Cognitive-behaviour Therapy (henceforth CBT) is lead evidence based psychological treatment for psychological disorders which has achieved substantial support and acknowledgement by the British Government and health-care authorities even though there are many other evidence-based effective therapies. Scientific research has shown that CBT is the best researched and authenticated psychological treatment using evidenced-based practice that is available for treating numerous psychological problems including; depression, anxiety, stress and pain which helps individuals to conquer obstacles and difficulties that people might face at work, home or in relationship situations (Hollon & Beck, in press). CBT was developed from two earlier types of psychotherapy; behaviour therapy in the early 20th century and cognitive therapy in the 1960s. However, like with any psychotherapy, this evidence-based psychological treatment has also been criticized generally for various reasons and from different sides. For instance, Psychotherapist and Professor Andrew Samuels (2007) at the Centre for Psychoanalytic Studies in the University of Essex wrote to the Times to say “We have allowed the proponents of CBT to caricature all other psychotherapies as delving unendingly into the patient’s past and lacking any scientific validation as regards efficacy. Everyone knows the limitations of CBT – except, it would seem the government. The science is inadequate, the methods naive and manipulative, and the reluctance to engage with the key aspect of psychotherapy – the deep and complex relationship that develops between client and therapist – really very careless. Clients who enter CBT are approached in a mechanistic way, required to be passive and obedient. Hence what is going to be on offer is a second-class therapy for citizens deemed to be second class”. As a result, this essay critically evaluates the current understanding of CBT and examines its effectiveness in relation to depression and panic disorder due to its “efficacy-research oriented nature” (Parry, 2004) and that CBT was initially developed to treat these disorders. Moreover, it will argue whether CBT is able to bring deep (i.e. changes in schemas and core beliefs) and enduring change (i.e. reducing relapse rates) to people’s lives and if it eliminates the pain they experience in the long-term.
Kendall and Hollon (1979), cited by Beidel and Turner (1982), defined cognitive-behavioural therapy as “purposeful attempts to preserve the demonstrated efficiencies of behaviour modification within a less doctrinaire context and to incorporate cognitive activities if efforts to produce therapeutic change”. In other words, CBT pays attention to how individuals attend, interpret, reason and reflect inner and outer events. The UK CBT organization states that “the term “Cognitive-behaviour Therapy” (CBT) is variously used to refer to behaviour therapy, cognitive therapy and to therapy based on the pragmatic combination of principles of behavioural and cognitive theories” (BABCP, 2008). As a result, contemporary CBT is influenced by behaviour therapy which is based on theories of behaviour such as learning theory (where the functions of classical and operant conditioning are viewed as the most important) to describe the acquisition of emotional problems and the modification of unwanted behaviour and was developed by Wolpe and his colleagues in the 1950s and 1960s (Wolpe, 1958). The wealth of this approach and its effectiveness meant that behaviour therapy rapidly became extensively used particularly with anxiety disorders (Westbrook et al. 2007). However, earlier behavioural approaches excluded the role of cognition and cognitive processes (i.e. thoughts and beliefs) in forming and maintaining emotional disorders (Mahoney, 1974). In sharp contrast, cognitive therapy is based on how cognitions and the way individuals interpret events lead to the development of emotional disorders. This therapy was developed by A.T. Beck in early 1960s but become more prominent with the “cognitive revolution” of the 1970s and is the most validated and widely used model of emotional disorders (Westbrook et al. 2007). Although Beck’s model was initially fixed on depression, it went on to be effectively applied to other disorders including anxiety (Beck, Emery & Greenberg, 1985), personality disorders (Beck, Freeman and Associates, 1990) and anger (Beck, 1999). Therefore, it can be concluded that psychological disorders occur as an effect of faulty patterns of thinking and behaviour. Epictetus, a first century Greek Philosopher once said “Men are disturbed not by things, but the views they take of them”. This clearly demonstrates the importance of CBT.
