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1 Korean Journal of Clinical Psychology Vol. 36, No. 4, Review Article 2017 Korean Clinical Psychology Association eissn X Evidence-Based Treatment of Panic Disorder Soo Hyun Park Department of Psychology, Yonsei University, Seoul, Korea Panic disorder is an anxiety disorder characterized by the presence of autonomic arousal symptoms in unexpected situations (panic attacks), which are accompanied by anticipatory anxiety regarding possible future attacks. Its prevalence rate is reported to be 1 4% worldwide and it ranks 11th among all diseases in terms of years lived with disability. Numerous studies have been conducted in the past 30 years and empirically validated cognitive behavior therapy for panic disorder has been developed based on the results of such studies. To this end, this review will focus on providing a brief clinical description and etiology of panic disorder, followed by an overview of the specific nature of evidence-based treatment for panic disorder. What are the core components of evidence-based treatment for panic disorder according to Korean and foreign treatment effectiveness studies and/or meta-analyses? What are the moderating or mediating factors that affect treatment effectiveness and outcomes? Furthermore, this review will summarize the current status of the effectiveness of computer- and internetbased treatment programs for panic disorder. Finally, a summary of treatment guidelines for panic disorder will be provided based on the treatment guidelines recommended by different related disciplines and organizations. Keywords: evidence-based treatment, psychological disorders, panic disorder 공황장애는예기치못한상황에서급작스러운불안감과더불어호 흡곤란, 어지러움, 발한과같은자율신경계각성을반영하는증상 을동반하는불안장애이다 (American Psychiatric Association, 2013). 특징적으로는극심한불안과함께가슴이답답하거나질식 할것같은느낌, 흉통등다양한증상을포함하는공황발작 (panic attack) 진단기준을충족시켜야한다. 공황발작은 13 개의증상중 최소 4 개이상의증상이극심한불안감과함께급작스럽게발현되 고 10 분이내에정점에이르게되는현상을말한다. 또한공황발작 이향후다시발생될것에대한지속적인걱정 ( 예기불안 ) 과공황발 작과연관된회피행동과같은부적응적인변화가초래된다. 공황발 작은공황장애에서만나타나는현상은아니나공황장애의핵심 요소라할수있다. 공황장애에는호흡형과비호흡형두아형이존 재한다고제안되었으며호흡형의경우주된증상이질식할것같은 Correspondence to Soo Hyun Park, Department of Psychology, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, Korea; parksoohyun@ yonsei.ac.kr Received Sep 26, 2017; Revised Nov 03, 2017; Accepted Nov 04, 2017 The author wishes to thank Jeong Hoon Park and Eun Jung Sung for their assistance in literature search for this work. 느낌, 죽음에대한두려움, 흉통등이거론되고있으며비호흡형의경우어지러움, 떨림, 일반화된발한이특성인공황발작을경험한다고보고되고있다 (Briggs, Stretch, & Brandon, 1993). 정신질환진단및통계편람 (Diagnostic and Statistical Manual of Mental Disorders, DSM) III판부터하나의독립된불안장애로분류되기시작한공황장애는지난 30여년동안미국을중심으로많은연구가진행되었다. 미국조사에따르면공황장애는 1년유병률이 2.7% 이며평생유병률은 4.6% 로보고되고있으며 (Kessler, Chiu, Demler, Merikangas, & Walters, 2005; Kessler, Ruscio, Shear, & Wittchen, 2010) 그외국가에서도 1 4% 정도의유병률을보이고있다 (Roy-Byrne, Craske, & Stein, 2006). 또한만 15 44세연령층에서장애지속기간 (years lived with disability) 이모든질환중 11위에해당한다 (World Health Organization, 2001). 다른불안장애와유사하게공황장애또한우울장애와높은공병률을보이고있으며우울이동반되는경우경과및치료반응 (treatment response) 이부정적인것으로보고되고있다 (Brown, Campbell, Lehman, Grisham, & Mancill, 2001). 많은사례들에서공황장애와함께광장공포증 (agoraphobia), 즉공황증상이나타날때안전하지않다고느껴이러한상황을두려워하고회피하는양상이동 458

