Factors associated with treatment outcomes in mindfulness-based cognitive therapy for panic disorder

Long-term benefits of mindfulness on white matter tracts underlying the cortical midline structures in panic disorder: A 2-year longitudinal study

AIMS

We aimed to examine the long-term benefits of mindfulness-based cognitive therapy (MBCT) on white matter plasticity in the cortical midline structures (CMS) for a period of 2 years in patients with panic disorder and the relationships between white matter changes in the CMS and severity of state and trait symptoms.

METHODS

Seventy-one participants were enrolled and underwent diffusion tensor imaging at baseline and after 2 years (26 who received MBCT as an adjunct to pharmacotherapy [MBCT+PT], 20 treated with pharmacotherapy alone [PT-alone], and 25 healthy controls [HCs]). The severity of symptoms and fractional anisotropy (FA) in white matter regions underlying the CMS were assessed at baseline and 2-year follow-up.

RESULTS

The MBCT+PT group showed better outcomes after 2 years than the PT-alone group. The groups showed different FA changes: the MBCT+PT group showed decreased FA in the left anterior cingulate cortex (ACC); the PT-alone group showed increased FA in the bilateral dorsomedial prefrontal cortex, posterior cingulate cortex (PCC), and precuneus. Decreased white matter FA in the ACC, PCC, and precuneus was associated with improvements in the severity of state and trait symptoms in patients with panic disorder.

CONCLUSION

Alleviation of excessive white matter connectivity in the CMS after MBCT leads to improvements in clinical symptoms and trait vulnerability in patients with panic disorder. Our study provides new evidence for the long-term benefits of MBCT on white matter plasticity and its clinical applicability as a robust treatment for panic disorder.

The potential mediating role of anxiety sensitivity in the impact of mindfulness training on anxiety and depression severity and impairment: A randomized controlled trial

The benefits of mindfulness-based interventions to alleviate anxiety and depression have been supported by many studies. Given the effectiveness of mindfulness-based interventions on anxiety and depression, the underlying mechanisms need to be explored. Using a randomized waitlist-controlled design, this study investigated whether anxiety sensitivity was a potential mechanism for the impact of mindfulness training on anxiety and depression. Participants with high psychological distress were randomly assigned to an eight-week mindfulness intervention (N = 35) or a wait-list control group (N = 34). Before and after the intervention or corresponding waitlist period, participants completed measures of anxiety and depression severity and impairment and anxiety sensitivity. Separate mixed ANOVA demonstrated significant group (intervention vs. control group) × time (pre- vs. post-test) interactions for anxiety sensitivity and overall anxiety severity and impairment and marginally significant interaction for overall depression severity and impairment. Moreover, simple mediation models showed that reductions of anxiety sensitivity from pre- to post-test mediated the impact of mindfulness training on changes in anxiety and depression severity and impairment. The findings suggest that anxiety sensitivity is a potential mechanism underlying the effect of mindfulness training on anxiety and depression, which provides a new perspective for the study of processes of change of mindfulness-based interventions.

Pathological Worry is Related to Poor Long-Term Pharmacological Treatment Response in Patients With Panic Disorder

OBJECTIVE

Several predictors of unfavorable pharmacological treatment response (PTR) in panic disorder (PD) patients have been suggested, such as the duration of the illness, presence of agoraphobia, depression, being a woman, and early trauma. This study aimed to examine whether pathological worry is associated with PTR in PD patients.

METHODS

This study included 335 PD patients and 418 healthy controls (HCs). The Penn State Worry Questionnaire (PSWQ), the Early Trauma Inventory Self Report-Short Form (ETISR-SF), Beck Depression Inventory (BDI), Panic Disorder Severity Scale (PDSS), and Anxiety Sensitivity Inventory-Revised (ASI-R) were administered. We measured the PTR at 8 weeks and 6 months. Student t-test, chisquare tests, Pearson's correlation analyses, and binary logistic regression model were used.

RESULTS

Our results showed that the total scores of the PSWQ correlated with the ETISR-SF, BDI, and ASI-R were significantly higher in patients with PD compared with HCs. The PSWQ and BDI could predict unfavorable PTR at 6 months in PD patients.

CONCLUSION

This is the first study to demonstrate that pathological worry may contribute to poor long-term PTR in PD patients. Therefore, our research suggests that clinicians must be aware of worry to optimize PTR for PD patients.

