공황과임소공포증의개념화 604

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1 KISEP Reviews J Korean Neuropsychiatr Assoc Vol 37, No 4 공황장애의인지행동치료 최영희 * 이정흠 ** Cognitive-behavioral Therapy for Panic Disorder Young Hee Choi, M.D.,* Jung Heum Lee, M.A.** 중심단어 국문초록 서 Department of Psychiatry, Seoul Paik Hospital, Inje University, Seoul Department of Clinical Psychology, Seoul Paik Hospital, Inje University, Seoul Corresponding author 론 603

2 공황과임소공포증의개념화 604

3 Fig. 1. A model of the etiology of panic disorder. 원전 Barlow DH1997Cognitive-behavioral therapy for panic disordercurrent status. J Clin Psychiatry 58suppl 공황과임소공포증의평가 1. 감별진단의문제들 (differential diagnostic issues) 605

4 2. 의학적상태및동반이환율 (medical conditions and comorbidity) 3. 자기-관찰 (self-monitoring) 4. 자기-보고 (self-report) 5. 과제 (homework) 606

5 행동적 / 인지적치료구성요소들 1. 인지재구조화 (cognitive restructuring) 607

6 608

7 2. 호흡재훈련 (breathing retraining) 609

8 3. 이완 (relaxation) 610

9 Ö Ö 4. 자극감응노출 (interoceptive exposure) 611

10 5. 실제상황노출 (in vivo exposure) 612

11 공황장애치료결과비교연구 613

12 Table 1. Controlled trials offull cognitive therapy for panic disorderintention-to-treat analysis* Percentagenumber of patients panic-free Study Treatments Posttreatment Follow-up Beck et al.1992 CT 9416/ /17 a ST 25 4/16 b Clark et al.1994 CT 8618/ /21 c AR 4810/ /21 c IMIP 5211/ /21 c WL 7 1/16 Öst and Westling 7414/ /19 CT 1995 d AR 5811/ /19 c Arntz and van den 7814/ /18 CT Hout1996 AR 47 9/ /19 WL 28 5/18 Margraf and Schneider1991 Combined CT 9120/22 e 7814/18 Pure 7316/22 e cognitive Pure EXP 5211/21 e WL 5 1/20 Total across all studies for CT 8582/ /75 * Clark DM1996Panic DisorderFrom theory to therapyinfrontiers of Cognitive Therapy The state of the art and beyond. Ed by Sakovskis PM, New York, Guilford Press Note. Intention-to-treat analysis includes dropouts as well as completers. Droputs are coded as still panicking. CTcognitive therapystsupportive therapyarapplied relaxationimipimipramineexpinteroceptive and situational exposurewlwaiting list. a One-year follow-up b At 8 weeks, which is the end of supportive therapy. At this time 71% of CT patients were panic free. c Percentage of patients who were panic free at follow-up and who received no additional treatment during the follow-up period. d The figures for CT are conservative because they include the therapists four training cases. e Four-week follow-up. 치료결과에영향을주는요인들 1. 진단적요인 (diagnostic factor) 2. 대인관계적요인 (interpersonal factor) 614

13 3. 치료자요인 (therapist factor) 4. 환자요인 (client factor) 5. 병행하는약물치료요인 (concurrent pharmacological treatment factor) 6. 집단치료요인 (group psychotherapeutic factors) 615