2 EBT of Panic Disorder 반될수있다. 많은사람들이광장공포증이부재한가운데공황장애를경험할수있으며일부의경우공황장애증상이없는가운데광장공포증을보일수있다 (Wittchen, Closter, Beesdo-Baum, Fava, & Craske, 2010). 이와같은연구결과에근거하여두장애는 DSM-5 에서진단적으로분리되었다. 공황장애는생물학적또는심리적취약성을가진개인이스트레스상황에서의오경보 (false alarm) 로인해발생하는공포반응으로개념화되고있다 (Barlow, 1988; Barlow, 2002). 현재많은뇌과학및신경과학기반연구가공황장애의생물학적기전을밝히고자진행되고있으나명확한기제는아직밝혀지지않았다. 공통적으로언급되는생물학적취약요인으로는과잉반응양상을보이는자율신경및신경내분비계반응성으로신경전달물질의특정활동양상과연관된다고간주되고있다. 심리적취약성으로는불안민감도 (anxiety sensitivity) 등신경증적성격기질 (neuroticism) 을반영하는요소가작용하는것으로알려져있다. 이와같은 Barlow(1988, 2002) 의정서 -기반모델이외에도 Clark(1986) 의인지적모델, 그리고 Reiss(1991) 의기대치모델 (expectancy model) 이이후공황장애에대한치료개발에상당한기여를하였다. 이중가장대표적인공황장애의원인론은 Barlow에의해구체화되었다. Barlow(1988, 2002) 에의하면공황장애의발현과유지에있어가장중요한역할을하는결정적요인은개인이주관적으로경험하는신체적증상과상황에대한통제력또는대처능력의결핍이다. 이와같은공황장애에대한원인론에근거한인지행동치료는공황통제치료 (Panic Control Treatmen, PCT; Barlow & Craske, 2000, 2016) 로전세계적으로가장많이사용되고있는프로그램이다. 일반적으로 12회기로구성된 PCT는공황장애의핵심증상을유지시키는주요기제가 (1) 내부감각적으로경험되는증상에대한과도한불안감, (2) 증상이갖는의미에대한부적응적사고, 그리고 (3) 광장공포증적행동과같은회피행동으로구성되었다고설명한다. 따라서치료는다음과같은구성으로진행된다 : (1) 공황, 불안및회피행동그리고치료적근거에대한심리교육 (psychoeducation); (2) 이완훈련 (relaxation training); (3) 내부감각적증상에대한과도한불안감을해결하기위한내부감각적노출 (interoceptive exposure); (4) 파국적사고를다루기위한인지치료 / 인지적재구조화 (cognitive restructuring); (5) 회피행동을감소시키기위한실제상황노출 (in-vivo exposure); (6) 재발방지및재평가 (relapse prevention and follow-up evaluation). 내부감각적및실제상황노출치료는전통적인공황장애인지행동치료에있어핵심요소이다. 충분한심리교육이제공되고치료의근거에대해내담자가적절히이해하고수용한다고판단된이후불 안감을상승시키는효과를갖는내담자의신체적증상양상을개인에맞춰파악하고내부감각적노출상황에서적응적으로활용될수있는이완훈련이진행된다. 내부감각적노출에서는공황발작상황에서흔히경험되는신체적증상을치료실내에서유발시키는활동위주로진행된다. 예를들어, 어지러움을유발시키기위해머리를흔들거나회전의자에앉아빙빙의자를돌리게된다. 과호흡 (hyperventilation) 을경험하도록제자리에서뛰기또는작은빨대를통해숨쉬기와같은활동이포함된다. 또한신체적각성상태를극대화시키기위해노출시행이전에신체적각성을상승시킬수있는커피와같은카페인음료를마시게하고실시할수도있다. 또한보편적인공황장애에대한인지행동치료에서는공황및공황장애를원인론적관점에서설명하는인지이론에대한교육을제공하고자동적사고, 파국적사고 (catastrophic thinking), 인지적왜곡등의양상을평가하여수정하게된다. 실제파국적사고가공황발작의인접유발요인역할을한다는사실이보고되었다 (Roth, Wilhelm, & Pettit, 2005). 하지만파국적사고이외공황장애에서의핵심두려움은발작자체에대한두려움일수있다. 이와같은맥락에서조건화된자극 ( 두려움 ) 과조건화된반응 ( 더많은두려움 ) 은동일한것으로간주된다 (Bouton, Mineka, & Barlow, 2001). 어떠한이유에서공황장애진단을받은개인이그렇지않은개인보다불안을더두려워하게되는것인가? 하나의가능성은공황발작유형과관련될수있다. 즉, 공황발작에는촉발이유가불분명한예기치못한발작 (spontaneous panic attack) 과비좁은공간과같은특정불안신호또는상황으로예기되는발작이있다. 예기치못한발작은차후이차적으로학습된발작으로이어져불안을가중시킬수있다. 예기치못한발작은위험신호가부재한가운데공포체계의자발적활성화를나타내며이는오경보인것이다 (Barlow, 2002). 학습되지않은심한발작을경험하면서두려움을미묘하게느낄때마다발작을예상하게되며특히과거발작이발생하였던상황에놓이게되면이와같은양상은더욱가중될수있다. 따라서공황장애초기시점이후부터는이와같은학습된공황발작이지배하게되는것이다 (Roth, 2010). 이와같은연구결과를근거로일반적인공황장애에대한인지행동치료는예기불안과관련된부적응적사고를수정하는요소가포함된다. 공황장애의근거기반치료공황장애의치료에있어인지행동치료가우수한효과를갖고있음은이미여러연구들을통하여검증되었다. 이를기반으로미국심리학회산하임상심리분과 (Division 12 Society for Clinical Psy- 459

3 Park chology) 는인지행동치료가공황장애치료에있어가장유의미한효과 (strong evidence) 를갖는근거기반치료로소개하고있다. 국내에서도인지행동치료의치료적효과가검증되었다 (Chae et al., 1999; Choi, Choi, Park, & Woo, 2002; Choi, Kim, Park, & Yoon, 2003). 공황장애에대한근거기반치료연구중주요결과들을좀더자세히논의하겠다. 공황장애의근거기반치료 : 해외인지행동치료는공황장애및공황발작에대한효과적인치료법으로이미많은치료효과연구및메타분석연구에서밝혀졌으며 (Barlow et al., 2002; Butler, Chapman, Formance, & Beck, 2006; Marchand et al., 2009) (Table 1) 임상군의 60% 정도가증상이호전되는것으로알려져있다 (Mitte, 2005). 특히인지행동치료는약물치료를포함한다른치료적접근들에비해치료효과가장기적으로더지속되는것으로보고되고있다 (Otto & Deveney, 2005). 메타분석연구에서도집단인지행동치료군이치료를제공받지않은대상군에비해더큰효과크기를보였으나대안적치료 (alternative treatment) 군과비교해서는유의미한차이가발견되지않았다 (Schwartze et al., 2017). 영국 National Institute for Health and Clinical Excellence (NICE, 2011) 에서발표한치료권고안에의하 Table 1. Summary of Major Panic Disorder Treatment Studies Source Type of Study Results Bandelow et al. (2015) Barlow et al. (2000) Heuzenroeder et al. (2004) Hofmann et al. (2008) Mitte (2005) Porter et al. (2015) Sánchez-Meca, et al. (2010) Schmidt et al. (2010) Schwartze et al. (2017) Meta-analysis of effect size for psychotherapy and pharmacotherapy for anxiety disorder Comparison of treatment effectiveness of imipramine and CBT (RCT) Meta-analysis addressing clinical utility and cost effectiveness of psychotherapy and pharmacotherapy Meta-analysis of only RCTs comparing CBT and placebo control for anxiety disorders Efficacy of psychotherapy and pharmacotherapy for panic disorder Meta-analysis of predictor and moderating