Predictors and moderators of outcomes in mindfulness-based cognitive therapy intervention for early breast cancer patients

OBJECTIVES

To deliver mindfulness-based cognitive therapy (MBCT) efficiently, the present study aimed (1) to identify predictors and moderators of patients who benefit from MBCT for psychological distress and (2) to explore the initial treatment reaction to identify the optimal number of sessions that produce a significant clinical effect.

METHODS

This is the secondary analysis of a randomized controlled trial of MBCT for breast cancer patients (N = 74). We classified the participants into remitters vs. non-remitters, and responder vs. non-responders, according to the total score of the Hospital Anxiety and Depression Scale at the end of the intervention. We conducted multivariate analyses to explore for predictors of response and remission. We adopted generalized estimating equations to explore the optimal number of sessions.

RESULTS

Sociodemographic and clinical backgrounds did not have significant influence on the treatment outcomes of the MBCT. Better program adherence, which was represented as the participants' better attendance to the MBCT program, was a significant predictor of both remission and response [odds ratio (OR) = 1.90, 95% confidence interval (CI) 1.25-2.89, p = 0.003, and OR = 1.72, 95% CI 1.12-2.65, p = 0.013, respectively]. It was not until seventh session that the remission rate exceeded 50% and the response rate showed significance.

SIGNIFICANCE OF RESULTS

Sociodemographic and clinical characteristics did not significantly influence the treatment outcomes, while homework minutes and class attendance had significant effects on treatment outcomes. This implies that MBCT is recommended to any cancer patient, if he/she is motivated to the program, regardless of their sociodemographic and clinical characteristics. Patients are encouraged to attend a standard MBCT program (eight sessions) and do the assigned homework as intensely as possible. Further studies with larger sample and objective measurements are desired.

A Mixed-Methods Study Protocol for Soma Experiencing Motion Program (Soma e-motion Program): The Effectiveness of Contemplative Movement for Emotion Regulation

Somatics refers to body work and movement study that emphasize internal perception and experience. Recently, a new perspective has emerged that views somatics-based techniques as a kind of mindful movement. Somatic techniques as contemplative movement can improve emotional regulation ability through improvement of body awareness or interoception. Based on this background, the present study attempts to develop a somatics based program suitable for a group of clinical patients suffering from emotional dysregulation. This study plans to collect quantitative and qualitative data in order to clarify how interoception and the related emotional regulation ability change after the program. These findings will help to explore whether the somatics technique has potential as an emotion regulation program in the future. In addition, the results are expected to contribute to finding an alternative treatment modality for patients who have not achieved a sufficient effect with conventional psychotherapy.

Early Trauma Is Associated with Poor Pharmacological Treatment Response in Patients with Panic Disorder

OBJECTIVE

Pharmacotherapy is established as an effective method for reducing symptoms of panic disorder (PD). However, about 20-40% of PD patients are treatment-resistant. Predictors of pharmacotherapy outcomes for PD patients are needed.

METHODS

This study included 152 PD patients to measure the clinical severities of PD symptoms and used the Early Trauma Inventory (ETI) to measure early trauma. Treatment response was defined as a 40% reduction in the total Panic Disorder Severity Scale score from baseline. We measured the treatment responses at 8 weeks and 6 months. Binary logistic regression was used to predict treatment response after controlling for confounding variables.

RESULTS

Early sexual trauma alone was associated with poor treatment response at 8 weeks. However, at 6 months, the total ETI score was associated with an unfavorable treatment response.

CONCLUSION

Therefore, our study suggests that clinicians need to be aware of a history of early trauma to optimize treatment outcomes for PD patients.

Cognitive Behavioral Therapy and Mindfulness-Based Cognitive Therapy for Depressive Disorders

Recently, the importance of cognitive behavioral therapy (CBT) in the treatment of depression is gradually emerging. Particularly, mindfulness meditation has various approaches related to dialectical behavioral therapy (DBT), acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT), and evidence has been provided that they alleviate depressive symptoms. In particular, as MBCT increases the level of evidence in the treatment of repetitive depressive disorders, guidelines are being recommended to prevent recurrence. Mindfulness may also contribute to improving the patient's symptoms as well as improving the therapeutic relationship with the therapist. For both mindful patients and therapists, positive awareness of internal experiences can be a good way to enrich the mind and overcome depressive disorders.

