patients who started (a new) medication less than 2 months before inclusion had to wait for participation until they had fulfilled this 2-month criterion. When assessment was completed and informed consent was given, patients were randomized to one of the treatment conditions, i.e. COMET- panic or AR. Since AR is a well-established empirically supported treatment, and (within) effect sizes of COMET for panic in pilot studies were large, a small to intermediate difference between the conditions was expected. To have sufficient power to demonstrate a real differential effect between both conditions (whilst also allowing for some attrition), a total sample size of 130–160 participants was required. Enrolment was performed in 12 blocks, resulting in 12 AR and 12 COMET-panic groups, each consisting of 5–9 patients. Figure 1 shows the flow of participants during the study. Of the 157 patients assessed for study participation, 14 patients did not enter the study: 4 were excluded by the assessor (1 for not fulfilling the inclusion criterion for diagnosis, 2 for violating the pharmacological requirements, and 1 because of hospitalization during the assessment phase), and 10 patients declined to participate. Thus, 143 patients were randomized: 73 to AR and 70 to COMET. Of these patients, 52 (36 %) were male and 91 (64 %) female, their mean age was 36.1 (SD 11.9) years, and 113 (79 %) were diagnosed with panic disorder with
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agoraphobia and 30 (21 %) with panic disorder alone. All further calculations pertain to these 143 patients. Instruments In the recruitment phase of the study all patients were assessed with a Dutch translation of the Mini-International Neuropsychiatric Interview (MINI: Sheehan et al. 1998; van Vliet et al. 2000). Pre-treatment and post-treatment, patients were assessed with a Dutch translation of the Panic Appraisal Inventory (PAI: Telch et al. 1989; de Beurs et al. 2005). The PAI consists of three scales that assess three aspects of cognitive appraisal of panic: the anticipation of panic (PAI-ant), the feared consequences of panic (PAI-cons), and the expectancy to be able to cope with panic (PAI-cop). Total scores on all subscales range from 0–100. Low scores are favorable on PAI-ant and PAI-cons, while high scores are favorable on PAI-cop. Psychometric qualities of the Dutch translation of the PAI are good (Feske and de Beurs 1997; de Beurs et al. 2005). In the present study, the PAI-cop was considered the main outcome measure. Patients were also assessed with a frequently-used Dutch translation of the Mobility Inventory (MI: Chambles et al. 1985; de Beurs 1993). The MI assesses three dimensions of agoraphobia: agoraphobic avoidance when alone (MI-A), agoraphobic avoidance when accompanied by a trusted person (MI-T), and the estimated number of panic attacks (panic frequency) during the last week (MIPF). Total scores on both avoidance scales are calculated by dividing the sum of the item scores by the number of filled-in items and can range from 1 (no avoidance) to 5 (maximum avoidance), while scores on the panic frequency can take any positive value or zero. Psychometric qualities of the MI are good (Chambles et al. 1985). Therapists Each treatment group was led by two therapists, both regular therapists of the DAD. Since the DAD has a long tradition in which nurses provide different sorts of relaxation training, a pool consisting of four cognitive-behaviorally trained nurses provided AR. On the other hand, COMET-panic was provided by a similar pool of three cognitive-behaviorally trained psychologists and one cognitive-behaviorally trained nurse, all of whom had experience in providing COMET-panic. Procedure Newly referred patients who fulfilled the DSM-IV TR criteria for panic disorder with or without agoraphobia, were eligible. After further screening for inclusion and
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exclusion criteria and after providing informed consent, these patients were randomized to COMET-panic or AR. Then, pre-treatment measurements were taken. Each treatment procedure encompassed 7 weekly sessions of 1.5 h each, which were performed in small groups (5–9 patients/group) led by two therapists. Pre-treatment measurements (M-pre) were performed at the start of both treatments. Post-treatment measurements (M-post) were performed at the end of stage 1, i.e. after completion of either seven sessions of COMET-panic, or seven sessions of AR. From then on, patients either stopped with further treatment or they continued treatment with exposure in vivo. Since randomization was neutralized after the first stage of treatment, this study pertains only to the effects of this part of the treatment. All patients who completed stage 1 and had no further treatment, were approached 6 months later by mail and telephone for follow-up (M-fu). Treatments At the start of the therapies, all patients were provided with a comprehensive treatment manual (for COMET-panic or for AR) in which the rationale, background and specific procedures, and homework assignments of the treatment were specified. In both manuals, panic is described as a frightening but harmless ‘false-alarm reaction’ to internal and external triggers. The perceived uncontrollability of these physical sensations is stressed, as is the desirability and possibility to regain control over them. The AR protocol explains the AR way of gaining control, whereas the COMET way is described in the COMET-panic protocol. In the course of both treatments patients were requested to do daily homework assignments and to monitor panic attacks and ‘near panic attacks’, together with their reactions to these. They also had to log the completion of their homework assignments. The main difference between the two manuals was the way in which ‘gaining control’ was to be achieved. COMET-Panic COMET-panic was aimed at facilitating patients in ‘getting access to their sense of control’ that was supposed to be too low in the retrieval hierarchy and, subsequently, ‘to use this sense of control in handling (self-provoked) panic sensations’, in order to become more confident and self-reliant in handling future panic attacks in real life. To achieve these aims the COMET protocol was divided into several steps. In the first step patients had to identify situations in which they normally felt in control. These could be daily activities such as gardening or playing with one’s child, or