variables in treatment effectiveness of CBT Meta-analysis of psychological treatment for panic disorder Systematic review of effectiveness of panic disorder treatment Meta-analysis of treatment efficacy of group therapy for panic disorder - Effect size of pharmacotherapy> psychotherapy - Effect size of mindfulness-based therapy > relaxation training > individual CBT > group CBT > psychodynamic therapy > non-interaction therapy (e.g., computer-based therapy) > EMDR > interpersonal therapy - At 9-month follow-up, CBT and pharmacotherapy was more effective compared to control group - In the acute phase (3 months), CBT + pharmacotherapy group showed a 60% response rate. - In the maintenance phase (6 months), response rate of the CBT + pharmacotherapy group was greater than CBT only, pharmacotherapy only group. However, there was no difference between CBT + pharmacotherapy and CBT + placebo group in terms of response rate. - CBT most effective and cost-effective - Strong effect size of CBT for OCD and acute stress disorder - Weak but significant effect size of CBT for panic disorder - CBT > no treatment, placebo - No significant difference regarding the inclusion of cognitive therapy component in treatment - Pharmacotherapy > no treatment, placebo - Effect size was agoraphobic avoidance > low expectations regarding change > severe functional impairment > pathological Cluster C personality traits - Relaxation and breathing training + exposure therapy > exposure therapy only > exposure therapy + cognitive therapy > breathing training only > breathing training + exposure therapy - EMDR showed insignificant treatment effects - Inclusion of exposure therapy more effective - Inclusion of behavioral component in treatment more effective than cognitive therapy alone - CBT showed greatest efficacy - Use of manualized CBT protocol in community mental health centers and primary care settings recommended - Pharmacotherapy combined with CBT holds advantages in the short run. However, their combined effectiveness is questionable in the long term. - CBT + exposure therapy showed greater effect size compared to exposure therapy alone - Large effect size for group therapy compared to no treatment group - Effect size not statistically different from other treatment modalities (individual therapy, pharmacotherapy, relaxation training) 460

4 EBT of Panic Disorder 면광장공포증을동반한 / 동반하지않은공황장애에있어심리치료와약물치료가효과를갖는것으로보고되었다. Mitte(2005) 에의하면인지행동치료는통제집단에비해불안수준감소에있어더큰효과크기를보였으며위약통제군에비해중간정도의효과크기를보였다. 최근여러치료유형의효과를메타분석을통해분석한결과인지행동치료가치료를받지않은대기자군그리고심리치료및약물치료위약군에비해더효과적인것으로나타났다 (Bandelow et al., 2015). 해당연구에의하면단독으로실시된인지행동치료가다른치료또는위약군에비해일반적으로더효과적이나인지행동치료와약물치료 (selective serotonin reuptake inhibitors, SSRIs) 가병행되었을때효과크기가가장컸다. 이와같은치료성과를이끄는공통요소들을보다명확히파악하기위해서는공황발작및공황장애의발병및경과에영향을주는다양한요인들에대한연구가필요하다. 예를들어, 현재까지가장대규모의무선할당통제연구 (randomized clinical trial, RCT) 로알려져있는연구 (Barlow, Gorman, Shear, & Woods, 2010) 에서는공황장애진단을받은내담자를이미프라민 (imipramine), 인지행동치료, 인지행동치료 + 이미프라민, 인지행동치료 + 위약, 그리고위약집단으로무선할당하였다. 모든참가자는 11번의개별치료를 12주에걸쳐제공받았다. 치료반응은치료후 Panic Disorder Severity Scale (PDSS) 점수상 40% 이상의증상완화가측정될경우로정의되었다. 연구결과에따르면위약집단에비해모든치료집단의치료반응이유의미하게컸으며치료집단간의차이는유의미하지않은것으로나타났다. 해당연구에서인지행동치료군의치료반응비율은 49%, 이미프라민군은 46%, 인지행동치료 + 위약군은 57%, 인지행동치료 + 이미프라민군은 60% 로나타났다. 다른연구들에의하면공황관련인지가인지행동치료또는인지행동치료 + 약물치료 ( 이미프라민 ; imipramine) 집단에서의공황증상완화정도를매개하는것으로나타났으며이와같은영향은이미프라민약물치료집단에서는관찰되지않았다 (Hofmann et al., 2007). 이는치료유형에따라치료적기제가다를수있음을시사한다. PCT에기반한인지행동치료는노인대상연구에서도큰효과크기를보였으며 (Cohen s d = 0.85) 효과적인것으로밝혀졌다 (Hendriks, Kampman, Keijsers, Hoogduin, & Voshaar, 2014). 하지만아동 청소년기에발현되는공황장애에대해서는상대적으로연구가부족한실태이다. 