More Purpose in Life and Less Novelty Seeking Predict Improvements in Self-Compassion During a Mindfulness-Based Intervention: The EXMIND Study

OBJECTIVES

Recently, a 4-week mindfulness-based intervention followed by a 4-week existential approach was found to be as effective for increasing self-compassion as an 8-week mindfulness-based intervention. The purpose of the present study was to identify the factors that predicted change in self-compassion during the 8-week mindfulness-based intervention.

METHODS

Fifty-seven of the 61 completers of the 8-week mindfulness-based intervention provided baseline, 4-week, and 8-week self-compassion scale scores. The mean age of the 47 females and 10 males was 49.6 years. Pearson's correlation coefficients were generated on the associations between the change of total self-compassion scale scores from baseline to 8 weeks with age; gender; and the baseline scores on the Temperament Evaluation of Memphis, Pisa and San Diego Auto-questionnaire, Temperament and Character Inventory (TCI), Mini-Mental State Examination, Japanese Adult Reading Test, Young Mania Rating Scale, Hamilton Rating Scale for Depression, Parental Bonding Instrument, and purpose in life (PIL). Multiple regression analysis was performed to identify the predictors of the change in total self-compassion scale scores.

RESULTS

Novelty seeking (TCI) was significantly and negatively associated with the change in total self-compassion scale scores, whereas the PIL scores were significantly and positively associated with the change in total self-compassion scale scores. Novelty seeking was not significantly associated with baseline, 4-week, or 8-week total self-compassion scale scores, whereas the PIL scores were significantly and positively associated with baseline, 4-week, and 8-week total self-compassion scale scores. The limitation of the present study was a relatively small number of subjects which deterred a more sophisticated analysis of the pathways involved.

CONCLUSIONS

The present findings suggest that more PIL and less novelty seeking predict improvements in self-compassion during mindfulness-based interventions, although novelty seeking might substantially predict the improvement but self-compassion scale and PIL might somewhat conceptually overlap.

A panel of miRNAs is involved in the effect of sertraline on panic disorder, as implicated by a microarray-based analysis

BACKGROUND

MiRNAs are considered to be significant contributors to the pathogenesis of psychiatric diseases, but little is known about the potential roles of miRNAs in the treatment effect of panic disorder (PD). Therefore, we aimed to identify the miRNAs association with PD over the course of sertraline treatment.

METHODS

Sixty-seven patients were collected for a 6-week period of sertraline treatment, and evaluated using HAMD-17, HAMA-14 and PDSS both at the baseline and 6 weeks later. Blood samples were collected before and after treatment, respectively. Ten pairs of samples were analyzed using miRNA array, and the differentially expressed miRNAs were further validated using RT-PCR in the whole sample.

RESULTS

miR-451a, miR-144-5p, miR-25-3p and miR-660-5p were found to be significantly up-regulated, while miR-1 and miR-148-5p significantly down-regulated after sertraline treatment. The change of miR-25-3p before and after treatment (△miR-25-3p) was positively related to both the changes of PDSS3 scores (△PDSS3) (p = 0.017, 31.5% contribution) and △ PDSS7 (p = 0.016, 32.3% contribution). The △miR-660-5p was positively related to both the △HAMA5 (p = 0.03, 26% contribution) and △PDSS7 (p = 0.032). The △miR-148-5p was positively related to the △PDSS4 (p = 0.046, 21.5% contribution), but negatively related to the △HAMA13 (p = 0.005, 41.9% contribution). The △miR-144-5p was negatively related to the △HAMA9 (p = 0.032, 25.3% contribution).

CONCLUSIONS

These findings might provide some evidences to the involvement of miRNA in the effect of anti-anxiety agents, which contributed to the better understanding the disease and developing new therapeutic genetic targets.

Altered auditory feedback perception following an 8-week mindfulness meditation practice

Our own ongoing motor actions are perceived through sensory feedback pathways, and are integrated with neural processes to modulate further actions. This sensory feedback mechanism is known to contribute to the rehabilitation of impaired motor functions. Recent evidence also suggests that mindfulness meditation improves our awareness to sensation; therefore, enhancement of awareness to sensory feedback through mindfulness meditation training may have potential clinical applications. This study investigated an effect of eight-week practice of mindfulness meditation on speech perception/production processes. Among the thirty healthy participants, half of them engaged in regular meditation practice of 10 min per day for eight weeks, and the other half were not given any instructions for their daily life. The change of speech performance in sentence reading under 200 ms delayed auditory feedback (DAF) condition were assessed compared to without delay condition. Also, event-related potential response to the short sound of /a/, were measured. The result showed that, after the eight-week practice, the meditation group showed significantly improved speech fluency in the DAF condition, when 16-min meditation was introduced before the experiments. Furthermore, significantly increased auditory evoked potentials were observed in the central-parietal region when the participants listened to the delayed auditory feedback sound of their own voice. These findings provide the first glimpses into the possible relationship between mindfulness meditation and auditory feedback. Different instructions for daily activity between the meditation and control groups should be considered in further studies.