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more or less unique situations from the past when, for example, the patient had managed to skillfully conquer a ‘black descent’ in skiing. Then, patients elaborated on these situations by repeatedly (during sessions and homework) imaging them, meanwhile formulating positive selfstatements pertaining to having control, and adapting a facial expression and bodily posture that were thought to promote the sense of control even further. These exercises are expected to enhance the emotional saliency of ‘being in control’, and thus the retrievability of this feeling state from long-term memory. From the third session onward, interoceptive exposure was gradually introduced. Patients had to imagine scenes in which they normally fear they will panic, meanwhile provoking panic sensations of an accumulating intensity. After each provocation they had to ‘switch over’ to the ‘being in control’ scene they had practiced in the first two sessions, by imaging this scene, meanwhile adapting the positive posture, facial expression and positive self-verbalization until they felt in control again. These panic provocations, followed by switching, were repeated again and again. Patients were encouraged to diminish their fear for paniclike sensations by experiencing that they could gain control, and by conceiving of panic sensations as ‘innocuous small nuisances that can be handled’. Applied Relaxation for Panic The AR treatment is based on the original description of ¨ st (1987). However, the original format has been transO formed into a 7-session (1.5 h per session) group format, encompassing the same ingredients and practices. Patients had to practice successively progressive muscle relaxation, ‘release only’ relaxation (relaxation without tensing the muscles in the first place), cue-controlled relaxation (relaxation conditioned to a cue word), differential relaxation (relaxation in daily situations), rapid relaxation, and applied relaxation (relaxation in reaction to deliberate exposure to natural triggers for panic-like sensations). Treatment Integrity Both panic management techniques were available in written form (a manual) for therapists and patients. In regular meetings therapists and researchers discussed adherence to the treatment protocols. As an additional check on treatment integrity, patients filled in a checklist containing specific questions about the nature of the treatments they had just received. This checklist contained statements about specific differential identifying elements of both therapies. If both treatments had been delivered properly, AR patients should identify more AR ingredients
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in the treatment they had received and few/none of the COMET elements, and vice versa for the COMET patients. Statistical Analyses Analyses were on an intention-to-treat basis. First, in a binary logistic regression analysis, it was checked whether dropout was predicted by age, diagnosis, gender or any of the outcome measures at M-pre. Then missing values were imputed with the SPSS 20 multiple imputation algorithm. Consequently, differences between groups on each of the outcome variables at M-post were tested for significance with analysis of covariance, taking the score at M-pre as a covariate. Moreover, the effect sizes (Cohen’s d) between groups, if appropriate, i.e. when significant differences had been detected, and within groups (M-pre–M-post/SD-pre) were calculated. Finally, the stability of the treatment effects was assessed by analyzing the differences between M-post and M-fu of those patients that completed stage 1 and had no further treatment.
Results The sample consisted of 91 (64 %) females and 52 (36 %) males. Of these, 113 (89 %) were diagnosed as having panic disorder with agoraphobia, and 30 (21 %) with panic disorder alone. Mean age was 36.1 (SD = 11.9) years. According to the treatment integrity check, both treatments were delivered as they were intended to. A random selection of 30 AR patients identified significantly more AR elements than COMET elements in their treatment condition, and a similar sample of patients did so in the COMET condition for COMET elements. During treatment, a total of 24 patients (17 %) dropped out (13 in AR and 11 in COMET). In the original dataset, there were no predictors for dropout in COMET; in AR, however, dropout was predicted by a higher score at MI-A (p = 0.07). When considering all the patients together, there were no predictors for dropout in the original dataset. However, after multiple imputation, age and PAI-ant predicted group, age being significantly higher in AR (M = 37.6 years, SD = 12.4 vs. M = 34.5 years, SD = 11.2; p = 0.1) and PAI-ant being significantly less severe in AR (M = 36.81, SD = 19.91 vs. M = 45.05, SD = 23.86; p = 0.02). Therefore, in addition to any specific variable at M-pre, age and PAI-ant at M-pre were taken as extra covariates in all further calculations. None of the separate ANCOVAs yielded significant differences between the groups at any of the outcome measures at M-post. Within-effect sizes on the main outcome measure (PAI-cop) were large in both treatments (COMET: 1.3; AR: 1.1) and intermediate to large on the two other PAI scales.