아동이자연적으로발생하는공황발작을실제경험할수있는지여부가큰쟁점으로떠올랐다. 이는아동이발달학적으로죽음, 통제력상실, 또는 미쳐버릴수있다 와같은파국적사고양상을경험할수있는인지적능력을충분히발달시키지못했을가능성때문이다. 하지만청소년기에도공황발작과공황장 애가발생한다 (King et al., 1997). 지역사회청소년표본의 35.9% 에서 63.3% 정도가공황발작을경험한것으로보고되었으며공황장애진단을받은청소년과성인이아동기에공황발작을경험한것으로회상하였다 (for review, see Barlow et al., 2003). 대부분의연구는청소년대상으로치료효과를검증하였으며기존인지행동치료구성요소들을기반으로보다쉬운언어와더많은언어적그리고시각적예시를활용하는청소년용근거기반인지행동치료프로그램이효과적인것으로보고되었다 (Hoffman & Mattis, 2000). 비록아동 청소년기공황장애에국한된치료효과를검증한메타분석연구는아직보고되지않았으나 30,431명의아동 청소년을대상으로지난 50여년간진행된 447편의 RCT 연구들에대한다수준메타분석 (multilevel meta-analysis) 을실시한결과해당발달시기에발현되는불안장애에대한인지행동치료의효과크기는중간정도 (Cohen s d= 0.61) 인것으로나타났다 (Weisz et al., 2017). 어떠한치료적요소가치료효과에있어가장핵심적인작용을하는가? 연구결과에의하면불안과연관된내부감각에대한공포감을수정하는것이인지행동치료의우수한치료효과성의중심에있는것으로간주되고있다 (Smits, Berry, Tart, & Powers, 2008; Smits, Powers, Cho, & Telch, 2004). 실제이와같은공포에초점을두는치료가공황장애예방에있어서도효과적인것으로나타났다 (Gardenswartz & Craske, 2001). 그밖에 Schmidt 등 (2000) 은호흡재훈련 (breathing retraining) 은치료효과에있어필수요소가아니라고제안하였으며이완훈련또한추가적인효능성및유용성을제공하지않는다고밝혔다. 이와같은맥락에서공황장애의핵심적요소로밝혀진기제에초점을둔단기인지행동치료 (brief CBT) 또는집중인지행동치료 (intensive CBT) 의효과에대한연구들이진행되었으며임상적으로유의미한변화를가져오는것으로보고되었다 (Otto & Pollack, 2009; Otto et al., 2009; Roy-Byrne et al., 2005). 단기인지행동치료는두려움을유발하는불안감그리고공황발작에동반되는신체적감각에대한내부감각적노출에초점을둔다. 또한파국적사고를감소시키기위한인지적재구조화훈련이제공된다. 따라서기존 12회기에서 4회기내외로단축되어실시되는단기인지행동치료는위핵심치료적요소를집중적으로제공한다. 하지만이와같은긍정적인결과에도불구하고주의할점도제기되고있다. 공황장애를포함한다른불안장애에대한무려 400건이상의 RCT 연구결과를개관한논문에의하면공황장애에대한전통인지행동치료의평균효과크기는 1980년대에비해 2007년에이르러실제감소한것으로나타났다 (Öst, 2008). 예를들어, Öst(2008) 는치료결과측정치상의효과크기와논문게재년도간 461

5 Park 의유의미한부적상관관계를보고하였다. 이와같은결과를설명할수있는하나의가능성으로최근진행된연구일수록보다심각한증상을보이는내담자를치료에포함시켰을가능성이언급되었다. 하지만인지치료와내부감각적노출이구성요소로포함되었을경우공황장애치료의효과가실제증진되는지의문을갖게하기에충분하다 (Schmidt & Keough, 2010). 공황장애진단을받은개인중 30% 정도가약물치료에대한치료불응성을보이며 (Liebowitz, 1997) 약물치료가중단될경우대상자의 50% 이상이증상재발을경험한다고알려져있는바 (Toni et al., 2000), 보다많은개인들이치료성과를보다장기적으로경험할수있는방안이절실하다. 공황장애치료에있어인지행동치료가우수한효과를보이는것은널리수용되고있으나역시증상완화의정도가미미하거나유의미한기능회복을경험하지못하는경우도있다 (Boswell et al., 2013; Porter & Chambless, 2015). 따라서최근 PCT(Barlow & Craske, 2000) 와같은표준화된공황장애인지행동치료의치료적성과에영향을줄수있는내담자및치료제공자특성과같은치료효과에대한조절또는매개요인을파악할필요성이제기되고있다. 미국국립정신건강연구소 (National Institute for Mental Health, NIMH) 는치료사의역량 (competence) 및치료지침준수정도 (therapist adherence) 를중점적으로검증하는것을목표로향후연구계획을공표하였다 (Boswell et al., 2013). 최근 52편의연구결과를기반으로발표된체계적고찰논문에서는내담자의광장공포증적회피양상이공황증상의미흡한치료성과에대한가장일관된예측변인으로나타났으며변화에대한낮은기대감, 높은기능적손상수준, 그리고 C군성격적특성도포함되었다 (Porter & Chambless, 2015). 치료효과를조절또는매개하는요인을파악하고자성격특성그리고정서적경험이최근관심을받고있다. 공병률이높은이유로인해최근불안장애를포함한정서장애의위계적구조에대한연구가활발히진행되고있는가운데특히정서장애의발달및지속여부와연관된범진단적구성요소들이제안되고있다. 여기에는정서적경험에대한혐오성을공통적으로보이는경험적회피, 불안민감성, 마음챙김결핍, 그리고통제불가성에대한신경증적감각을반영하는부정적평가와귀인양식이주목받고있다 (Barlow, Sauer-Zavala, Carl, Bullis, & Ellard, 2014). 이는공황장애에대한근거기반치료의장기적효과성에영향을줄수있는기질적요소를기존이론적기제에포함시켜보다통합적인개인-맞춤형치료를제공하여치료효과를극대화하려는시도로간주될수있다. 현재임상적유용성및치료효과검증이진행되고있는 [ 정서장애의단일화된범진단적치료프로토콜 ](Unified Protocol for Diagnostic Treatment of Emotional Disorders, UP; Barlow et al., 2010; Cho, Noh, & Choi, 2017) 은행동적회피, 인지적회피, 그리고안전신호사용으로대표되는정서적회피양상을집중적으로평가하여치료하도록고안되었다. 예를들어, 카페인섭취에대한회피양상은신체적감각에대한미묘할수있는행동적회피로간주되며주의분산과같은인지적회피, 그리고빈약통을가지고다니는것과같은불안유발상황의발생가능성을감소시키기위한미신적인안전행동 (safety behavior) 이기능평가를통해파악된다. 그외추가된요소로는정서-주도행동 (emotion-driven behavior, EDB) 을확인하는것이다. 이는기존연구자들이행동성향 (action tendencies; Barlow, 1988) 으로명명한정서의행동적반응요소를설명하는개념으로적응적그리고부적응적정서-주도행동이있다. 실제적인위협상황이아님에도불구하고공황장애에서는오경보 (false alarm) 체계가활성화되는양상이반복되며이는부적응적인악순환을지속시킨다. 따라서기존노출치료전략과유사하게회피하고있는정서및상황을직면하고경험하도록하여부적응적정서-주도행동을보다적응적인대체행동으로변화시키는작업을병행하게된다. 초기효과검증연구에의하면집단인지행동치료군에비해다양한불안장애진단을받은 UP군이더유의미한향상을보였으며치료종결 18개월후에도치료효과가유지되는것으로나타났다 (Bullis, Fortune, Farchione, & Barlow, 2014). 공황장애의근거기반치료관련사이트여러국가에서근거기반치료권고안을검증하고공유하고자많은자료들을제공하고있다. 몇개의유용한사이트를 Table 2에제시하였다. 해당기관이대변하는전문분야에따라권장되는치료권고안간의미묘한차이가관찰된다. 예를들어, 미국정신의학회 (American Psychiatric Association, 2013) 는공황장애치료에있어약물치료와심리치료를병행할것을권장하면서인지행동치료가치료효과가가장잘성립된치료로기술하고있다. 이에반해미국심리학회 (American Psychological Association) 는인지행동치료를권장하고있다. 공황장애인터넷및앱치료프로그램현황심리치료중인지행동치료가가장활발하게검증된치료이나그외이완훈련 (relaxation training), 정신역동치료, 대인관계치료 (interpersonal therapy, IPT), 안구운동민감소실및재처리요법 (eye movement desensitization reprocessing, EMDR), 마음챙김명상 (mindfulness meditation) 그리고인터넷또는컴퓨터기반치료의 462

