Efficacy of temporally intensified exposure for anxiety disorders: A multicenter randomized clinical trial

Andre Pittig; Ingmar Heinig; Stephan Goerigk; Freya Thiel; Katrin Hummel; Lucie Scholl; Jürgen Deckert; Paul Pauli; Katharina Domschke; Ulrike Lueken; Thomas Fydrich; Lydia Fehm; Jens Plag; Andreas Ströhle; Tilo Kircher; Benjamin Straube; Winfried Rief; Katja Koelkebeck; Volker Arolt; Udo Dannlowski; Jürgen Margraf; Christina Totzeck; Silvia Schneider; Peter Neudeck; Michelle G Craske; Maike Hollandt; Jan Richter; Alfons Hamm; Hans-Ulrich Wittchen

doi:10.1002/da.23204

Efficacy of temporally intensified exposure for anxiety disorders: A multicenter randomized clinical trial

Depress Anxiety. 2021 Nov;38(11):1169-1181. doi: 10.1002/da.23204. Epub 2021 Jul 22.

Authors

Andre Pittig^{1

2}, Ingmar Heinig², Stephan Goerigk^{2

3}, Freya Thiel², Katrin Hummel², Lucie Scholl², Jürgen Deckert⁴, Paul Pauli¹, Katharina Domschke^{4

5

6}, Ulrike Lueken^{4

7}, Thomas Fydrich⁷, Lydia Fehm⁷, Jens Plag⁸, Andreas Ströhle⁸, Tilo Kircher⁹, Benjamin Straube⁹, Winfried Rief¹⁰, Katja Koelkebeck¹¹, Volker Arolt¹¹, Udo Dannlowski¹¹, Jürgen Margraf¹², Christina Totzeck¹², Silvia Schneider¹², Peter Neudeck^{2

13}, Michelle G Craske¹⁴, Maike Hollandt¹⁵, Jan Richter¹⁵, Alfons Hamm¹⁵, Hans-Ulrich Wittchen^{2

3}

Affiliations

¹ Department of Psychology (Biological Psychology Clinical Psychology, and Psychotherapy), Center of Mental Health, University of Würzburg, Würzburg, Germany.
² Institute of Clinical Psychology & Psychotherapy, Technische Universität Dresden, Dresden, Germany.
³ Department of Psychiatry and Psychotherapy, University Hospital, Ludwig Maximilians University, Munich, Germany.
⁴ Department of Psychiatry, Psychosomatics, and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany.
⁵ Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
⁶ Center for Basics in NeuroModulation, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
⁷ Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany.
⁸ Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany.
⁹ Department of Psychiatry and Psychotherapy & Center for Mind Brain and Behavior - CMBB, Philipps-University Marburg, Marburg, Germany.
¹⁰ Department of Clinical Psychology and Psychotherapy, Faculty of Psychology & Center for Mind, Brain and Behavior - CMBB, Philipps-University of Marburg, Marburg, Germany.
¹¹ Institute for Translational Psychiatry, University of Muenster, Muenster, Germany.
¹² Mental Health Research and Treatment Center, Ruhr-Universität Bochum, Bochum, Germany.
¹³ Protect-AD Study Site Cologne, Cologne, Germany.
¹⁴ Department of Psychology and Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USA.
¹⁵ Department of Psychology, Biological and Clinical Psychology, University of Greifswald, Greifswald, Germany.

PMID: 34293223
DOI: 10.1002/da.23204

Abstract

Background: The need to optimize exposure treatments for anxiety disorders may be addressed by temporally intensified exposure sessions. Effects on symptom reduction and public health benefits should be examined across different anxiety disorders with comorbid conditions.

Methods: This multicenter randomized controlled trial compared two variants of prediction error-based exposure therapy (PeEx) in various anxiety disorders (both 12 sessions + 2 booster sessions, 100 min/session): temporally intensified exposure (PeEx-I) with exposure sessions condensed to 2 weeks (n = 358) and standard nonintensified exposure (PeEx-S) with weekly exposure sessions (n = 368). Primary outcomes were anxiety symptoms (pre, post, and 6-months follow-up). Secondary outcomes were global severity (across sessions), quality of life, disability days, and comorbid depression.

Results: Both treatments resulted in substantial improvements at post (PeEx-I: d_within = 1.50, PeEx-S: d_within = 1.78) and follow-up (PeEx-I: d_within = 2.34; PeEx-S: d_within = 2.03). Both groups showed formally equivalent symptom reduction at post and follow-up. However, time until response during treatment was 32% shorter in PeEx-I (median = 68 days) than PeEx-S (108 days; TR_PeEx-I = 0.68). Interestingly, drop-out rates were lower during intensified exposure. PeEx-I was also superior in reducing disability days and improving quality of life at follow-up without increasing relapse.

Conclusions: Both treatment variants focusing on the transdiagnostic exposure-based violation of threat beliefs were effective in reducing symptom severity and disability in severe anxiety disorders. Temporally intensified exposure resulted in faster treatment response with substantial public health benefits and lower drop-out during the exposure phase, without higher relapse. Clinicians can expect better or at least comparable outcomes when delivering exposure in a temporally intensified manner.

Keywords: anxiety disorders; exposure therapy; intensified treatment; public health; randomized controlled trial.

Publication types

Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Anxiety / therapy
Anxiety Disorders / epidemiology
Anxiety Disorders / therapy
Comorbidity
Humans
Implosive Therapy*
Quality of Life*
Treatment Outcome

Associated data

DRKS/DRKS00008743