Before arguing whether CBT is able to bring deep and enduring change, one must first clarify what does the term enduring and deep change for a particular disorder means. It has been argued by scientists that psychosocial interventions have been shown to produce enduring change to individual’s problems and significantly decrease distress and anxieties in a way that creates long-lasting change over time. But the most important question is whether psychosocial interventions (i.e. CBT) do produce enduring and deep change and reduce relapse rates as well as bring about changes at a deeper level (e.g. changes in schemas and core beliefs,) or just produce simply symptom-relief. This means that whether the outcome of CBT results in reduced distress and improved well-being and quality of life and happiness after the intervention is terminated and is stable over time. However, in some instances the problem can return, but still can be enduring as long as it affects the person at a smaller rate or intensity compared to previous distresses if the treatment had not been provided (Hollon et al. 2006). Deep changes can be defined as changes that results in a positive and lasting effect subjectively for the person. The following part of this essay will critically examine and explain depression and panic disorder from cognitive-behaviour perspective and argue whether CBT is able to change a person’s core beliefs and assumptions and whether this is stable over time.
Research trials have shown that CBT is an effective approach for many emotional disorders, and that it has more support than some other approaches such as psychodynamic psychotherapy (Roth and Fonagy, 2005). Roth and Fonagy (2005), in their recent update of what works for whom, report evidence showing that CBT is highly effective treatment choice for most of the psychological disorders in adults compared to other forms of treatments. They indicated that there is a clear evidence of efficacy in the following disorders; depression, panic/agoraphobia, generalised anxiety disorder, specific phobias, social phobia/ OCD, PTSD, bulimia, and some personality disorders. There is also growing evidence that CBT is also effective outside of randomised controlled trials in routine clinical practice (e.g. Westbrook & Kirk, 2005; Merrill, Tolbert, & Wade, 2003). In recent times, the Government funded Improved Access to Psychological Therapies (IAPT) movement also advises the use of CBT. Furthermore, the Government has planned in the UK to provide CBT for depression and anxiety in 250 therapy centres (Layard, 2006). However, one must be very critical when examining the link between the Government and their funding for training CBT therapists. The Government does make mistakes and the fact that CBT is being cheap, speedy and simplistic can be very appealing to the Government. Therefore, it is best to argue that CBT does bring change to people’s lives by examining RCTs and meta-analyses which are more regarded within the academic world than Government funding decisions. In addition, more support for the effectiveness of CBT for depression, anxiety disorders comes from UK National Institute for Clinical Excellence (NICE) guidelines. They state the following recommendations;
Depression (NICE, 2OO4a): “For patients with mild depression, healthcare professionals should consider recommending a guided self-help programme based on cognitive behavioural therapy (CBT)… ‘(p.5); ‘When considering individual psychological treatments for moderate severe and treatment-resistant depression, the treatment of choice is CBT…’ (p.27);
Generalised anxiety and panic (NICE, 2004c): ‘the interventions that have evidence for the longest duration of effect, in descending order, are: (first) cognitive behavioural therapy…’ (p.6); (Cited from Westbrook et al, 2007)
However, most research trials base their evidence on randomized controlled trials proving the success of CBT in the treatment for many psychological disorders. Therefore, gold standard evidence for the effectiveness of CBT is the randomized controlled trials. Nevertheless, this claim may possibly lack positive support, for a number of causes (Moloney & Kelly, 2004). One of the biggest downfalls of such clinical trials is that only those studies who achieve positive results tends to get published more often (Boyle, 2002). Therefore, there is a huge bias towards some studies that do not produce positive effects. This can produce significant problems as we only see one side of the outcome and totally not aware of the other side. The second problem is that studies concerning CBT share major methodological problems. Problems include; studies often use privileged research populations i.e. university students and lack of adequate sample sizes to allow generalizations to a wider clinical populations which makes it hard to interpret results and make definitive conclusions (Holmes, 2002) . Also, studies tend to use insufficient control groups for comparison reasons (i.e. waiting list group) and there are no sufficient longer-term follow-up studies of individuals treated with CBT. This can create problems in the long-term as the effects of CBT are less hopeful when the follow-up go beyond 12-months (James, 2007). Moloney & Kelly, (2004) states that “A further and highly significant challenge to the evidence base for the effectiveness of CBT consists in the large body of comparative clinical-outcome literature that has accumulated over the last half century. This has convincingly shown that for a wide range of clinical problems, psychotherapy effectiveness bears little relation to the therapist’s clinical orientation or even to their qualifications and alleged expertise”. As a result, one must be critical when reaching to conclusions in respect to randomized controlled trials.