6 EBT of Panic Disorder Table 2. Major Treatment Guidelines and Resources for Panic Disorder Organization American Psychological Association Society of Clinical Psychology (Division 12): Panic Disorder (United States of America) Website Address cognitive-behavioral-therapy-for-panic-disorder/ National Institutes of Clinical Excellence (United Kingdom) National Health and Medical Research Council (Australia) Australian Psychological Society Evidence-based and Quality Information for Psychologists (EQIP) (Australia) British Psychological Society (United Kingdom) Society for Behavioural Medicine University of Ottawa s Psychotherapy and Practice Research Network Center for Anxiety and Related Disorders, Boston University 효과도연구되었다 (Bandelow et al., 2015). 이완훈련을제외한다른치료유형에대한효과크기는상대적으로낮거나논란의소지가있는것으로보고되고있으며 (APA Division 12) 이에최신연구흐름은인지행동치료에기반을둔컴퓨터또는인터넷기반치료프로그램을검증하는데에집중되고있다. 즉, 공황장애에대한인지행동치료의효과성과비교적유리한비용적측면에도불구하고임상장면을찾는대부분의내담자들은인지행동치료를제공받지못한다 (Hofmann & Spiegel, 1999). 이로인해단기인지행동치료및인터넷-기반치료프로그램의효과성에대한관심이높아졌다. 치료유용성을저해할수있는비용과접근성의문제를해결하기위해진행되고있는이와같은새로운시도들은기존의전통적인지행동치료에비해치료효과에있어가장핵심적구성요소로검증된요인을파악하여치료를재구성하고있다. 이와같은연구들을종합적으로개관한연구에의하면대기자집단에비해컴퓨터및인터넷기반치료를받은내담자가유의미한증상완화를보였으며이와같은결과는면대면치료에서나타나는치료성과와유사한정도였다 (Reger & Gahm, 2009). 공황장애를포함한우울및불안장애에대한컴퓨터기반인지행동치료를 RCT를통해검증한 22편의논문을체계적으로고찰한결과모든장애에있어평균효과크기가 0.88로나타났으며치료효과는평균 26주뒤까지지속되는것으로보고되었다 (Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010). 하지만대기자통제군과비교하여효과크기가유의미하게더크지않았다. 인터넷기반인지행동치료의치료적성과가대기자대조군에비해 4배정도높았으며이러한차이는면대면심리치료와의차이보다더컸으며근거수준은중간정도로평가되었다 (Olthuis, Watt, Bailey, Hayden, & Stewart, 2015). 같은연구에서공황장애군만을대상으로분석한결과에서도근거수준이중간정도로평가되었다. 이와같은발전에 대해내담자들도비교적긍정적으로평가하는것으로밝혀졌다. 보다다양한장면에서포괄적으로활용될수있도록 Craske 등 (2009) 은일차의료장면에서상대적으로경험이부족한치료사가제공할수있도록고안된컴퓨터기반인지행동치료프로그램을개발하였다. 내담자들은경험이풍부하지않은치료사와상호작용하면서인지행동치료에포함된일상적인기술의학습을도모하는컴퓨터프로그램을사용하게된다. 결과에의하면참가한내담자들이프로그램을긍정적으로평가한것으로나타났다 (Craske et al., 2009). 단, 컴퓨터기반심리치료가일정수준의효과크기를보이고있으나치료성과가장애유형, 비교집단유형, 컴퓨터기반심리치료의전달방법 ( 인터넷, 데스크톱, 태블릿 PC) 과실제무관하며컴퓨터가치료사의참여시간을더많이대체할수록효과크기가감소한다는결과 (Cuijpers et al., 2009) 는주시할필요가있다. 즉, 아직검증되지않은불특정요소가이와같은치료효과를주도하고있을가능성이시사되어향후더많은연구가필요하다. 보다최근에는인지행동치료의핵심요소라할수있는노출치료를보다유용하게활용하고도모할수있도록개발된가상현실프로그램이개발되고있다. 가상현실시뮬레이션은짧은시간내에많은노출상황과시나리오를생성할수있다는장점과더불어치료적한계 ( 예를들어, 상황에나타나는사람의수 ) 를통제및설정할수있다는큰임상적유용성을과시한다. 또한노출치료를감행하기어려운상황이나이행하기에는너무많은비용이요구되는상황 ( 예를들어, 비행기탑승 ) 을가상현실속에서재현할수도있다. 노출치료에대한거부감이심한내담자의경우가상현실프로그램을활용한심상훈련을통해상황에대한통제력을경험하면서실제상황노출을병행하는컴퓨터시뮬레이션도개발되어치료효과에대한검증이이루어지고있다. 해당프로그램에서는 40초간중립자극을제시한후 3분동안버스와같은대중교통수단에탄후승 463

7 Park 객인원수가점차증가하면서터널을통과하고마지막으로 20초간중립자극이제시되도록제작되었다 (Freire, 2017). 이와같은최신치료방안에대한초기연구결과는긍정적이나 (Martin et al., 2007) 아직까지는사례연구또는소규모의 RCT 연구들이다. 한국형공황장애약물치료알고리듬 (Lee et al., 2008) 에서권장하는인지행동치료기법중노출치료가해외에비해상대적으로덜강조되고있다는점을고려할때국내실정상노출치료가현실적으로활용되기어려운점이있어가상현실을활용한노출치료의국내에서의임상적유용성이검증될필요가있겠다. 국내에서국제협력연구로진행된가상현실치료연구에의하면가상현실노출을전통적인집단인지행동치료프로그램에통합한 4회기의단기치료를기존의 12회기 PCT 집단치료와비교한결과두치료유형간에유사한단기적효과가있었으나치료효과의장기적유지측면에서는 PCT가더우세하였다 (Choi et al., 2005). 이외에도캐나다에서진행된연구에서는 12회기간제공되는전화심리치료 (telepsychotherapy) 가공황발작발생빈도, 공황관련예기불안, 증상심각도를통계적그리고임상적으로유의미하게감소시킨것으로나타났다 (Kenardy et al., 2003). 또한미국심리학회산하임상심리분과는스마트폰어플리케이션으로개발된두개의인지행동치료기반프로그램을소개하고있으며 ( 예를들어, Stop Panic and Anxiety Self-Help ) 이는구매를통해보다수월하게치료에접근할수있다. 