Emptiness in agoraphobia patients

In light of new research findings about the efficacy of psychodynamic treatment for panic disorder and agoraphobia, it seems a prudent time to carefully address psychoanalytic thinking about the treatment of agoraphobia. The literature has highlighted oedipal contributions to its genesis and clinical unraveling in psychoanalysis. While those contributions are indeed central to the disorder, structural deficits in the self-representation often become a central focus of treatment once symptomatic remission has been achieved in psychoanalytic treatment. This aspect of the clinical presentation of agoraphobia has not yet been specifically addressed in the psychiatric literature. Some aspects of the phenomenon have been described by psychoanalysts. It is more difficult to treat this "emptiness" than the overt symptoms of agoraphobia, as described in DSM-IV. Nonetheless, this phenomenon may be one of the contributors to the chronicity of the disorder. Two clinical cases illustrate these points.     

The efficacy of couples-based interventions for panic disorder with agoraphobia

From this systematic literature review it was concluded that panic disorder with agoraphobia (PDA) can sometimes occur in conjunction with marital problems. Couples-based treatments for PDA – partner-assisted exposure and marital therapy – can be an effective treatment for the condition. It is as effective as individually based cognitive behaviour therapy. Involving partners of people with PDA in therapy may be appropriate in some cases, particularly those in which there are marital difficulties. Couple-focused interventions may enhance the maintenance of treatment gains by facilitating interactions that positively reinforce and perpetuate attempts by people with PDA to enter feared situations and cope with these effectively. People with PDA who have good marital relationships show a better response to both individual and couples-based treatment programmes. In some instances effective couples-based treatment leads to improvement in marital adjustment as well as in PDA symptomatology.     

The treatment of hysterical spasm and agoraphobia by behaviour therapy

A case of muscular spasm and agoraphobia is described and the techniques of treatment by behaviour therapy outlined. A particular plea is made for the accommodation within the conceptual framework of learning theory, of practices more akin to traditional psychotherapy and it is shown how this may support more specific symptom orientated approaches, such as reciprocal inhibition and systematic desensitization.     

The relationship of adult attachment dimensions to depression and agoraphobia

We examined the unique relations between the five dimensions of the Attachment Style Questionnaire (ASQ; Feeney, Noller, & Hanrahan, 1994 ) and depression and agoraphobic behavior (i.e., avoidance of situations where high anxiety is experienced). In addition, we examined mediation models in an attempt to clarify the link between adult attachment and these two dimensions of psychopathology. In testing these models, we administered the ASQ, General Self‐Efficacy Scale, Agoraphobic Catastrophic Cognitions Questionnaire, Beck Depression Inventory, and the Mobility Inventory for Agoraphobia (a measure of the degree to which situations are avoided that are typically anxiety provoking for people with agoraphobia) to 122 participants (44 with agoraphobia, 25 with a current major depressive disorder, and 53 with no current psychopathology). The results showed that the insecure attachment dimensions of need for approval, preoccupation with relationships, and relationships as secondary were uniquely associated with depression and that general self‐efficacy partly mediated the relationship between need for approval and depression. In contrast, only preoccupation with relationships was uniquely associated with agoraphobic behavior, and catastrophic cognitions about bodily sensations partly mediated this association.     

Behavioral assessment of avoidance in agoraphobia

Behavioral avoidance testing is a substantial addition to self-report questionnaires in the assessment of agoraphobia. However, the tests currently in use have drawbacks and limitations. A multitask behavioral avoidance test (M-BAT) is presented, designed to meet some of these problems. The test was administered to a group of 58 patients and proved to be reliable in terms of internal consistency. Concordance with self-report measures of agoraphobia indicated a high concurrent validity. In comparison with self-report questionnaires, the tests produced a slightly more conservative picture of gains achieved in treatment. Finally, the data revealed that the multitask test was more concordant with other measures of agoraphobia than a single-task test would have been.     

An experimental investigation of the role of safety-seeking behaviours in the maintenance of panic disorder with agoraphobia.

This study evaluates the hypothesis that safety-seeking behaviours play an important role in maintaining anxiety because they prevent patients from benefiting from disconfirmatory experience. Patients suffering from panic disorder with agoraphobia carried out a behaviour test, closely followed by an experimental session, which included a brief (15 min) period of exposure during which participants either stopped or maintained within-situation safety-seeking behaviours. When the behaviour test was repeated within two days, patients who had stopped their safety-seeking behaviours during the experimental session showed a significantly greater decrease in catastrophic beliefs and anxiety than those who had maintained safety-seeking behaviour. This difference was also reflected in questionnaires measuring clinical anxiety. These results are consistent with the cognitive hypothesis.     