14 참고문헌 1) Fyer AJ(1988):Effects of discontinuation of antipanic medication. In:Panic and Phobias II. Ed by Hand I & Wittchen H, Berlin:Springer-Verlag 2) Sheehan DV(1986):Tricyclic antidepressants in the treatment of panic and anxiety disorders. Psychosomatics 27: ) Gould RA, Otto MW, Pollack MH(1995):A metaanalysis of treatment outcome for panic disorder. Clin Psychol Review 15: ) 김영신, 임기영 (1995) : 공황장애의인지-행동집단치료 : 치료효과와치유인자. 신경정신의학 34: ) 임기영, 김창기, 노재성 (1996): 공황장애환자의공황발작증상의특성. 신경정신의학 35: ) Klein DF(1967):Importance of psychiatric diagnosis and prediction of clinical drug effects. Arch Gen Psychiatry 19: ) Mendel JGC, Klein DF(1969):Anxiety attacks with subsequent agoraphobia. Compr Psychiatry 10: ) Barlow DH(1988):Anxiety and Its Disorders:the nature and treatment of anxiety and panic. New York, Guilford Press 9) Clark D, Salkovskis P, Gelder M, Koehler C, Martin M, et al.(1988):tests of a cognitive theory of panic. In:Panic and Phobias II. Ed by Hand I & Wittchen H, Berlin:Springer-Verlag 10) Ehlers A, Margraf J(1989):The psychophysiological model of panic attacks. In:Anxiety Disorders: Annual series of European research in behavior therapy. Vol 4, Ed by Emmelkamp PMG, Amsterdam:Swets 11) Crowe RR, Noyes R, Pauls DL, Slymen DJ(1983): A family study of panic disorder. Arch Gen Psy-hiatry 40: ) Moran C, Andrews G(1985):The familial occurrence of agoraphobia. Br J Psychiatry 146: ) Torgerson S(1983):Genetic factors in anxiety disorders. Arch Gen Psychiatry 40: ) Barlow DH, Chorpita BF, Turovsky J(1996): Fear, panic, anxiety, and disorders of emotion. In: Nebraska Symposium on Motivation. Vol 43, Ed by Hope DA, Perspectives on anxiety, panic, and fear. Lincoln. Nebraska:University of Nebraska Press, pp ) Razran G(1961):The observable unconscious and the inferable conscious in current soviet psychophysiology:interoceptive conditioning, semantic conditioning, and the orienting reflex. Psychol Review 68: ) Craske MG(1991):Phobic fear and panic attacks: The same emotional state triggered by different cues? Clin Psychol Review 11: ) Craske MG, Barlow DH(1988):A review of the relationship between panic and avoidance. Clin Psychol Review 8: ) Thyer BA, Himle J, Curtis GC, Cameron OG, Nesse RM(1985):A comparison of panic disorder and agoraphobia with panic attacks. Compr Psychiatry 26: ) Arnow BA, Taylor CB, Agras WS, Telch MJ (1985):Enhancing agoraphobia treatment outcome by changing couple communication patterns. Behavior Therapy 16: ) Rapee RM, Craske MG, Barlow DH(1990):Subject described features of panic attacks using a new self-monitoring form. J Anxiety Dis 4: ) Beck AT, AJ, Shaw BF, Emory G(1979):Cognitive Therapy of Depression. New York, Guilford Press 22) Bonn JA, Harrison J, Rees L(1971):Lactate induced anxiety:therapeutic application. Br J Psychiatry 119: ) Pitts FN, McClure JN(1967):Lactate metabolism in anxiety neuroses. New England J Med 277: ) Rapee R(1986):Differential response to hyperventiation in panic disorder and generalized anxiety disorder. J abnorm Psychol 95: ) Orwin A(1973): The running treatment :a preliminary communication on a new use for an old therapy(physical activity) in the agoraphobic syndrome. Br J Psychiatry 122: ) Waddell MT, Barlow DH, O Brien GT(1984):A preliminary investigation of cognitive and relaxation treatment of panic disorder:effects on intense anxiety vs. background anxiety. Behav Res Ther 22: ) Wolpe J(1981):The dichotomy between classical conditioned and cognitively learned anxiety. J Behav Ther Exp Psychiatry 12: ) Beck AT(1988):Cognitive approaches to panic disorder:theory and therapy. In:Panic:Psycholog- 616