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Author's personal copy 188 Table 1 Effects of all patients: intention-to-treat basis
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Variable/ group
N
Mean (SD) Pretreatment (M-pre)
Mean (SD) Posttreatment (M-post)
Significance (between)
0.36 (n.s.)
Cohen’s D (within)
Panic appraisal inventory-cop: coping with panic COMET
70
36.05 (19.34)
60.90 (19.56)
AR
73
40.15 (18.32)
60.58 (21.61)
1.3 1.1
Panic appraisal inventory-ant: anticipation of panic COMET
70
45.05 (23.86)
34.03 (22.63)
AR
73
36.81 (19.91)
25.43 (19.46)
0.37 (n.s.)
0.5 0.6
Panic appraisal inventory-cons: feared consequences of panic COMET
70
33.68 (20.94)
17.24 (15.70)
AR
73
27.26 (21.23)
13.23 (16.50)
0.55 (n.s.)
0.8 0.7
Mobility inventory-PF: number of panic attacks during last week COMET AR
70 73
1.74 (2.49) 1.85 (3.05)
1.09 (2.10) 0.77 (2.11)
0.51 (n.s.)
0.72 (n.s.)
0.3 0.4
Mobility inventory-A: avoidance when alone
COMET competitive memory training, AR applied relaxation, n.s. not significant at alpha = 0.05
COMET
70
2.69 (1.18)
2.30 (1.09)
AR
73
2.57 (1.06)
2.17 (1.01)
Mobility inventory-T: avoidance when together with a trusted person COMET
70
2.06 (0.87)
1.82 (0.79)
AR
73
1.93 (0.76)
1.69 (0.73)
Effects of both treatments on panic frequency were small (COMET: 0.3 and AR: 0.4). Table 1 presents an overview of the results of both anti-panic treatments. After anti-panic training, 60 patients (42 %) continued treatment with exposure in vivo (31 in AR and 29 in COMET), while 59 patients did not need further treatment after completion of the anti-panic interventions (29 in AR and 30 in COMET). Of these 59 ‘treatment completers ? stoppers’ after anti-panic training, 28 (47 %) sent in their follow-up results 6 months later: 9 (31 %) in AR and 19 (66 %) in COMET. In both groups the results remained stable; no significant changes were found between M-post and M-fu on any of the outcome measures. However, in both groups these follow-up data are somewhat biased, since only a minority of ‘treatment completers ? stoppers’ filled in their measures; also, at M-post, COMET patients with follow-up measures scored significantly lower (i.e. were less problematic) on PIA-ant than COMET patients without these measures, while AR patients with follow-up data were significantly older and showed to be less problematic on the MI-A scale than AR patients without a follow-up.
Discussion COMET-panic, a new coping-based intervention for treating panic disorder was compared with AR, one of the psychological interventions for the treatment of panic recommended by the Dutch Multidisciplinary Guidelines
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0.3 0.4
0.74 (n.s.)
0.3 0.3
for Anxiety Disorders. Contrary to expectations, COMET did not outperform AR on any of the specified outcome measures. Both treatments were equally effective on all outcome variables attaining adequate within-effect sizes, specifically where coping with panic sensations was concerned. When evaluating the small and intermediate within-effect sizes on several outcome measures, two items need to be taken into account. First, according to Dutch norm groups, the mean scores at M-pre on both avoidance scales (MI-T and MI-A) were low to very low, leaving little room for improvement. Further, for about half of the patients, the anti-panic training stage was only half of their treatment. After this therapy stage (stage 1) they received exposure in vivo during the next phase of their treatment; however, scores of these patients after this second therapy stage, or at followup, are not a part of the current study. The present study has several strengths. It involves a relatively large sample of patients who sought help along the regular referral procedures and were treated by regular therapists in a regular mental health organization. Thus, the ecological validity of this study can be considered to be relatively high. However, some limitations need to be addressed. First, the second author was involved in applying the procedures of inclusion and exclusion and was also one of the therapists in the COMET condition; this might have biased the inclusion procedure. However, as described in the second limitation, the COMET group was slightly more handicapped in comparison with the AR group.
