Anticipatory anxiety and avoidance in panic disorder with agoraphobia

The present study utilized the responses of 34 patients with panic disorder with agoraphobia to investigate the occurrence and anticipation of panic attacks in relation to the avoidance of specific situations from the Fear Questionnaire [Marks & Mathews (1979) Behaviour Research and Therapy, 17, 263-267]. Results indicated that self-reports of avoidance of specific situations were often significantly correlated with the anticipation of panic but rarely with the occurrence of panic. The occurrence and anticipation of panic were also frequently associated with social phobic situations in addition to agoraphobic situations.     

Role of cognitive appraisal in panic-related avoidance

The present study examined several dimensions of panic cognitions to test whether panic appraisals predict phobicity among panic sufferers. Thirty-five patients meeting DSM-III-R criteria for panic disorder with minimal or no phobic avoidance were compared to 40 patients meeting DSM-III-R criteria for panic disorder with agoraphobia (severe). The two groups looked strikingly similar on measures of panic symptoms, panic frequency and panic severity. As expected, patients diagnosed as having panic disorder with agoraphobia reported significantly more depression and phobic avoidance than patients with PD. Striking differences emerged on each of the following panic appraisal dimensions: (a) anticipated panic, (b) perceived consequences of panic, and (c) perceived self-efficacy in coping with panic. In each case, patients with panic disorder and agoraphobia reported significantly more dysfunctional panic appraisals than patients with panic disorder and no avoidance. Of those panic appraisal dimensions studied, anticipated panic emerged as the most potent correlate of agoraphobic avoidance. These findings support the hypothesis that cognitive appraisal factors may play an important role in the genesis or maintenance of phobic avoidance among panic patients.     

Brief treatment with alprazolam and behavioral guidance in panic disorder

Abstract

Thirty-two patients with panic disorder, with or without agoraphobic limitations, were treated with alprazolam (mean dose 3.5 mg/d) plus brief behavioral guidance in an open study during eight weeks. The sample had a notorious severity in the frequency of panics and phobic avoidance but was only mildly depressed. Before starting treatment the presence of demoralized mood and extensive avoidance were significant indicators of clinical severity, whereas the presence of dizziness as a relevant somatic complaint was not related to higher severity. After eight weeks of treatment a clinical improvement equal to or exceeding 80% of change was obtained in all cases (29) who completed treatment. Ninety-two percent of the patients were panic free at the end of treatment. There were significant reductions in all the scales with comparable declines in the subgroups formed according to the presence or absence of agoraphobic avoidance and demoralization. The data suggested that moderate doses of alprazolam could be a quick and effective treatment for panic-agoraphobic patients in the short term. The behavioral guidance probably helped in reducing agoraphobic avoidance and in obtaining global good effectiveness although this awaits controlled tests. Finally, the similarity in the response to treatment regardless of the presence of extensive avoidance or demoralized mood argues in favor of not considering the different variants of panic-agoraphobic syndrome differently, at least in samples with similar severity to the present one.     

Three years follow-up of panic disorder patients: A naturalistic study

Forty Danish panic disorder patients participating in a placebo controlled study of alprazolam and imipramine (The Cross National Collaborative Panic Study, Phase II) were followed up by a telephone interview three years later, with essentially the same battery of evaluation procedures applied at baseline, end of study, and follow-up. The main finding was that panic disorder is a chronic disorder, but fluctuating in form and severity in the course of time. Twenty-five percent of the patients no longer fulfilled the DSM-III criteria for panic disorder, but had substantial disability due to a variety of symptoms, including panic attacks at infrequent rate, generalized anxiety symptoms, affective symptoms, and phobic avoidance behavior. Nearly three fourths of the patients were under treatment at follow-up. Benzodiazepines were the drugs most often prescribed, usually in combination with supportive psychotherapy. It was concluded that the different types of treatment offered were insufficient. Variables predicting panic disorder or substantial disability at 3-years follow-up were few.     