The body of the other: intercorporeality and the phenomenology of agoraphobia

How is our experience of the world affected by our experience of others? Such is the question I will be exploring in this paper. I will do so via the agoraphobic condition. In agoraphobia, we are rewarded with an enriched glimpse into the intersubjective formation of the world, and in particular to our embodied experience of that social space. I will be making two key claims. First, intersubjectivity is essentially an issue of intercorporeality, a point I shall explore with recourse to Merleau-Ponty’s account of the prepersonal body. The implication of this claim is that evading or withdrawing from the other remains structurally impossible so long as we remain bodily subjects. Second, the necessary relation with others defines our thematic and affective experience of the world. Far from a formal connection with others, the corporeal basis of intersubjectivity means that our lived experience of the world is mediated via our bodily relations with others. In this way, intercorporeality reveals the body as being dynamically receptive to social interactions with others. Each of these claims is demonstrated via a phenomenological analysis of the agoraphobe’s interaction with others. From this analysis, I conclude that our experience of the world is affected by our experience of others precisely because we are in a bodily relation with others. Such a relation is not causally linked, as though first there were a body, then a world, and then a subject that provided a thematic and affective context to that experience. Instead, body, other, and world are each intertwined in a single unity and cannot be considered apart.     

The renaissance of the experimental analysis of human behavior

Ten years ago, a number of authors commented on the dismal state of the basic research area known as the experimental analysis of human behavior (EAHB). At that time, data on the number of research articles using human subjects published in the Journal of the Experimental Analysis of Behavior (JEAB) indicated little progress since the early 1960s. However, updated publication data through 1991 reveal that EAHB research has accelerated in the last decade, reaching a peak of nearly half of all research articles published in JEAB, with an increasing trend evident. The increase in this percentage is not due solely to a long-term declining trend in the total number of experimental articles in JEAB using either human or nonhuman subjects, a trend that appears to have slowed or stabilized in the last 6 years. These data indicate that the EAHB has made dramatic progress in a decade and is healthy and growing.     

Predicting the outcome of behaviour therapy for agoraphobia

Multiple linear regression analyses were conducted on questionnaire data obtained from 33 agoraphobic women and their husbands before and after intensive exposure in vivo for the agoraphobia. The dependent variable in the regression equation was treatment outcome as determined by changes in composite ratings of patients' two main phobias. On this criterion, patients improved by 64% immediately after treatment and by 69% 1 year later. The main predictors of treatment outcome were patients' pre-treatment levels of agoraphobic disability and of extrapunitiveness. The main pre-treatment predictors of change during follow-up were patients' levels of social fear, and of fears which suggested dependency problems. When post-treatment questionnaire responses were used to predict patients' phobia change during follow-up, husbands' scores contributed 50% to the variance. This finding, together with clinical observations, suggested that if husbands were unable to fully acknowledge the emotional impact upon themselves of rapid and substantial improvements in their wives, then they were unlikely to facilitate further phobia improvement in their wives during the first 6 months of follow-up. It was concluded that involvement of the husbands in their wives' therapy would increase the likelihood of continuing phobia improvement after treatment.     

The hyperventilation syndrome in panic disorder, agoraphobia and generalized anxiety disorder

The symptom complex of panic disorder and generalized anxiety disorder suggests an etiological role for hyperventilation. The present study investigates the overlap between DSM-III-R panic disorder, panic disorder with agoraphobia and generalized anxiety disorder with hyperventilation syndrome (HVS). The anxiety disorder diagnoses were based on a structured interview, and HVS syndrome (HVS). The anxiety disorder diagnoses were based on a structured interview, and HVS determined by the so-called hyperventilation provocation test (a brief period of voluntary hyperventilation with recognition of symptoms). The overlap rates with HVS were: 48% for panic disorder, 83% for panic disorder with agoraphobia and 82% for generalized anxiety disorder. However, a pilot study on transcutaneous monitoring of carbon dioxide tension leads us to question the validity of the voluntary hyperventilation method that we used to determine HVS-status. It is unclear whether hyperventilation plays an important role in panic and general anxiety, as our overlap findings suggest. For patients who recognize the symptoms induced by voluntary hyperventilation, the hyperventilation provocation procedure provides a therapeutic means of exposure to feared bodily sensations.     

Assessment and significance of behavioral avoidance in agoraphobia

Two behavioral avoidance tests were administered, before and after in vivo exposure treatment, to 39 female patients with chronic and severe agoraphobia. The first test consisted of walking alone along a standard course covering several city blocks, and the second of entering and remaining in five different, individually selected phobic situations. Although significant improvement on the tests was observed in the sample as a whole, neither test had a high nosographic sensitivity (nearly two-thirds of the patients completed them initially) and subgroups of avoiders and nonavoiders, classified simultaneously on both tests, did not differ significantly in their clinical characteristics or response to treatment. The difficulty for the behavioral test to account for the majority of variance in phobic avoidance, and the severity of agoraphobia in general, is discussed with particular reference to the differences between the going to and the being in types of phobic situations and the essentially anticipatory nature of anxiety and fear.This research was supported by Grants MH40141 and MH34177 from the National Institute of Mental Health.     

Employing paradoxical intention in the treatment of agoraphobia

The present study assessed the efficacy of paradoxical intention in ameliorating the travel restriction of agoraphobics. A combined score indicating proximity to two difficult target locations represented the dependent variable. A multiple baseline across subjects was used with each of two groups of five clients. This was accomplished by sequentially staggering introduction of treatment. At the conclusion of baseline phase. Group A received 6 weeks of gradual exposure followed by paradoxical intention to criterion. Group B received paradoxical intention to criterion immediately after baseline. Results indicated that paradoxical intention produced greater movement toward targets for clients in Group B when compared both with their baseline and with the performance of Group A following an equal period of gradual exposure.