마지막으로공황장애를포함한불안장애에대한컴퓨터기반인지행동치료효과검증 1단계 (Phase I) 연구 ( 가미국 National Institute of Health의지원하에무선할당통제연구를 10년동안진행중이다. 공황장애의근거기반치료 : 국내국내의경우공황장애에대한근거기반인지행동치료를체계적으로훈련받은전문인력의부족으로인해약물치료를선호하는것이현실이다. 또한체계적인공황장애에대한경험적효과검증연구의부족으로인해해외에서검증된치료프로그램이국내에서도유사한효과크기를보일지경험적근거가충분하지않은실정이다. 해외에서권장되고있는공황장애에대한근거기반치료프로그램의효과를알아본몇안되는연구가존재하나 (Choi, Lee, & Cho, 2017) (1) 방법론적으로일관되지않은절차, (2) 소규모의무선할당또는 RCT 연구, (3) 적절한통계적분석을어렵게하는상이한치료프로그램또는구성요소로특징된치료프로그램의활용, 그리고 (4) 임상적경과를평가하는결과측정치상의비일관성등의문제로메타분석은물론체계적으로고찰할충분한객관적정보가부 족한실정이다. 국내데이터베이스 (RISS) 를통해최근 20년동안 불안장애 와관련된메타분석은 1편 (Kim H. S. & Kim E. J., 2015) 이있었으며 공황장애 와관련된치료효과연구는전체 1,138 편에서 27편으로이중대표적인논문들을 Table 3에제시하였다. 흥미롭게도국내에서는해외연구와다르게비교적다양한측정도구를활용하고있는것이확인된다. 불안장애에대한비약물적중재 ( 인지행동치료, 이완요법, 명상, 보완대체요법 ) 를검증한 2,690편의논문중 23편의논문을대상으로효과크기를알아본결과효과크기는큰것으로나타났다 (Hedges s g =1.693; Kim H. S. & Kim E. J., 2015). 하지만해당연구는공황장애에국한된연구결과가아니며 23편의논문중불안장애관련 RCT 연구는 8편이었으며모두사회불안에대한치료효과를알아본연구였다. 몇몇연구를살펴보면가장대규모로진행된연구로 224명의공황장애진단을받은환자를치료종결 12개월이후추적조사한결과약물의종류와무관하게인지행동치료이후모든결과측정치가유의미하게향상된것으로보고되어대상자의 54% 가약물치료를중단하였으며참가자중약 70% 가상태를유지하고있는것으로나타났다 (Choi et al., 2003). 다른연구에서는약물치료만제공된임상군에비해인지행동치료가약물치료와병행되었을때공황관련부적응적사고, 신체감각증상, 불안민감성이유의미하게감소하는것으로나타났으며향후약물치료를중단하는비율도높은것으로보고되었다 (Choi, 2004). 기존치료집단 (treatment as usual, TAU) 을비교집단으로두어보다엄격한기준을토대로공황장애진단을받은노인들을위한집단인지행동치료의효과성을검증한연구에서는집단인지행동치료의효과크기가기존치료집단에비해유의미하게더컸으며참가후참가자의공황관련신념, 지각된불안통제감, 약물치료사용정도가긍정적으로변화한것으로나타났다 (Choi, Lee, & Cho, 2017). 최근이루어진공황장애관련정신의학전문가대상의설문조사에서공황장애에대한인지행동치료는모든치료단계에서권장되었으며경도공황장애의경우약물치료보다인지행동치료를단독으로적용하는것을전문의집단에서선호하는것으로나타났다 (Executive Committee for Korean Medication Algorithm for Panic Disorder, 2008; Seo, Lee, Lee, & Suh, 2016). 또한증상심각성이중등도이상일경우약물치료와인지행동치료가병행될것을권장하는것으로합의되었다 (Lee et al., 2008). 특히, 한국형공황장애약물치료알고리듬개발연구에서정신의학전공의들은공황장애치료에권장되는인지행동치료기법으로심리교육과인지적재구조화를 1차선택안, 노출치료, 이완훈련, 재발방지는 2차상위, 자극감응훈련과문제해결훈련은 2차하위선택안으로평가하였다. 464

8 EBT of Panic Disorder Table 3. Summary of Major Panic Disorder Treatment Studies in Korea Source Treatment N Main Panic Outcome Measure Choi et al. (2002) CBGT 108 STAI; ASI; ACQ; PBQ; BSQ Choi et al. (2006) CCBT 75 (Control = 18; Treatment = 57) Choi et al. (2017) CBGT 76 (Treatment as Usual = 31; Treatment = 45) Choi et al. (2000) CBT 148 (Control = 78; Treatment = 70) PDSS; CGI; STAI; ASI-R; ACQ; BSQ; ATQ-P; ATQ-N PAS CGI; STAI-state; ASI; BSQ; PBQ; ACQ; FQ; TAS Results - CBGT significant improved quality of life. - CBGT decreased anxiety sensivity, improved panic-related beliefs. - Presence of agoraphobia did not significantly affect symptom severity and clinical characteristics following treatment - PDSS score was reduced more in participants with agoraphobia following treatment. - Catastrophic cognitive distortion decreased, while perceived controllability over anxiety increased. - Panic symptoms decreased. - After a 12-week CBT program, significant differences were found on the CGI, STAI, ACQ, BSQ, TAS, PBQ scales between participants who had ceased medication versus those who were still receiving pharmacotherapy. Choi et al. (2003) CBGT 236 BSQ - At 12-month follow-up, 75% of participants maintained therapeutic gains. Huh et al. (2003) CBGT 161 ESF; Yalom s Curative Factors Scale Kim (1999) CBGT 5 PAS; FQ; APPQ; ACQ; BSQ; ASI Park et al. (2001) CBGT 111 CEQ; ESF; STAI; ASI; ACQ; BSQ; FQ - Participants maintaining high end state functioning and group cohesiveness, instillation of hope, self-understanding, altruism scores increased following CBGT. - Overall scores on the outcome measures improved following treatment. - CBT significantly improved panic symptoms. - Expectations regarding treatment positively correlated with treatment gains. Note. CBT = Cognitive Behavior Therapy (individual); CBGT = Cognitive