Breathing retraining, exposure and a combination of both, in the treatment of panic disorder with agoraphobia

The present study investigates the differential effectiveness of three treatment packages for agoraphobia. Patients suffering from panic disorder with agoraphobia (DSM-III-R) received one of three treatments: Breathing Retraining with Cognitive Restructuring (BRCR), graded self-exposure in vivo (EXP), or a combination of BRCR and EXP. Treatments consisted of 8 sessions. Assessments consisted of self-report measures for panic, phobic anxiety and avoidance, depression, general anxiety, somatic complaints and fear of bodily sensations, and of two respiratory measures (respiratory rate and alveolar pCO₂).

The treatments resulted in a reduction in symptomatology on all self-report measures, except panic frequency, and in a decrease in respiratory rate. There was no evidence for a differential efficacy for any of the treatments on any of the variables. Contrary to expectation, and at odds with findings from earlier studies, BRCR had no significant effect on panic frequency. A detailed comparison of sample characteristics of patients in our study and previous studies, did not yield insight into possible causes for the failure to replicate earlier results. The limited effectiveness of breathing retraining in reducing panic, as observed in the present study, leads us to conclude that the role of hyperventilation in panic is less important than previously thought.     

Latent growth curve analysis of fear during a speech task before and after treatment for social phobia

Models of social phobia highlight the importance of anticipatory anxiety in the experience of fear during a social situation. Anticipatory anxiety has been shown to be highly correlated with performance anxiety for a variety of social situations. A few studies show that average ratings of anxiety during the anticipation and performance phases of a social situation decline following treatment. Evidence also suggests that the point of confrontation with the feared stimulus is the peak level of fear. No study to date has evaluated the pattern of anxious responding across the anticipation, confrontation, and performance phases before and after treatment, which is the focus of the current study. Socially phobic individuals (N = 51) completed a behavioral avoidance task before and after two types of manualized cognitive behavioral therapy, and gave ratings of fear during the anticipation and performance phases.Results from latent growth curve analysis were the same for the two treatments and suggested that before treatment, anxiety sharply increased during the anticipation phase, was highly elevated at the confrontation, and gradually increased during the performance phase. After treatment, anxiety increased during the anticipation phase, although at a much slower rate than at pretreatment, peaked at confrontation, and declined during the performance phase. The findings suggest that anticipatory experiences are critical to the experience of fear for public speaking and should be incorporated into exposures.     

Intolerance of Uncertainty as a Contributor to Fear and Avoidance Symptoms of Panic Attacks

Panic disorder symptoms are persistent for 50–80% of cases even after treatment, resulting in experiences of disability and dissatisfaction in life. Previous research has focused on anxiety sensitivity (AS) and its dimensions as contributing to symptoms of panic disorder; however, recent research has suggested that intolerance of uncertainty (IU)—the tendency for a person to consider the possibility of a negative event occurring as threatening, irrespective of the actual probability of its occurrence—may also play a critical role. The current study was designed to assess the specific relationships between dimensions of IU (i.e. prospective IU and inhibitory IU) and the fear and avoidance symptoms associated with panic disorder. Participants included 122 community members (81% women) with a history of at least one panic attack who participated in a larger study on fear. Participants completed measures of AS, IU, and panic disorder symptoms. Correlation and regression analyses supported a significant and substantial relationship between AS, inhibitory IU, and panic disorder symptoms. Inhibitory IU accounted for relatively more variance in avoidance symptoms related to panic disorder than did the fears of physical sensations dimension of AS. As such, further investigation of the role of IU in panic disorder symptoms appears warranted. Comprehensive results, implications, and directions for future research are discussed.     

Influence of response time frame on mood assessment

Abstract

Dental anxiety and the related avoidance of dental treatment can result in severe impairment of health. We investigated the influence on avoidance behavior of phobic severity, gender, characteristics related to generalized anxiety and depression, such as dysfunctional cognitions and sensitivity of bodily symptoms, as well as personality traits of self-efficacy and locus of control. Forty-eight dental phobics were given an initial assessment and avoidance behavior was determined by the degree of observance of three subsequent dental appointments. Principal component analysis revealed separate factors for trait and phobic anxiety as well as for avoidance and dysfunctional cognitions. Women showed a higher degree of avoidance than men. Regression analysis revealed a high desire for control over dental treatment combined with a low level of perceived control as the only significant predictor variable of avoidance. The results suggest that avoidance behavior in dental phobia could be reduced by extending patients’ control over treatment conditions.     