15 ical Perspectives, Ed by Rachman S, Maser JD, Hilsdale, NJ:Erlbaum 29) Margraf J(1989):Comparative efficacy of cognitive, exposure, and combined treatments for panic disorder. Paper presented at the annual meeting of the European Association for Behavior Therapy, Vienna 30) Salkovskis P, Clark D, Hackmann A(1991):Treatment of panic attacks using cognitive therapy without exposure or breathing retraining. Behav Res Ther 29: ) Beck AT, Emery G(1985):Anxiety Disorders and Phobias:A cognitive perspective. NY:Basic Books 32) Barlow DH, Craske MG(1994):Mastery of Your Anxiety and Panic - II. Albany, NY:Graywind 33) Hibbert G, Pilsbury D(1988):Hyperventilation in panic attacks:ambulatory monitoring of transcutaneous carbon dioxide. Brit J Psychiatry 153: ) Hornsveld H, Garssen B, Fiedeldij Dop M, van Spiegel P(1990):Symposium reporting during voluntary hyperventilation and mental load:implications for diagnosing hyperventilation syndrome. J Psychosom Res 34: ) Clark D, Salkovskis P, Chalkey A(1985):Respiratory control as a treatment for panic attacks. J Behav Ther Exper Psychiatry 16: ) Salkovskis P, Warwick H, Clark D, Wessels D (1986):A demonstration of acute hyperventilation during naturally occurring panic attacks. Behav Res Ther 24: ) de Ruiter C, Rijken H, Garssen B, Kraaimaat F(1989):Breath retraining, exposure and a combination of both, in the treatment of panic disorder with agoraphobia. Behav Res Ther 27: ) Hibbert G, Chan M(1989):Respiratory control: Its contribution to the treatment of panic attacks. Br J Psychiatry 154: ) Garssen B, de Ruiter C, van Dyck R(1992):Breathing retraining:a rational placebo? Clin Psychol Review 12: ) Papp LA, Martinez JM, Klein DF, Coplan JD, et al. (1997):Respiratory psychophysiology of panic disorder:three respiratory challenges in 98 subjects. Am J Psychiatry 154: ) Rupert PA, Dobbins K, Mathew RJ(1981):EMG biofeedback and relaxation instructions in the treatment of chronic anxiety. Am J Clin Biofeedback 4: ) Bandura A(1977):Self-efficacy:Toward a unifying theory of behavioral change. Psychol Review 84: ) Rice KM, Blanchard EB(1982):Biofeedback in the treatment of anxiety disorders. Clin Psychol Review 2: ) st LG(1988):Applied relaxation vs. progressive relaxation in the treatment of panic disorder. Behav Res Ther 26: ) Barlow DH, Craske MG, Cerny JA, Klosko JS (1989):Behavioral treatment of panic disorder. Behav Ther 20: ) Clark DM, Salkovskis PM, Hackmann A, Middleton H, et al.(1994):a comparison of cognitive therapy, applied relaxation, and imipramine in the treatment of panic disorder. Br J Psychiatry 164: ) Beck GJ, Stanley MA, Baldwin LE, et al.(1994): Comparison of cognitive therapy and relaxation training for panic disorder. J Consulting Clin Psychol 62: ) Öst LG, Westling B(1995):Applied relaxation vs. cognitive therapy in the treatment of panic disorder. Behav Res Ther 33: ) Arntz A, van den Hout M(1996):Psychological treatments of panic disorder without agoraphobia: cognitive therapy versus applied relaxation. Behav Res Ther 34: ) Griez E, van den Hout M(1986):CO 2 inhalation in the treatment of panic attacks. Behav Res Ther 24: ) Craske MG, Brown TA, Barlow DH(1991) : Behavioral treatment of panic disorder:a two-year follow-up. Behav Ther 22: ) Chaplin EW, Levine BA(1981):The effects of total exposure duration and interrupted versus continued exposure in flooding therapy. Behav Ther 12: ) Marshall WL(1985):The effects of variable exposure in flooding therapy. Behav Ther 16: ) Stern RS, Marks IM(1973):Brief and prolonged flooding : A comparison of agoraphobic patients. Arch Gen Psychiatry 28: ) Foa EB, Jameson JS, Turner RM, Payne LL (1980):Massed vs. spaced exposure sessions in the treatment of agoraphobia. Behav Res Ther 18: ) Marks IM(1978):Living with Fear. New York: 617