Behavior Group Therapy; CCBT = Combined Cognitive Behavior Therapy; STAI= State-Trait Anxiety Inventory; ASI= Anxiety Sensitivity Inventory; ACQ= Agoraphobic Cognition Questionnaire; PBQ= Panic Beliefs Questionnaire; BSQ = Body Sensations Questionnaire; PDSS = Panic Disorder Severity Scale; CGI = Clinical Global Impression; ATQ-P = Automatic Thoughts Questionnaire-Positive; ATQ-N= Automatic Thoughts Questionnaire-Negative; PAS= Panic and Agoraphobia Scale; TAS= Toronto Alexythymia Scale; ESF = End-State Functioning; FQ = Fear Questionnaire; APPQ = Albany Panic and Phobia Questionnaire; CEQ = Counselor Evaluation Questionnaire. Table 4. Summary of Treatment Guidelines for Evidence-Based Treatment for Panic Disorder Level of Evidence Treatment Modality (Korea) Treatment Modality (Other Countries) Strong/well-established Cognitive Behavior Therapy / Medication (SSRIs) Cognitive Behavior Therapy / Medication (SSRIs) Modest/probably efficacious Mindfulness-Based Therapy Applied Relaxation Controversial/experimental Psychoanalytic Therapy 이와같은권고안은 Canadian Psychiatric Association (CPA) 과같은해외권고안과대부분일치하는것으로간주될수있으나 (Seo et al., 2016) 해외연구에서치료적효과가두드러지는것으로현재추정되고있는노출치료를 2차상위로지정하고있다는흥미로운차이가발견된다. 한국형공황장애약물치료알고리듬권고안은회피행동양상을보이는내담자의경우전통적인 12회기인지행동치료가단기인지행동치료보다더효과적인것으로평가하고있어해외연구결과들과일치한다. 다만, 강화회기 (booster session) 의필요성과관련하여 2차상위, 인지행동치료의재발방지구성요소의유용성과단기인지행동치료의유용성에대해서는설문조사결과 2 차하위로구분되어해외연구추세와는다소다른양상을보였다. 즉, 해외의경우권장되고있는핵심근거기반치료요소로재발방지와관련된내용을포함하고있으며특히임상적으로보다유용할수있는단기인지행동치료의효과를지속적으로검증하고있는데에반해국내의경우이러한치료적요소의중요성을상대적으로덜강조하고있는것으로조사되었다. 이는공황장애에대한인지행동치료를제공할수있는전문가수의부족및노출치료를이행할수있는상황적제한등국내의현실적인사정을일부반영한양상일수있다. 465

9 Park 공황장애의근거기반치료 : 권고안및제언 공황장애의근거기반치료와관련된여러실무권고안이제시되었 다 (Katzman et al., 2014). 이러한권고안은엄격한치료효과근거 수준에기반하여작성되었으며근거수준이최소 modest 이상일 경우채택되었다. 공황장애의근거기반심리평가방안에대한의견 은비교적일관되게도출되었으며 (Antony & Rowa, 2005) 이에대 한국내적용방안에대한권고안도마련되었다 (B. N. Kim & J. H. Kim, 2015). 단, 국내의경우해외와는달리 RCT 에근거한경험적 으로지지된 (empirically supported treatment) 공황장애치료에대 한메타분석연구는현재부재한상황이다. 향후이에대한보완책 및관련전문분야간의협력을통한 RCT 가진행되어국내에서도 인지행동치료가공황장애치료에있어근거기반치료로보다경험 적으로성립될필요가있겠다. Table 4 에국내외연구결과를종합 하여공황장애의근거기반치료권고안을요약하였다. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Andrews, G., Cuijpers, P., Craske, M. G., McEvoy, P., & Titov, N. (2010). Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: A metaanalysis. PloS ONE, 5, e Antony, M. M., & Rowa, K. (2005). Evidence-based assessment of anxiety disorders in adults. Psychological Assessment, 17, Bandelow, B., Reitt, M., Rover, C., Michaelis, S., Gorlich, Y., & Wedekind, D. (2015). Efficacy of treatments for anxiety disorders: A meta-analysis. International Clinical Psychopharmacology, 30, Barlow, D. H. (1988). Anxiety and its disorders. New York: Guilford. Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York: Guilford Press. Barlow, D. H., & Craske, M. (2016). Mastery of your anxiety and panic: Workbook (B. H. Choi, Trans.). Seoul: Sigma Press. Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Allen, L. B., & Ehrenreich-May, J. (2010). Unified protocol for transdiagnostic treatment of emotional disorders: Workbook (Y. R. Cho, S. S. Noh, M. K. Choi, Trans.). Seoul: Hakjisa. Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. JAMA, 283, Barlow, D. H., & Kennedy, K. A. (2016). New approaches to diagnosis and treatment in anxiety and related emotional disorders: A focus on temperament. Canadian Psychology, 57, Barlow, D. H., Pincus, D. B., Heinrichs, N., & Choate, M. A. (2003). Anxiety disorders. In G. S. Stricker & T. A. Widiger (Eds.), Handbook of psychology, Vol. 8: Clinical psychology (pp ). New York: Wiley & Sons. Barlow, D. H., Raffa, S. D., & Cohen, E. M. (2002). Psychosocial treatments for panic disorders, phobias, and generalized anxiety disorder. In P. E. Nathan & J. M. Gorman (Eds.), A guide to treatments that work (pp ). London: Oxford University Press. Barlow, D. H., Sauer-Zavala, S., Carl, J. R., Bullis, J. R., & Ellard, K. K. (2014). The nature, diagnosis, and treatment of neuroticism: Back to the future. Clinical Psychological Science, 2, Boswell, J. F., Gallagher, M. W., Sauer-Zavala, S. E., Bullis, J., Farchione, T. J., & Barlow, D. H. (2013). Patient characteristics and variability in adherence and competence in cognitive-behavioral therapy for panic disorder. Journal of Consulting and Clinical Psychology, 81, Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory perspective on the etiology of panic disorder. Psychological Review, 108, Briggs, A. C., Stretch, D. D., & Brandon, S. (1993). Subtyping of panic disorder by symptom profile. British Journal of Psychiatry, 163, Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, R. J., & Mancill, K. B. (2001). Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology, 110, Bullis, J. R., Fortune, M. R., Farchione, T. J., & Barlow, D. H. (2014). A preliminary investigation of the long-term outcome of the unified protocol for transdiagnostic treatment of emotional disorders. Comprehensive Psychiatry, 55, Butler, A., Chapman, J., Formance, E., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, Chae, J. H., Ahn, H. W., Lee, J. J., Bahk, W. M., Jun, T. Y., & Kim, K. S. (1999). Short-term effect of combined cognitive-behavioral therapy with pharmacotherapy for panic disorder. The Korean Journal of Psychopathology, 8, Choi, Y. H. (2004). Comparison of the effectiveness between combined therapy and pharmacotherapy for panic disorder. Cognitive Behavior Therapy in Korea, 4, Choi, Y. H., Choi, Y. J., Park, K. H., & Woo, J. M. (2002). Impact of group cognitive behavioral therapy on quality of life in patients with panic disorder. Journal of the Korean Neuropsychiatric Association, 41, Choi, Y. H.,Choi, Y. J., Woo, J. M., & Yoon, H. Y. (2006). A comparison study of treatment outcome in panic disorder with or with- 466

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12 EBT of Panic Disorder Akiskal, H. S. (2000). A prospective naturalistic study of 326 panic-agoraphobic patients treated with antidepressants. Pharmacopsychiatry, 33, Weisz, J. R., Kuppens, S., Ng, M. Y., Eckshtain, D., Uqueto, A. M., Vaughn-Coaxum, R.,...Fordwood, S. R. (2017). What five decades of research tells us about the effects of youth psychological therapy: A multilevel meta-analysis and implications for science and practice. American Psychologist, 72, Wittchen, H. U., Gloster, A. T., Beesdo-Baum, K., Fava, G. A., & Craske, M. G. (2010). Agoraphobia: A review of the diagnostic classificatory position and criteria. Depression and Anxiety, 27, World Health Organization. (2001). The world health report Mental health: New understanding, new hope. Geneva: World Health Organization. 국문초록공황장애에대한근거기반치료박수현연세대학교심리학과공황장애는극심한불안감과함께자율신경계각성을반영하는다양한증상이예기치못한상황에서동반되어나타나는불안장애로이와같은공황발작이다시경험될것이라는예기불안이특징적으로보고된다. 전세계적으로 1 4% 사이의유병률이보고되고있으며모든질환중장애지속기간이 11번째로높은장애로알려져있다. 지난 30여년간많은연구가진행되었고이를기반으로인지행동치료중심의경험적으로검증된다양한치료프로그램들이개발되었다. 본논문에서는공황장애에대한임상적기술및원인론에대해살펴보고이에기반을두고개발된치료적접근들을소개할것이다. 국내외에서진행된치료효과및메타분석연구결과를토대로공황장애에대한근거기반치료로우선적으로권장되고있는인지행동치료의핵심구성요소가무엇인지그리고치료효과에대한조절또는매개변인에는어떠한것이있는지논의될것이다. 또한최근검증작업이시작된공황장애에대한컴퓨터또는인터넷기반치료프로그램의효과및임상적유용성과관련된연구결과들을토대로향후공황장애치료에있어어떠한함의를갖는지질문을던지고자한다. 마지막으로국내외저명기관및주요연구결과가제안하고있는공황장애에대한치료권고안을토대로현재어떠한방향으로공황장애에대한근거기반치료가권장되고있는지요약할것이다. 주요어 : 근거기반치료, 심리장애, 공황장애 469