Sensations, cognitions and the perception of cues associated with expected and unexpected panic attacks

Panic attacks may be perceived by patients as either cued or uncued (spontaneous) and either expected or unexpected. The purpose of the present study was to examine the prevalence and characteristics of these types of panic. Twenty-six panic disorder patients with mild avoidance and 18 with moderate or severe avoidance were instructed to complete a questionnaire during or immediately following each of three consecutive naturally occurring panic attacks they experienced. They were asked to rate the extent to which they expected the panic attack to occur, whether they felt it was associated with an external panic "cue" (e.g. a shopping mall), whether they would expect to panic again in similar circumstances, their mood, present level of life stress, and fear and severity of their body sensations and disturbing cognitions. Results indicated that from a sample of 92 questionnaires, each representing a separate panic, nearly 70% of panic attacks were rated as cued-expected and only one panic was rated as uncued-expected. The other two categories each comprised about 15% of all panic attacks. There were few reported differences in body sensations and cognitions reported as a function of type of panic and no differences with regard to extent of agoraphobic avoidance. Expected panic was associated with a higher expectation of future panic in similar circumstances.     

Case Study: A Quantitative Report of Early Attention,Fear, Disgust,and Avoidance in Specific Phobia for Buttons

Specific phobia is characterized by elevated early attention to the phobic object, negative emotion, and avoidance. Typically, phobic objects are biologically relevant, such as potentially threatening snakes or spiders, or potentially contaminating needles or rodents. It is unclear whether the same early attention, emotion, and avoidance responses can be observed in phobia for uncommon, nonbiologically relevant objects, such as buttons (koumpounophobia). In an experimental case study, we measured early attention (detection rates to briefly presented images before a backward mask), emotion, and avoidance to clothing buttons in a button-phobic participant. We compared these responses to nonphobic objects (zippers), and to well-matched control participants. We observed elevated early attention, fear, and disgust to buttons, which did not generalize to nonphobic emotional stimuli. In addition, we observed elevated avoidance of buttons, which did generalize to normatively fearful and disgusting pictures. If replicated, our results indicate that nonbiologically prepared phobic objects elicit similar elevated early attention, emotion, and avoidance as biologically prepared phobic objects. The finding that avoidance was the only response that generalized to nonphobic objects may have treatment implications—namely, that therapeutic attempts to reduce avoidance might consider including a variety of objects, not just the phobic object.     

The role of modeling in prevention and extinction of phobic behaviour in cynomolgus monkeys (Macaca Fascicularis)

In previous studies surrogate reared cynomolgus monkeys have been shown to become phobic of an unprepared harmless object. In the present study an attempt was made to prevent the development of phobic behaviour in young monkeys and to extinguish avoidance behaviour in phobic monkeys. In the first experiment subjects were exposed to the object in company of their (surrogate) mothers which approached the object. In the second experiment phobic subjects were exposed to the object in company of non-phobic conspecifics which approached the object. The results of the first experiment show that modeling was unsuccessful in preventing the acquisition of phobia in the surrogate-reared monkeys but seemed successful in accelerating approach in the mother-reared subjects. The results of the second experiment show that during the modeling treatment the phobic subjects followed the model and approached the object. However, in post treatment tests all subjects but one relapsed into avoidance. The effect of modeling during treatment is interpreted in terms of coaclive facilitation.     

