Does prior traumatization affect the treatment outcome of CBT for panic disorder? The potential role of the MAOA gene and depression symptoms

  • Sebastian TrautmannEmail author
  • Jan Richter
  • Markus Muehlhan
  • Michael Höfler
  • Hans-Ulrich Wittchen
  • Katharina Domschke
  • Andreas Ströhle
  • Alfons O. Hamm
  • Heike Weber
  • Tilo Kircher
  • Volker Arolt
  • Alexander L. Gerlach
  • Georg W. Alpers
  • Thomas Fydrich
  • Thomas Lang
  • Andreas Reif
Original Paper


Although cognitive behavioral therapy (CBT) is highly effective in the treatment of anxiety disorders, many patients still do not benefit. This study investigates whether a history of traumatic event experience is negatively associated with outcomes of CBT for panic disorder. The moderating role of the monoamine oxidase A (MAOA) gene and depression symptoms as well as the association between trauma history and fear reactivity as a potential mechanism are further analyzed. We conducted a post-hoc analysis of 172 male and 60 female patients with panic disorder treated with CBT in a multi-center study. Treatment outcome was assessed at post-treatment using self-report and clinician rating scales. Fear reactivity before treatment was assessed via heart rate and self-reported anxiety during a behavioral avoidance test. Among females, we did not find any differences in treatment response between traumatized and non-traumatized individuals or any two-way interaction trauma history × MAOA genotype. There was a significant three-way interaction trauma history × MAOA genotype × depression symptoms on all treatment outcomes indicating that in traumatized female patients carrying the low-activity allele, treatment effect sizes decreased with increasing depression symptoms at baseline. No such effects were observed for males. In conclusion, we found no evidence for a differential treatment response in traumatized and non-traumatized individuals. There is preliminary evidence for poorer treatment outcomes in a subgroup of female traumatized individuals carrying the low-active variant of the MAOA gene. These patients also report more symptoms of depression symptomatology and exhibit a dampened fear response before treatment which warrants further investigation.


Panic disorder CBT Trauma MAOA Fear reactivity Depression 



This work is part of the German multi-center trial ‘Mechanisms of Action in CBT’ (MAC). The MAC study was funded by the German Federal Ministry of Education and Research (BMBF; project no. 01GV0615) as part of the BMBF Psychotherapy Research Funding Initiative. The study was further supported by the DFG (Grant RE1632/5-1 to AR, DE357/4-1 to JD, RTG 1256 to JD and AR, and SFB TRR 58 Z02 to JD and AR). The principal investigators (PIs) of the centers with respective areas of responsibility in the MAC study were: V Arolt (Münster: Overall MAC Program Coordination), HU Wittchen (Dresden: PI for the Randomized Clinical Trial and Manual Development), A. Hamm (Greifswald: PI for Psychophysiology), A. L. Gerlach (Münster: PI for Psychophysiology and Panic subtypes), A. Ströhle (Berlin: PI for Experimental Pharmacology), T. Kircher (Marburg: PI for functional neuroimaging) and J. Deckert (Würzburg: PI for Genetics). Additional site directors in the RTC component of the program were GW Alpers (Würzburg), T. Fydrich and L. Fehm (Berlin-Adlershof) and T. Lang (Bremen). T. Töpner, N. Steigerwald, C. Gagel and J. Auer are credited for excellent technical assistance.

Compliance with ethical standards

Ethical standards

All participants provided informed consent. The study protocol was approved by the Ethics Committee of the Medical Faculty of the Technische Universität Dresden (EK164082006).

Conflict of interest

HUW has served as a general consultant (non-product related) for Lundbeck.

Supplementary material

406_2017_823_MOESM1_ESM.docx (20 kb)
Supplementary material 1 (DOCX 20 kb)


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Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  • Sebastian Trautmann
    • 1
    Email author
  • Jan Richter
    • 2
  • Markus Muehlhan
    • 1
    • 3
  • Michael Höfler
    • 1
  • Hans-Ulrich Wittchen
    • 1
    • 15
  • Katharina Domschke
    • 4
    • 5
  • Andreas Ströhle
    • 6
  • Alfons O. Hamm
    • 2
  • Heike Weber
    • 4
    • 7
  • Tilo Kircher
    • 8
  • Volker Arolt
    • 9
  • Alexander L. Gerlach
    • 10
  • Georg W. Alpers
    • 11
  • Thomas Fydrich
    • 12
  • Thomas Lang
    • 13
    • 14
  • Andreas Reif
    • 7
  1. 1.Institute of Clinical Psychology and PsychotherapyTechnische Universität DresdenDresdenGermany
  2. 2.Department of Biological and Clinical PsychologyUniversity of GreifswaldGreifswaldGermany
  3. 3.Department of Psychology, Faculty of Human ScienceMedical School HamburgHamburgGermany
  4. 4.Department of Psychiatry, Psychosomatics, and PsychotherapyUniversity of WürzburgWürzburgGermany
  5. 5.Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
  6. 6.Department of Psychiatry and Psychotherapy, Campus Charité MitteCharité-Universitätsmedizin BerlinBerlinGermany
  7. 7.Department of Psychiatry, Psychosomatic Medicine and PsychotherapyGoethe-University FrankfurtFrankfurtGermany
  8. 8.Department of Psychiatry and PsychotherapyPhilipps-University MarburgMarburgGermany
  9. 9.Department of Psychiatry and PsychotherapyUniversity of MuensterMuensterGermany
  10. 10.Department of Clinical Psychology and PsychotherapyUniversity of CologneCologneGermany
  11. 11.Psychology, School of Social SciencesUniversity of MannheimMannheimGermany
  12. 12.Institute of PsychologyHumboldt-UniversityBerlinGermany
  13. 13.Christoph-Dornier-Foundation for Clinical PsychologyBremenGermany
  14. 14.Department of Clinical Psychology and PsychotherapyUniversity of HamburgHamburgGermany
  15. 15.Clinical Psychology and Psychotherapy RG, Department of Psychiatry and PsychotherapyLudwig Maximilans Universität MunichMunichGermany

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