Empirical evidence of the effect of personality pathology on the outcome of panic disorder

BACKGROUND

Treatment resistant disorders are a significant clinical problem. Impediments to good outcome need to be identified and addressed. Personality pathology has been hypothesized to be one such factor in panic disorder. There is no consensus as to the effects of personality pathology on the outcome of panic disorder. This study examined empirical evidence. The hypothesis was that personality pathology would cause poorer outcome of panic disorder.

METHODS

A literature search was conducted that winnowed 2627 articles down to 27 based on 1) longitudinal design; 2) validated measures of personality; 3) validated outcome measures; and 4) the presence of effect size or data to calculate effect size. All effect sizes were translated into odds ratios (ORs) for ease of comparison.

RESULTS

An overall median OR of 2.7 was found, indicating personality pathology negatively affected outcome. This finding persisted even when adjusted for baseline severity of illness. The effects were found for both clinical outcomes (OR = 2.7) and for social adjustment (OR = 2.9). There was a tendency for more dropouts in the personality pathology group. More highly structured drug therapy regimens and highly structured psychotherapy seemed to partially mitigate this outcome.

CONCLUSION

The negative effect of personality pathology was confirmed in well-designed longitudinal studies. This was not related to initial clinical severity. Clinical implications are that patients with personality pathology require the therapist to stick more closely to treatment protocols and to mitigate the tendency of these patients to drop out of treatment.

Predictors of Improvements in Mental Health From Mindfulness Meditation in Stressed Older Adults

Context • The benefits of a mindfulness meditation (MM) intervention are most often evidenced by improvements in self-rated stress and mental health. Given the physiological complexity of the psychological stress system, it is likely that some people benefit significantly, whereas others do not. Clinicians and researchers could benefit from further exploration to determine which baseline factors can predict clinically significant improvements from MM. Objectives • The study intended to determine (1) whether the baseline measures for participants who significantly benefitted from MM training were different from the baseline measures of participants who did not, and (2) whether a classification analysis using a decision-tree, machine-learning approach could be useful in predicting which individuals would be most likely to improve. Design • The research team performed a secondary analysis of a previously completed randomized, controlled clinical trial. Setting • The study occurred at the Oregon Health & Science University (Portland, OR, USA) and in participants' homes. Participants • Participants were 134 stressed, generally healthy adults from the metropolitan area of Portland, Oregon, who were 50 to 85 y old. Intervention • Participants were randomly assigned either to a 6-wk MM intervention group or to a waitlist control group, who received the same MM intervention after the waitlist period. Outcome Measures • Outcome measures were assessed at baseline and at 2-mo follow-up intervals. A responder was defined as someone who demonstrated a moderate, clinically significant improvement on the mental health component (MHC) of the short-form health-related quality of life (SF-36) (ie, a change ≥4). The MHC had demonstrated the greatest effect size in the primary analysis of the previously mentioned randomized, controlled clinical trial. Potential predictors were demographic information and baseline measures related to stress and affect. Univariate statistical analyses were performed to compare the values of predictors in the responder and nonresponder groups. In addition, predictors were chosen for a classification analysis using a decision tree approach. Results • Of the 134 original participants, 121 completed the MM intervention. As defined previously, 61 were responders and 60 were nonresponders. Analyses of the baseline measures demonstrated significant differences between the 2 groups in several measures: (1) the positive and negative affect schedule negative subscale (PANAS-neg), (2) the SF-36-MHC, and (3) the SF-36 energy/fatigue, with clinically worse scores being associated with greater likelihood of being a responder. Disappointingly, the decision-tree analyses were unable to achieve a classification rate of better than 65%. Conclusions • The differences in predictor variables between responders and nonresponders to an MM intervention suggested that those with worse mental health at baseline were more likely to improve. Decision-tree analysis was unable to usefully predict who would respond to the intervention.