It has been shown that CBT interventions have been demonstrated to have enduring effects which go beyond the end of treatment. In addition, this intervention is said to decrease risks for relapse occurrence in chronic disorders and risk for recurrence in episodic disorders. Even more remarkable, CBT interventions is said to have the power to prevent early onset in persons who are vulnerable (Hollon, DeRubeis & Seligman, 1992). “Whether CBT is truly curative remains to be seen, but there is more good evidence for CBT having an enduring effect than for any other intervention in the field today” (Hollon, 2003). Department of Health, in 2006 stated that the UK Government wants to provide patients more access to “talking therapies” (i.e. CBT), with the intention of reducing the rates of depression. Some scientists argue that CBT is the treatment choice for depression as it is an evidence-based and cost-effective therapy for depression (Tudor, 2006). Patients who are treated with CBT intervention are less probable to experience a depressive relapse after the intervention have ended compared to patients who are treated with medication (Hollon & Shelton, 2001).The enduring effect of CBT intervention has also been proven to shown in other psychological disorders as well. Studies have been consistently revealing that CBT is more enduring than medications for the treatment of panic disorder (Barlow, Gorman & Shear & Woods, 2000; Clark et al, 1994) as well as social phobia (Liebowitz, Heimberg, Schneier et al. 1999). The enduring effects has also been found in the treatment of bulimia nervosa and it has been shown that CBT emerges to be more effectual than interpersonal psychotherapy (Agras et al. 2000) and more stable than both medication or behaviour therapy (Craighead & Agras, 1991).
Depression is one of the most common of psychiatric disorders and most important causes of illness worldwide. The most widely studied psychosocial treatment for depression is Beck’s cognitive-behaviour therapy (CBT) also known as cognitive therapy (CT) (Beck et al. 1979). The most important strength of CBT to depression is its foundation in empirical research. From a cognitive-behavioural standpoint the crucial trait of depression is a negative cognitive thinking pattern. Essentially, this therapy is a brief, short term (8-16 sessions), directive therapy which is based on problematic thoughts and behaviours that preserve dysfunctional beliefs about self, world and future. Beck’s cognitive model of depression is founded on the hypothesis that a person’s distorted cognitions (thoughts, beliefs, images) and idealistic evaluations of themselves, situations and events can negatively affect their feelings and behaviour. It is thus not events as such (e.g. divorce or job redundancy) that can cause suffering but a person’s understanding of them. This explains how individuals can react in a different way to the same life event, or situation. Additionally the association among affect and cognition is mutual, meaning that both impact on the other leading to a growth of the psychological problem in question (Beck, 1971). As a result, how the individual reacts to their environmental stimuli and negative dysfunctional assumptions that are associated with that stimulus are said to be both the cause of his or her depression and patients are not usually aware of their negative automatic thoughts or do not examine their thoughts in any detail. Therefore, cognitive therapy aims to pay attention to these negative automatic thoughts and how the person interprets events around them and attempts to identify different ways of thinking by challenging individual’s negative thoughts and try to find different ways of altering their thinking patterns, beliefs and cognitions. Unhelpful cycles of thoughts, feelings, emotions and physiology should be broken, and steps taken to reduce the chances of the problem recurring (Bennett-Levy et al. 2004).
Cognitive-behavioural therapy for depression entails the following steps: 1) the sessions begin with explaining the rationale of CBT which is intended to enlighten the individual of how the therapy model works and the progression of therapeutic change. CBT is an intervention where the patient is very active therefore 2) early sessions are dedicated to boost active behavioural performance. By doing so, this helps the therapist to observe behaviours and related thoughts and feelings of the individual and therefore get a better picture of the problems that the person is experiencing. Later on, the sessions include 3) expanded self-monitoring techniques to make obvious the connection between thoughts and how their feelings integrate and consequently produce their behaviours. Patients also at this stage encouraged to appraise their thinking patterns for logical inaccuracies that consist of arbitrary inference, selective abstraction, overgeneralization, magnification and minimalization, personalization, and dichotomous thinking (Beck, 1976). When the therapy is half way through, 4) the concept of schema is introduced and the therapy concentrates on negative and positive thoughts and with the help of the patient, the negative thoughts are challenged that bring rise to depression. This part of the therapy is very important and therefore is crucial for remission and producing deep and enduring change later on in patient’s life. In the final stage of the therapy, 5) relapse prevention strategies and how to prevent future reappearance of depression is discussed (psychosocial treatments for major depressive disorder, a guide to treatments that work).
