Reinecke, A., Waldenmaier, L., Cooper, M. J., & Harmer, C. J. (2013). Changes in Automatic Threat Processing Precede and Predict Clinical Changes with Exposure-Based Cognitive-Behavior Therapy for Panic Disorder. Biological Psychiatry.
According to a recent study published in Biological Psychiatry, cognitive behavior therapy (CBT) impacts automatic threat processing early on in treatment for patients with panic disorder. Research suggests that biased processing of emotional information is an underlying mechanism of affective disorders and influences the effectiveness of interventions used to treat them. For example, when simultaneously shown a face with a negative expression and a face with a neutral expression, patients with anxiety will automatically direct their attention to the face with the negative expression. This is believed to increase the likelihood of anxiety attacks. Pharmacological treatment methods have been shown to reduce the automatic threat processing bias after an acute, short-term dose, before changes in anxiety and mood become evident. These changes have been shown to be predictive of later changes in therapeutic effects measured 6 weeks later, suggesting that the early changes in automatic biases drive recovery. While CBT has been shown to reduce the automatic threat processing bias as well, it is usually assumed that CBT functions primarily as a top-down treatment approach, primarily targeting more explicit cognitive beliefs and control processes rather than automatic processes. By this view, CBT would only reduce the automatic threat processing bias over time with repeated practice and learning. The current study sought to examine the effects of an acute-dose CBT administration on the automatic threat processing bias. Participants (n=28) satisfied DSM-IV criteria for panic disorder and were randomly assigned to either the treatment group (n=14), which received a single session of CBT, or the control group (n=14), which received no intervention. Participants completed a faces dot probe task the day after treatment, which measured reaction times to the presentation of negative, neutral, and happy expression faces. Additionally, participants’ general clinical symptoms were measured at baseline, the day after treatment, and at a 4-week follow-up. Participants’ responses to a stress test, which placed them in situations designed to elicit anxious reactions, were also measured at all three test times to provide evidence for the efficacy of the single CBT session. Results showed that the treatment group showed significantly reduced vigilance for the negative expression faces one day following treatment, while the control group showed no reduction. The two groups did not differ in measures of clinical symptoms at baseline or the day after treatment. However, the treatment group showed significant reductions in fear of physical symptoms and agoraphobia severity at the 4-week follow-up, while the control group showed no changes. In fact, 35.7% of patients in the treatment group fulfilled criteria for agoraphobia recovery at the follow-up, with their scores falling within the range of healthy individuals. The treatment group also reported lower stress in response to the stress tests both the day after treatment and at the 4-week follow-up. The reduction in fear bias was also attributed to 22% of the variance in symptom improvement over time. These results indicate that a single session of CBT rapidly reduces the automatic threat processing bias, before the more explicit cognitive changes occur. This finding contradicts the generally assumed model of CBT, suggesting that it is more similar to pharmacological models, at least for anxiety and panic disorders, than previously thought. The results also provide evidence for the predictive effects of automatic threat processing bias reduction on overall symptom improvement over time, suggesting that this is a key component to the effective treatment of panic disorders. Additionally, these results imply that a subset of roughly one-third of panic disorder patients may only require a single session of CBT in order to recover from co-morbid agoraphobia.