16 McGraw-Hill 57) Craske MG, Street L, Barlow DH(1989):Instructions to focus upon or distract from internal cues during exposure treatment for agoraphobic avoidance. Behav Res Ther 27: ) Clark DM, Wells A(1997):Cognitive therapy for anxiety disorder. In:Review of Psychiatry. Vol 16, Ed by Dickstein LJ, Riba MB, Oldham JM, Washington DC:American Psychiatric Press 59) Beck AT, Sokol L, Clark DA, et al(1992):focused cognitive therapy for panic disorder:a crossover design and one-year follow-up. Am J Psychiatry 147: ) Margraf J, Schneider S(1991):Outcome and active ingredients of cognitive-behavioral treatments for panic disorder. Paper presented at the annual meeting of the Association for Advancement of Behavior Therapy, New York 61) Sanderson WC, DiNardo PA, Rapee RM(1990): Syndrome comorbidity in patients diagnosed with a DSM-III-R Anxiety Disorder. J Abnormal Psychol 99: ) Chambless DL, Renneberg B(1988):Personality disorders of agoraphobics. Paper presented at World Congress of Behavior Therapy, Edinburgh, Scotland 63) Mavissakalian M, Hamman M(1986):DSM-III personality disorder in agoraphobia. Compr Psychiatry 27: ) Reich J, Noyes R, Troughton E(1987):Dependent personality disorder associated with phobic avoidance in patients with panic disorder. Am J Psychiatry 144: ) Mavissakalian M, Hamman M(1987):DSM-III personality disorder in agoraphobia. II Changes with treatment. Compr Psychiatry 28: ) Noyes R, Reich J, Suezler M, Christiansen J (1991):Personality traits associated with panic disorder:change associated with treatment. Compr Psychiatry 32: ) Goldstein A, Chambless D(1978):A reanalysis of agoraphobia. Behav Ther 9: ) Fry W(1962):The marital context of an anxiety syndrome. Family Proc 1: ) Barlow DH, O'Brien GT, Last CG, Hoden A (1983):Couples treatment of agoraphobia:initial outcome. In:Advances in Clinical Behavior Therapy, Ed by Craig KD, McMahon RJ, New York, Brunner/Mazel 70) Michelson L, Mavissakalian M, Marchione K, et al.(1990):psychological outcome of cognitive, behavioral, and psychologically based treatments of agoraphobia. Behav Res Ther 28: ) Welkowitz L, Papp L, Cloitre M, et al.(1991): Cognitive-behavior therapy for panic disorder delivered by psychopharmacologically oriented clinicians. J Nerv Ment Disease 179: ) Yalom ID(1975):The Theory and Practice of Group Psychotherapy. 2nd ed, Basic Books, Inc 618

17 ABSTRACT J Korean Neuropsychiatr Assoc Vol 37, No 4, July, 1998 Cognitive-behavioral Therapy for Panic Disorder Young Hee Choi, M.D., Jung Heum Lee, M.A. Department of Psychiatry, Seoul Paik Hospital, Inje University, Seoul The therapeutic effect of cognitive-behavioral therapycbt for panic disorder and agoraphobia PD/PDA has been supported by evidences from the several studies. We the have experienced good results of CBT for more than 50 patients with PD/PDA for last two years. In spite of the powerful therapeutic effect, CBT has not been utilized well by psychiatrists in this country. We described the cognitive conceptualization of panic and agoraphobia, frequently used assessments and homeworks in CBT for PD/PDA, and detailed concepts and methods of the each component of CBT based on our experience. Also, we discussed the comparative studies of the therapeutic results and factors that could influence the effect of CBT for PD/PDA. KEY WORDSPanic disorder Cognitive-behavioral therapy. 619

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A 617 Special Issue Diabetic Retinopathy Won Ki Lee, M.D. Department of Ophthalmology The Catholic University of Korea College of Medicine Kangnam St. Mary s Hospital E mail : wklee@catholic.ac.kr Abstract R