CBT intensity and outcome for panic disorder in a primary care setting

A hybrid efficacy-effectiveness design in which participants (n = 91/93) were retained in the study regardless of whether or not they received treatment enabled evaluation of CBT intensity in relation to panic disorder in the primary care setting. CBT intensity was operationalized as number of cognitive-behavioral therapy sessions, number of follow-up booster phone calls, and secondarily, as number of cognitive behavioral coping and exposure strategies. Baseline psychosocial and demographic predictors of CBT intensity were analyzed first. Severity of anxiety sensitivity predicted number of cognitive behavioral sessions, but no baseline variables predicted number of follow-up booster phone calls or number of coping and exposure strategies. Multivariate logistic and linear regressions were used to evaluate the degree to which treatment intensity predicted 3-month and 12-month outcomes (anxiety sensitivity, phobic avoidance, depressive symptoms, disability, and medical and mental health functioning) after controlling for potential confounding baseline variables. Number of cognitive behavioral therapy sessions predicted lower anxiety sensitivity at 3 and 12 months, and number of follow-up booster phone calls predicted lower anxiety sensitivity, less phobic avoidance, and less depression at 12 months. These findings indicate that "dose" of psychotherapy was an important predictor of outcome. The significance of follow-up booster phone contact is discussed as an index of continued self-management of panic and anxiety following acute treatment.     

The role of modeling in prevention and extinction of phobic behaviour in cynomolgus monkeys (Macaca fascicularis)

In previous studies surrogate reared cynomolgus monkeys have been shown to become phobic of an unprepared harmless object. In the present study an attempt was made to prevent the development of phobic behaviour in young monkeys and to extinguish avoidance behaviour in phobic monkeys. In the first experiment subjects were exposed to the object in company of their (surrogate) mothers which approached the object. In the second experiment phobic subjects were exposed to the object in company of non-phobic conspecifics which approached the object. The results of the first experiment show that modeling was unsuccessful in preventing the acquisition of phobia in the surrogate-reared monkeys but seemed successful in accelerating approach in the mother-reared subjects. The results of the second experiment show that during the modeling treatment the phobic subjects followed the model and approached the object. However, in post treatment tests all subjects but one relapsed into avoidance. The effect of modeling during treatment is interpreted in terms of coaclive facilitation.     

Placebo effects in spider phobia: an eye-tracking experiment

ABSTRACT

Several eye-tracking studies have revealed that spider phobic patients show a typical hypervigilance-avoidance pattern when confronted with images of spiders. The present experiment investigated if this pattern can be changed via placebo treatment. We conducted an eye-tracking experiment with 37 women with spider phobia. They looked at picture pairs (a spider paired with a neutral picture) for 7?s each in a retest design: once with and once without a placebo pill presented along with the verbal suggestion that it can reduce phobic symptoms. The placebo was labelled as Propranolol, a beta-blocker that has been successfully used to treat spider phobia. In the placebo condition, both the fixation count and the dwell time on the spider pictures increased, especially in the second half of the presentation time. This was associated with a slight decrease in self-reported symptom severity. In summary, we were able to show that a placebo was able to positively influence visual avoidance in spider phobia. This effect might help to overcome apprehension about engaging in exposure therapy, which is present in many phobic patients.     

The importance of assessing treatment integrity: An example in the anxiety disorders

One purpose of this investigation was to examine the importance of assessing treatment integrity in a study evaluating a treatment for specific anxiety disorders. Three subjects, two social phobics and one simple phobic, received self-instruction training (Phase I) followed by exposure and self-instruction training (Phase II) in a multiple baseline across subjects design. All subjects were assessed during a pretreatment baseline and throughout treatment using measures of treatment integrity and measures of change in phobic severity. Improvement took place at different times for different subjects. Measures of treatment integrity, which consisted of monitoring of self-statements as well as practice outside the session, indicated that treatment was not always received as intended and that improvement was correlated with practice. The usefulness of measures of treatment integrity in both clinical and research settings is highlighted.     

Subjective Screening of Stuttering severity, locus of control and avoidance: research edition

This article describes the Subjective Screening of Stuttering (SSS): research edition that is designed to quantify the selected self-reports of people who stutter (PWS) prior to, during, and following their treatment. The three areas screened by the SSS are perceived stuttering severity, the level of internal or external locus of control, and reported word or situation avoidance. Each of the areas has two or three items rated for three audiences on a one to nine rating scale. Other available measures were reviewed and the need for a single instrument that provides quantified screening of each of the areas was recognized. Results of a research project using the SSS with 16 PWS indicated that percent of syllables stuttered correlated with stuttering severity (r=0.75) and with locus of control (r=0.43) but did not correlate with avoidance. These results were interpreted to indicate a need for other types of therapy following the experimental treatment studied. Reliability and validity of the SSS were judged adequate for research and clinical screening. The possible role of screening self-reports of PWS in combination with more extensive self-report instruments and with objective measures of stuttering is discussed. EDUCATIONAL OBJECTIVES: The reader will be able to (1) assess the perception of stuttering severity, avoidance and locus of control of people who stutter (PWS), and (2) determine from the PWS the self-reported outcome of treatment.     

