Particular person, group and guided self-help CBT for panic dysfunction


Cognitive-behavioural remedy (CBT) is the simplest psychological therapy for panic dysfunction (Papola et al., 2022), and is partially primarily based on Clark’s (1996) cognitive mannequin of panic dysfunction. This mannequin proposes that panic assaults are the results of catastrophic misinterpretation of bodily sensations (e.g., deciphering a raised heartrate as a coronary heart assault), which then snowballs (i.e., elevated anxiousness ranges, heartrate quickening) and subsequently strengthens the preliminary catastrophic perception. This considering creates a cycle, maintained by security behaviours. CBT for panic dysfunction works to problem the beliefs and behaviours described by Clark, and to interrupt the cycle of catastrophic misinterpretation maintained by security behaviours.

Nonetheless, an enormous situation throughout psychological therapies is accessibility. Essentially the most frequent obstacles to therapy supply consists of issues like:

  • Geographical obstacles, with individuals from rural areas having longer commutes to therapy (Webb, Rosso and Rauch, 2017)
  • Full-time employees with day-time commitments that forestall them from attending remedy throughout typical hours
  • Sufferers with comorbid agoraphobia struggling to go away the home, and due to this fact not attending therapy (Newman et al., 2011).

Remedy delivered on-line and over the phone can overcome these obstacles, with these strategies having extra flexibility. The current COVID-19 pandemic has elevated momentum for implementing various supply codecs for remedy, with most therapists working remotely throughout this time (Chevance et al., 2020). Nonetheless, the query stays: are various supply codecs of CBT for panic dysfunction as efficient as face-to-face supply?

Earlier research have investigated this query in relation to CBT supply codecs for melancholy and anxiousness, however Papola et al. (2023) is the primary to do a head-to-head comparability of the effectiveness of CBT supply codecs for panic dysfunction.

Alternative CBT delivery formats can increase access to psychological treatments for people who would struggle to attend face-to-face therapy, but are these remote delivery formats as effective?

Different CBT supply codecs can improve entry to psychological therapies for individuals who would wrestle to attend face-to-face remedy, however are these distant supply codecs as efficient?


Papola and colleagues performed a community meta-analysis of randomised management trials (RCTs) with the intention of evaluating “the comparative efficacy and acceptability of all CBT supply codecs to deal with panic dysfunction”.

5 analysis databases had been searched from database inception to 1st January 2022, to determine RCTs inspecting the consequences of psychotherapy for panic dysfunction, in contrast with some other psychotherapy or management situations.

The inclusion standards had been:

  1. Adults with a major analysis of panic dysfunction, with or with out agoraphobia
  2. CBT because the psychotherapeutic intervention
  3. Delivered by a therapist or as self-help.

The outcomes measured had been efficacy in lowering panic signs, and the proportion of members who discontinued from the trial. A collection of pairwise meta-analyses for all direct comparisons was performed utilizing a random effects-pooling mannequin.

Confidence within the proof was assessed utilizing Confidence in Community Meta Evaluation (CINeMA). Not one of the comparisons had been rated as excessive confidence, primarily attributable to within-study bias.


Examine traits

After screening was full, 74 research together with 6,699 members had been included. The imply age of members was 37.3 years, with 69.4% being ladies and the bulk (77.6%) having agoraphobia. Solely 56 of the 74 research had been eligible for the community meta-analysis.

The researchers used Clark and Salkovskis (2009)’s definition of CBT for his or her paper: “a therapy that focuses on sufferers’ interoceptive fears and makes use of each cognitive restructuring and behavioural procedures to cut back these fears”. Members had been randomised to obtain CBT in 4 completely different supply codecs:

  • Face-to-face particular person
  • Face-to-face group
  • Guided self-help
  • Unguided self assist.

The desk under exhibits the share of RCTs included within the evaluation that had a sure quantity (N) of classes/modules:

N classes/modules % research
1-6 20.3
7-12 60.8
13-19 16.2
Unclear 2.7

Most members (91.9%) had been receiving medicines throughout the therapy interval.

Efficacy outcomes (n = 56)

  • Group (reasonable research confidence), particular person (reasonable research confidence) and guided self-help (low research confidence) CBT had been superior to therapy as typical and waitlist in relieving the signs of panic dysfunction.
  • Unguided self-help was not superior to therapy as typical.