Fava et al. (2004) conducted a 6 year follow-up study comparing 40 patients with recurrent major depression who had been treated with antidepressant drugs. The patients were randomly allocated to either CBT or clinical management group. In the mean time, in the both groups, antidepressant medication was terminated. Results were remarkable and the group who received CBT intervention resulted in considerably lower relapse rate (40%) compared to clinical management (90%) at a 6 year follow-up period. The results suggest that CBT may well improve the enduring effect of recurrent depression. However, this study was criticized due to small sample size. In addition, the therapy sessions were conducted by an experienced psychiatrist and as a result, the findings might be different with various, less skilled therapists. An important point to consider is that CBT is a short term intervention that focuses on here and now situations. When examining whether CBT results in deep changes i.e. changes in core beliefs and schemas, it is difficult to interpret these beliefs as many events that form our core assumptions take place in childhood and adolescence. As CBT concentrates on here and now situations, probably one of the biggest limitations of this intervention is perhaps for those who does not recover from CBT and face with relapse is that their core beliefs and schemas are that strongly held, it is not possible with CBT to dig out their core beliefs that are formed in childhood and early adulthood in detail with such a brief therapy. Therefore, in the case of Fava al el. (2004) study, enduring effects are clearly present and stable however, for those 40% of patients who still faces with relapse, CBT has not be able to produce deep changes. From this it can be concluded that CBT can ease a current episode of depression, but is not able to stop future depressions totally because CBT did not alter the core schemas that Beck believed to be the primary cause of depression.
One of the limitations of CBT is that “there is continuing uncertainty about the effectiveness of different psychotherapies (that is, their clinical relevance) as opposed to their efficacy (ability to produce change under “laboratory” conditions). Cognitive behaviour therapy works well in university based clinical trials with subjects recruited from advertisements, but the evidence about how effective it can be in the real world of clinical practice is less secure. In the London depression trial, for example, couple therapy performed better than antidepressants for treating severe depression in patients living with partners, but cognitive behaviour therapy came nowhere, having been discontinued early in the trial because of poor compliance from a particularly problematic (but clinically typical) group of patients” (Holmes, 2001). Furthermore, Clinical Psychologist Oliver James (2009) argues that CBT does not produce deep and enduring change for people who are suffering from depression. He stated that, two years ago Department of Health invested A?173 million in CBT claiming that therapy enduringly heals half of people who are suffering from depression. Moreover, he argued that there is no single study that proves this claim. Contrary to this claim, he puts forward the study which was undertook by U.S. psychologist Professor Drew Weston and his colleagues (2004) and they found that 2 years after CBT, two-thirds of patient’s relapsed or wanted further help. “If given no treatment, most people with depression drift in and out of it. After 18 months, those given CBT have no better mental health than ones who have been untreated,” added Dr James. More recently, the Institute of Psychiatry, Kings College London (2005) undertook a Maudsley debate conference with the title being: “CBT is the New Coca-Cola: This house believes that cognitive behavioural therapy is superficially appealing but over-marketed and has few beneficial ingredients”. Pidd (2006), cited by the Guardian newspaper, stated that “Even CBT’s greatest proponents admit readily that the treatment has its limits and caution against billing it as healthcare’s great white hope.”There is the danger that CBT is being oversold as a cure-all. But no treatment is a cure-all,” says Philippa Garety, professor of clinical psychology at the Institute of Psychiatry and head of psychology at the South London and Maudsley Trust, who has conducted a lot of research into CBT and schizophrenia. “What is true, however, is that CBT is useful for quite a number of problems because so many things are related to how we experience and make meaning of the world.”