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Second, randomization was not entirely successful. Patients in COMET were not only slightly younger, they also seemed slightly more handicapped in certain aspects of their disorders compared to those in AR. The use of covariates, as is practiced in this study, can only be a partial solution to this limitation. Thirdly, in the two conditions, the comparability of the therapists is debatable. There was a clear difference in the education level between therapists in the AR condition (mainly CBT-trained nurses) and the COMET therapists (mainly CBT-trained psychologists). On the other hand, apart from the education level, both groups of therapists had similar training in and experience with the treatments that they delivered. Moreover, the provision of AR does not seem to require specific academic psychological skills, whereas the application of COMET presupposes some knowledge of basic memory mechanisms and conditioning theory. Thus, it seems unlikely that COMET had been applied more skillfully than AR. However, due to the difference in educational level between therapists in the two conditions, AR could have been a more cost-effective intervention than COMET-panic; this needs to be examined in a cost-effectiveness study. Fourth, considering that both treatments are primarily based on coping, and bearing in mind the more or less equivalent outcomes, one may question to what extent the treatments really did differ from each other. However, inspection of the treatment integrity checks indicates that they did indeed differ (at least according to the patients). In the AR condition the mean score for ‘AR ingredients’ was 36.7 (SD = 3.1) whereas the highest possible score was 40, while the mean score for ‘COMET ingredients’ in this condition was only 16.6 (SD = 9.5) whereas the lowest possible score was 4. On the other hand, in the COMET condition these figures were 34.0 (SD = 5.7) for ‘COMET ingredients’ (possible maximum of 40) and 15.2 (SD = 7.6) for ‘AR ingredients’ (possible minimum of 4). All these differences were significant in the expected directions. It is of course possible that what the researchers considered to be ‘core ingredients’ are in fact not so; or that these so-called ‘core ingredients’ of both treatments are more or less identical on a more basic level. Fifth, some discrepancy may exist between the large percentage of patients diagnosed with panic disorder with agoraphobia (79 %) and the relatively low pre-treatment scores on the avoidance scales (‘low’ at MI-A, and ‘below mean’ at MI-T). It is unknown why these scores were so low. All patients were diagnosed according to the MINI by trained assessors. In fact, a post hoc analysis of differences at M-pre between panic-disordered and panic-disordered with agoraphobia patients indeed revealed significant differences in avoidance scores between both groups on both avoidance scales in the expected directions (p \ 0.00 in
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both instances). Nevertheless, the mean scores of panic disorder with agoraphobia remain rather low at M-pre (M = 2.13; SD = 0.83 at MI-T and M = 2.83; SD = 1.10 at MI-A). It is possible that many agoraphobic patients had become so accustomed to their avoidance behavior, that they did not indicate all their avoidances on the MI questionnaire. A final limitation concerns the follow-up measurements. First of all, attrition was relatively high, particularly for patients in AR: only 47 % of all patients who completed anti-panic training and had no further treatment after stage 1 could be contacted for follow-up and returned their follow-up measurements. Moreover, at follow-up both subsamples were biased: in both treatment conditions, patients who returned their follow-up measurements were somewhat less handicapped at M-post than patients who did not. For these reasons, the follow-up results should be interpreted with caution.
Conclusion Despite the limitations of the study, both COMET-panic and Applied Relaxation appear to be effective treatments for patients with panic disorder, with or without agoraphobia. However, no differences in effectiveness between the two treatments could be detected. The effect sizes on the primary outcome variable (PAIcop) suggest that enhancing their sense of mastery and controllability is an important issue in the treatment of panic-disordered patients. In accordance with the final limitation (biased FU results) and limitation 3 (different educational levels of the therapists), some doubt still exists concerning the differential cost-effectiveness of both methods (AR might be cheaper), and the durability of the results (patients from both treatment conditions who returned their follow-up measurements were better off post-treatment than patients who did not). To further elucidate the possible usefulness and applicability of COMET-panic, direct comparisons with other evidence-based panic interventions are necessary. Moreover, other questions remain: Do AR and COMET-panic indeed address different kinds of coping; if so, would some patients profit more from AR and others from COMET? Also, are seven group sessions the optimal amount for both interventions; or should the seven sessions of COMET or AR be supplemented with more of the same or with exposure in vivo (EV)? This latter option was in fact investigated in a subsequent study with patients from the current study that did not derive sufficient benefit from seven sessions of COMET or AR. These patients were offered an additional
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seven (group) sessions of EV. However, since this additional study was not randomized (both AR and COMET patients were treated in the same EV groups) the results will be published separately.
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