The standardised imply distinction (SMD) and 95% confidence intervals (CI) of efficacy between teams had been:

  • Group CBT vs. therapy as typical: -0.47 (-0.87 to -0.07)
  • Group CBT vs. ready listing: -1.13 (-1.42 to -0.84)
  • Particular person CBT vs therapy as typical: -0.43 (-0.70 to -0.15)
  • Particular person CBT vs ready listing: -1.08 (-1.30 to -0.87)
  • Guided self-help vs therapy as typical: -0.42 (-0.77 to -0.07)
  • Guided self-help vs. ready listing: -1.08 (-1.33 to -0.83)
  • Unguided self-help vs. therapy as typical: -0.21 (-0.58 to 0.16)
  • Unguided self-help vs. ready listing: -0.87 (-1.14 to -0.60)

There have been no important variations when it comes to efficacy between group, particular person, guided self-help, and unguided self-help CBT.

Acceptability outcomes (n = 51)

No important variations had been discovered between completely different supply codecs, between supply codecs and comparators, and between comparators for the acceptability final result.

Face to face (individual and group) and guided self-help delivery formats of CBT for panic disorder do not significantly differ from each other in terms of efficacy, but are all superior to treatment as usual or waitlist controls.

In response to this evaluation, nose to nose (particular person and group) and guided self-help supply codecs of CBT for panic dysfunction don’t considerably differ from one another when it comes to efficacy, however are all superior to therapy as typical or waitlist controls.


The authors concluded that:

There are not any important variations when it comes to efficacy or acceptability when CBT is delivered by way of the face-to-face group, face-to-face particular person, or guided self-help format, indicating that the three therapy codecs are equally more practical over therapy as typical.

Unguided self-help, alternatively, was not considerably higher than waitlist controls, suggesting that CBT delivered on this format might not be as appropriate for these with panic dysfunction and shouldn’t be advisable.

Other than unguided self-help (which was inferior), there were no significant differences in treatment efficacy based on delivery format. This means that more accessible delivery formats are not necessarily detrimental to treatment quality.

Aside from unguided self-help (which was inferior), there have been no important variations in therapy efficacy primarily based on supply format. Which means extra accessible supply codecs will not be essentially detrimental to therapy high quality.

Strengths and limitations

One energy of this paper is that it’s the primary of its type to check various supply codecs on a typical metric for a particular anxiousness dysfunction. Profiting from all direct and oblique comparisons on the similar time meant that the estimates had been extra exact and constant, which will increase the reliability of the findings. Virtually, this methodology may also inform us so much about whether or not it’s worthwhile to put money into delivering extra accessible panic therapies when it comes to efficacy.

Nonetheless, there are some limitations:

  • The included research had been revealed throughout an extended timespan, had completely different durations, and administered roughly intensive CBT protocols. Which means there may be heterogeneity throughout the research included. These heterogeneous options throughout research had been not investigated, and should have contributed to the effectiveness of therapy. It might be the case that the outcomes are because of variations in methodology, relatively than representing variations in program efficacy.
  • Furthermore, the researchers didn’t think about the baseline severity of panic signs. It doesn’t appear inconceivable that sufferers with extreme panic dysfunction might reply favourably to face-to-face therapy over guided self-help, extra so than these with milder signs
  • The paper doesn’t touch upon variations between on-line and in-person deliveries of CBT. Whereas all guided self-help programmes are reported as being internet-based, the proportion of on-line supply inside the different intervention classes just isn’t reported. Future analysis may examine whether or not non-internet-based guided self-help is as efficient as its on-line counterpart.
  • As indicated by the authors, a post-hoc sensitivity evaluation eradicating research judged to be excessive danger of bias led to diminished results, bigger CIs, and to CBT in any format not being superior over therapy as typical. Which means the outcomes must be interpreted with some extent of warning.
Considerations for the baseline severity of panic symptoms may be an important factor in the current analysis, and should be considered in future studies using similar methods in order to inform stepped care approaches.

Concerns for the baseline severity of panic signs could also be an essential issue within the present evaluation, and ought to be thought-about in future research utilizing related strategies so as to inform stepped care approaches.

Implications for apply

Accessible supply codecs of well-established evidence-based therapies have appreciable sensible benefits within the current day. Nonetheless, for these codecs to be worthwhile, the therapies must be as efficient in assuaging signs as extra conventional face-to-face codecs. Papola et al. (2023)’s findings recommend that the extra accessible supply format of guided self-help is as efficient as group and particular person face-to-face CBT for treating panic dysfunction, offering proof for the continued use and funding on this format possibility.