Mindfulness in mood and anxiety disorders: a review of the literature

INTRODUCTION

The objective of this study was to conduct a review of the literature covering the use of different mindfulness-based therapy approaches in treatment of mood and anxiety disorders, including mindfulness skills and mindfulness linked to emotional regulation and fear of negative appraisal.

METHODS

A review was conducted of literature identified by searching the scientific databases PubMed and PsycINFO with the following keywords: mindfulness, mood disorders, and anxiety disorders. The search covered the past 10 years. The search returned 532 articles, 24 were selected, their full texts were read, and 16 were included in this review.

RESULTS

Six articles about mindfulness-based stress reduction, four about mindfulness-based cognitive therapy, and three about fear of negative appraisal and emotional regulation were reviewed. All of the articles covered mindfulness in relation to mood and anxiety disorders.

CONCLUSIONS

The literature in this field suggests that mindfulness is an effective strategy for the treatment of mood and anxiety disorders and is effective in therapy protocols with different structures including virtual modalities. Use of mindfulness in scientific models continues to expand.

White matter correlates of anxiety sensitivity in panic disorder

BACKGROUND

Anxiety sensitivity (AS) refers to a fear of anxiety-related sensations and is a dispositional variable especially elevated in patients with panic disorder (PD). Although several functional imaging studies of AS in patients with PD have suggested the presence of altered neural activity in paralimbic areas such as the insula, no study has investigated white matter (WM) alterations in patients with PD in relation to AS. The objective of this study was to investigate the WM correlates of AS in patients with PD.

METHODS

One-hundred and twelve right-handed patients with PD and 48 healthy control (HC) subjects were enrolled in this study. The Anxiety Sensitivity Inventory-Revised (ASI-R), the Panic Disorder Severity Scale (PDSS), the Albany Panic and Phobia Questionnaire (APPQ), the Beck Anxiety Inventory (BAI), and the Beck Depression Inventory (BDI) were administered. Tract-based spatial statistics were used for diffusion tensor magnetic resonance imaging analysis.

RESULTS

Among the patients with PD, the ASI-R total scores were significantly correlated with the fractional anisotropy values of the WM regions near the insula, the splenium of the corpus callosum, the tapetum, the fornix/stria terminalis, the posterior limb of the internal capsule, the retrolenticular part of the internal capsule, the posterior thalamic radiation, the sagittal striatum, and the posterior corona radiata located in temporo-parieto-limbic regions and are involved in interoceptive processing (p<0.01; threshold-free cluster enhancement [TFCE]-corrected). These WM regions were also significantly correlated with the APPQ interoceptive avoidance subscale and BDI scores in patients with PD (p<0.01, TFCE-corrected). Correlation analysis among the HC subjects revealed no significant findings.

LIMITATIONS

There has been no comparative study on the structural neural correlates of AS in PD.

CONCLUSIONS

The current study suggests that the WM correlates of AS in patients with PD may be associated with the insula and the adjacent temporo-parieto-limbic WM regions, which may play important roles in interoceptive processing in the brain and in depression in PD.

Impact of Mindfulness-Based Cognitive Therapy on Intolerance of Uncertainty in Patients with Panic Disorder

OBJECTIVE

Intolerance of uncertainty (IU) is a transdiagnostic construct in various anxiety and depressive disorders. However, the relationship between IU and panic symptom severity is not yet fully understood. We examined the relationship between IU, panic, and depressive symptoms during mindfulness-based cognitive therapy (MBCT) in patients with panic disorder.

METHODS

We screened 83 patients with panic disorder and subsequently enrolled 69 of them in the present study. Patients participating in MBCT for panic disorder were evaluated at baseline and at 8 weeks using the Intolerance of Uncertainty Scale (IUS), Panic Disorder Severity Scale-Self Report (PDSS-SR), and Beck Depression Inventory (BDI).

RESULTS

There was a significant decrease in scores on the IUS (p<0.001), PDSS (p<0.001), and BDI (p<0.001) following MBCT for panic disorder. Pre-treatment IUS scores significantly correlated with pre-treatment PDSS (p=0.003) and BDI (p=0.003) scores. We also found a significant association between the reduction in IU and PDSS after controlling for the reduction in the BDI score (p<0.001).

CONCLUSION

IU may play a critical role in the diagnosis and treatment of panic disorder. MBCT is effective in lowering IU in patients with panic disorder.