Self-observation versus flooding in the treatment of agoraphobia

The effects on agoraphobia of (1) self-observation with a minimum of therapeutic intervention. (2) flooding, (3) a combination of flooding and self-observation, and (4) no-treatment control were compared. Assessments were made at the beginning of treatment, during and at the end of treatment and at the follow-up three months later. They were carried out by the therapist (in vivo) measurement; phobic anxiety and phobic avoidance scale) by an independent observer (phobic anxiety scale and phobic avoidance scale) and by the client (phobic anxiety scale; phobic avoidance scale: FSS; social anxiety scale; SDS and I-E scale).Self-observation, flooding and flooding/self-observation resulted in significant improvement on several variables, whereas the no-treatment control group did not improve. No difference in effectiveness was found between the self-observation and flooding treatments. In addition, the results suggest that a combined flooding/self-observation treatment is more effective than each of the individual treatments.     

Differences in reported symptom profile between panic disorder and other DSM-III-R anxiety disorders.

Previous research has indicated that reports of panic attacks are associated with a different set of symptoms to reports of generalized anxiety. The present two studies attempted to extend these findings to specific (situational) fears. In Study 1, 55 subjects with panic disorder were compared on their symptom profile during their panic attacks to 65 subjects with other anxiety disorders [simple phobia, social phobia and obsessive-compulsive disorder (OCD)] during response to their feared cue. The results indicated that, compared to subjects with other anxiety disorders, subjects with panic disorder were more likely to report parasthesias, dizziness, faintness, unreality, dyspnea, fear of dying and fear of going crazy/losing control. In Study 2, 90 subjects meeting diagnostic criteria for both panic disorder and another anxiety disorder (simple phobia, social phobia or OCD) were compared on the symptoms experienced during their unexpected panic attacks and their situationally-triggered fears respectively. Combining the symptoms found in Study 1 to differ between the groups into a linear combination, there was a significant interaction found between the type of fear reaction (panic attack vs cued fear response) and symptom group. Taken together, these findings suggest that reports of unexpected panic attacks associated with panic disorder are characterized by a different symptom profile to reports of specific fear reactions that are part of a phobic disorder or OCD.     

A Study of Panic Attacks in University Students of Iran

This study examined the parameters of panic, fear, and avoidance among university students in Iran. Data were collected from 347 students using Farsi translations of the Panic Attack Questionnaire, Beck Depression Inventory, Taylor Manifest Anxiety Scale, State-Trait Anxiety Inventory, and Anxiety Sensitivity Index. Thirty-eight percent of participants reported panic attacks in the past year and 21.4% reported panic attacks in the past 4 weeks when prompted by a broad definition of panic. Men and those with unexpected panic reported greater panic severity whereas women with panic attacks reported greater situational fear and avoidance. Panickers who satisfied DSM-III-R panic disorder (PD) criteria reported greater lifestyle restriction and general psychopathology. The findings provide tentative support for cross-cultural similarity in panic phenomenology and the validity of DSM-III-R PD criteria among university students in Iran. The results are discussed by reference to nonclinical panic research and general themes of Iranian culture.     

Diathesis stress model for panic-related distress: a test in a Russian epidemiological sample

To investigate a cognitive diathesis-stress model, the present study evaluated the main and interactive effects of anxiety sensitivity (AS) and exposure to aversive conditions (past month) in predicting theoretically relevant panic vulnerability variables in an epidemiologically defined sample from Russia (N = 390). Consistent with expectation, findings suggested that the combination of high levels of exposure to aversive conditions and high AS physical concerns predicted panic attacks (past week) and agoraphobic avoidance above and beyond the variance accounted for by negative affect. These findings are discussed in relation to biopsychosocial theories of panic disorder, which emphasize the importance of both a cognitive diathesis and stress component in the pathogenesis of the disorder.