Let us now examine some more studies in detail and critically evaluate some clinical studies which used CBT as an intervention for treating individuals who are sufferers from depression. A study conducted by DeRubeis et al. (2005) illustrates one of the strongest results concerning enduring effects in the literature. The study compared the effectiveness in moderate to severe depression of antidepressant medications with cognitive therapy in a placebo-controlled trial in 240 patients. The researchers stated the following findings. Patients with moderate to severe depression responded well to 8 weeks of either CT or ADM compared to pill-placebo and the response rate for both interventions were almost indistinguishable by 16 weeks. At that point in time, patients who reacted to ADM intervention were divided randomly into continuance of ADM or withdrawn onto pill-placebo over the following year. In the mean time, patients who responded to CT, the intervention was terminated and they were only allowed one booster session per month for the following follow-up year. The results revealed that patients who carried on taking ADM relapsed less compared to those patients who were withdrawn onto pill-placebo. Moreover, patients with a history of CT intervention did well as patients continued on ADM (Hollon et al. 2005). More importantly, patients with a prior exposure to CT intervention, the risk for relapse reduced by about 70% compared with medication withdrawal. In sharp contrast, patients who continued taking their ADM reduced risk by half compared with medication withdrawal. The findings of this study therefore suggests that “prior CT has an enduring effect that is at least as large in magnitude as keeping patients on medications, a purely palliative intervention that is the current standard of treatment for recurrent depression” (Am, Psychiatric. Assoc. 2000), cited by Hollon et al (2006)
These findings were also confirmed by Blackburn et al. (1986), Kovacs et al.(1981) and Simons et al. (1986) study and the common results that all have reported was that patients who were treated with prior CT were only about half as likely to relapse and the results were the same for patients who were treated with medications alone following the treatment termination. Both treatment interventions were not superior to each other and both were effective in reducing relapse rates (Evans et al. 1992). Additionally, some researchers proposed the suggestion that CBT might have enduring effects if it is been supplied after medications have been used to prevent distress. For instance, Paykel et al.(1999), cited in Hollon et al.(2006) demonstrated that “adding CT to medication treatment for partial responders not only helped resolve residual symptoms of depression but also reduced risk for subsequent relapse after the end of the psychosocial treatment”. Moreover, an extended version of CBT called “mindfulness-based cognitive therapy” has also been proven to shown reduce relapse rates and reappearance of depressive symptoms after the treatment has been finished in patients who are initially treated with medications Teasdale et al. (2000).
In contrast to these findings, studies conducted by Perlis et al. (2002) and Shea et al. (1992) have failed to replicate earlier findings that prior CT produces enduring effects. For instance, Perlis et al. (2002) in their study reported that the grouping of cognitive therapy and fluoxetine 40mg did not produce significant symptom relief and failed to reduce relapse rates more than fluoxetine 40mg alone for the period of 28 weeks of follow-up. Moreover, the National Institute of Mental Health (NIMH) study of depression found only insignificant evidence for the efficiency of interpersonal psychotherapy and nothing for cognitive therapy (Elkin et al.1989). Therefore, it can be argued that enduring effects for CBT has produced mix results in the literature however, with few exceptions, studies generally have established that CBT do produce enduring effects which go beyond after the treatment has terminated (Hollon et al.2006), although larger trials are necessary. However, whether CBT is able to bring deep change to people’s lives and able to change people’s core beliefs and schemas which are generally formed during childhood and late adolescence remains less clear and not many studies are directed towards this phenomenon. But it can be argued that for patients who frequently experience relapse of their depressive symptoms have not yet fully experienced schema change and this is why they cannot prevent future relapse.
However, one might argue that changes in dysfunctional beliefs and schemas can be examined with the help of neuroscience during CBT for depression. This might give some evidence supporting the claim that CBT is able to produce deep change for people who suffer from depression. For instance, Meyer et al. (2004) found that people who were depressed showed high rates of dysfunctional beliefs which were associated with reduced serotonin transporter function. Similarly, a different PET imaging study revealed that “recovery through CBT was associated with changes in functioning in the limbic and cortical areas of the brain, with unique changes in the frontal cortex, cingulate, and hippocampus associated selectively with CBT, compared with a paroxetine-treated group” Goldapple et al. (2004), cited by Kuyken et al.(2007). An additional support and a more recent finding come from a small scale study conducted by Siegle et al (2006). They found that patterns of reactivity to distressing stimuli was evident in the cingulate and amygdale during the baseline and this was later associated with symptom alterations in a 16 session intervention with CBT. However, work on the neuroscience of CBT is still in its infancy but has broadened our knowledge of the cognitive theory of depression and the changes that occur in the brain before and after CBT is administered and this demonstrates that there might be deep changes predominantly of mind-brain adjustments related with recovery from depression (Kuyken et al.2007)