These findings ought to encourage providers to extend the roll out of extra accessible supply codecs. Elevated provision of on-line guided self-help for panic issues may scale back therapist hours per shopper, which can in flip scale back workload and permit for shorter ready lists. It’s also a extra accessible format for individuals who might expertise obstacles to face-to-face remedy, resembling working lengthy hours, dwelling in rural areas, and never with the ability to drive.

NHS psychological well being providers are extremely overstretched, with 23% of psychological well being sufferers ready greater than 12 weeks to start out therapy (Royal Faculty of Psychiatrists, 2022). Efficient interventions which are much less labour intensive will hopefully contribute to lowering the pressure on service suppliers. If practitioners spend much less time on every affected person, they may help extra individuals in a shorter time span.

Unguided self-help was discovered to be considerably much less efficient than different CBT codecs, and therapy as typical. One cause for this is perhaps the dearth of a client-therapist alliance. Though a relationship can nonetheless be made with a practitioner throughout distant intervention – and even with an app, as reported in Jenna Jacob’s newest Psychological Elf weblog! – this might not be the right method for everybody. It’s due to this fact essential for practitioners to fastidiously think about who they’re referring to distant interventions. It’s also essential for researchers to proceed investigating what stage of steerage is perfect for shoppers to get essentially the most out of self-help interventions, and what are the underlying mechanisms that make these interventions work.

Lastly, a future course for this analysis might be to analyze whether or not baseline severity is an element through which supply format has higher outcomes. The present research didn’t examine this, however realizing whether or not severity does impression effectiveness of accessible codecs could also be informative for creating stepped care approaches to assigning therapy.

Where the evidence is good, services and policymakers may want to consider the benefits of increasing the provision of digital guided self-help interventions, which may decrease staff workload while still delivering effective support.

The place the proof is nice, providers and policymakers might need to think about the advantages of accelerating the availability of digital guided self-help interventions, which can lower employees workload whereas nonetheless delivering efficient assist.

Assertion of pursuits

HW has a private curiosity in treating panic dysfunction, however just isn’t concerned in any analysis investigating the subject.


Main paper

Papola, D., Ostuzzi, G., Tedeschi, F., Gastaldon, C., Purgato, M., Del Giovane, C., … & Barbui, C. (2023). CBT therapy supply codecs for panic dysfunction: a scientific evaluation and community meta-analysis of randomised managed trials. Psychological Medication, 1-11.

Different references

Chevance, A., Gourion, D., Hoertel, N., Llorca, P. M., Thomas, P., Bocher, R., … & Gaillard, R. (2020). Making certain psychological well being care throughout the SARS-CoV-2 epidemic in France: A story evaluation. L’encephale, 46(3), 193-201.

Clark, D. (1996). Panic Dysfunction: From Principle to Remedy. In P. M. Salkovskis & S. Rachman, Frontiers of Cognitive Remedy (pp. 318–344). Guilford.

Clark, D. M., & Salkovskis, P. M. (1991). Panic Issues. Springer.

Jacob, J. (2023). Is it doable to kind a digital therapeutic alliance with a psychological well being app? The Psychological Elf.

Newman, M. G., Szkodny, L. E., Llera, S. J., & Przeworski, A. (2011). A evaluation of technology-assisted self-help and minimal contact therapies for anxiousness and melancholy: Is human contact mandatory for therapeutic efficacy? Medical Psychology Assessment, 31(1), 89–103.

Papola, D., Ostuzzi, G., Tedeschi, F., Gastaldon, C., Purgato, M., Giovane, C. D., Pompoli, A., Pauley, D., Karyotaki, E., Sijbrandij, M., Furukawa, T. A., Cuijpers, P., & Barbui, C. (2022). Comparative efficacy and acceptability of psychotherapies for panic dysfunction with or with out agoraphobia: Systematic evaluation and community meta-analysis of randomised managed trials. The British Journal of Psychiatry, 221(3), 507–519.

Royal Faculty of Psychiatrists. (2022). Hidden waits drive greater than three quarters of psychological well being sufferers to hunt assist from emergency providers. RC Psychiatrists.

Webb, C. A., Rosso, I. M., & Rauch, S. L. (2017). Web-based Cognitive Behavioral Remedy for Despair: Present Progress & Future Instructions. Harvard Assessment of Psychiatry, 25(3), 114–122.

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