The following part of this essay will concentrate on panic disorder and will explain how cognitive-behaviour theories explain this disorder and discuss whether CBT is able to bring deep and enduring change for this patient group. The reason why this essay is concentrating on this specific disorder is because recent studies have put forward the suggestion that CBT might be predominantly effective and have enduring effects following the treatment with CBT. Hollon & Beck, (2004) argue that enduring effects are evident with respect to anxiety disorders, specifically panic disorder; however it is not very well acknowledged like with depression. Let us know start discussing panic disorder. A well-known cognitive model of panic disorder is that of Clark (1986) and he argues the maintenance factors of panic attacks to be: “1) catastrophic misinterpretation of bodily sensations as indicative of impending mental or physical harm, 2) safety behaviours employed in order to reduce the likelihood of catastrophe and 3) selective attention as sufferers become highly sensitised to dangerous sensations or situations, and their attention becomes biased towards them” (cited from Westbrook et al. 2007). Behavioural models, in contrast, explain panic attacks in terms of conditional response to internal or external cues which require to be extinguished through exposure (Barlow & Lehman 1996). Numerous studies have demonstrated the enduring effects CBT for panic disorder (Margraf, Barlow, Clark & Telch, 1993). Clinical trials have reported that 12 to 15 sessions of CBT resulted in absence of panic in approximately 85% of patients 2 years later (e.g. Craske, Brown & Barlow, 1991). This suggests that CBT is able to bring deep and enduring change to individuals as most patients have not relapsed even after 2 years of CBT intervention.
Roth & Fonagy (2005) suggested that psychosocial interventions, particularly CBT, are more likely to endure after the treatment has come to an end compared to those achieved with medications. For instance, Sharp et al. (1996) concluded that patients treated with CBT alone or with medication were less likely to relapse and retain gains at 6-months follow-up compared to patients treated with fluvoxamine alone. Consistent with these findings, Clark et al (1994) found that CT was greater than both imipramine and applied relaxation intervention in patients with panic disorder and both were superior to wait-list control group. In addition, at 6-month follow-up period, only 5% of those patients who were treated with CT relapsed compared to 40% of the patients withdrawn from medications. This study clearly demonstrates the enduring effects of CT intervention once the treatment has been terminated. This trial also showed that CT brought deep changes to people with panic disorder. Specifically, CT helped to reduce catastrophic cognitions which were strongly held by the patient. However, this wasn’t the case with other two interventions and the frequency of such core beliefs at the end of treatment resulted in high relapse rates once the treatment was terminated. More support for the enduring effects for panic disorder with CBT intervention comes from Barlow and colleagues (2000). In their multisite study, panic disorder patients were randomly allocated to three months of weekly acute treatment followed by six months of monthly maintenance treatment with either CBT or imipramine, each alone and in combination, or pill-placebo, again alone or in combination with CBT. The researchers concluded that, patients showed better response to imipramine, however, CBT was more enduring. The relapse rates for those treated with CBT alone was 8% compared to 25% treated with imipramine. Interestingly, those patients who were added medication to their CBT appeared to weaken the enduring effects of CBT. The relapse rate for this group was 36%. The above studies therefore indicate that CBT clearly produces enduring effects in the treatment of panic disorder.
An important question is whether CBT is able to produce deep change (i.e. changes in core beliefs and schemas) for people? Brown & Barlow (1995) cited by Rees et al. (1999) argue that “50% of people with panic disorder who commence CBT achieve high-end state functioning, defined as absence of panics, relative freedom from negative affect, adequate social and occupational functioning, and subsequent freedom from use of other therapeutic assistance such as psychotropic medication and mental health treatment”. This suggests that CBT is able to bring deep change for some patients but this is limited in numbers. In another study conducted by Michelson & Marchione (1991), argued that CBT is the treatment of choice for panic disorder with agoraphobia (PDA). Their findings revealed that 150 research studies have indicated that 87% of patients with PDA showed significant improvement with CBT intervention with only a 10% relapse rate in comparison with 60% improvement rate with 35% relapse rate for those patients who are treated with antidepressants. Additionally, those who were treated with anti-anxiety medications showed 90% relapse rate with an improvement rate of 60%. In addition, those patients with only panic disorder had an improvement rate of 90% with a 5% relapse rate. These results evidently demonstrate the enduring and deep effects of CBT for panic disorder (http://www.excelatlife.com/effectiveness_cbt.htm).Numerous neuroanatomical hypothesis of panic disorder has been put f