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.     

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.     

Predicting treatment preferences for agoraphobia

Fifty-one university students completed two questionnaires: (1) The Millon Behavioral Health Inventory (MBHI) and (2) a questionnaire evaluating Ss' ratings of acceptability and effectiveness of five treatments for agoraphobia (Norton, Allen and Hilton, 1983a). The results showed that the Ss rated the three psychological treatments as more effective and acceptable than the two drug treatments. A discriminant function analysis, using the coping style measures of the MBHI and the Ss' ratings of acceptability and effectiveness of tranquilizers as predictor variables, correctly classified 78% of the Ss as to which psychological treatment they rated as more acceptable and effective for agoraphobia.     

The experimental analysis of agoraphobia

A concerted move towards the use of experimental analyses is proposed. It is suggested that our understanding of agoraphobia can best be advanced by taking this step. The argument in support of such a move is illustrated and developed in respect of the role of safety signals in maintaining and influencing agoraphobic behaviour. A detailed analysis is given of the factors postulated to determine the strength of safety signals, and the complex inter-relations between fear and safety are examined.     

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.     

Temporal stability of self-report measures in agoraphobia research

Forty subjects, meeting DSM-III criteria for agoraphobia completed, on two occasions, a comprehensive assessment battery. Measures encompassed anxiety, phobia, depression and general symptomatology dimensions of functioning, and consisted of instruments widely employed as outcome measures in agoraphobia research. The test-retest time periods were divided into 4-, 10- and 16-week intervals to ascertain their temporal stability, an often ignored parameter of reliability. The results indicate that agoraphobia, anxiety, depression and general symptomatology measures were temporally stable. However, test-retest reliabilities of the scales' subscores were generally inferior to those of the total score. The findings are discussed, with recommendations for more programmatic psychometric research in the assessment of anxiety disorders.     

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.     

Patterns of desynchrony in agoraphobia: A preliminary report

Changes in heart rate in three moderate to severe agoraphobic women were monitored by a Holter Recorder, used for obtaining portable EKGs. These data were collected before, half-way through, and at the end of a 12 session, group therapy program consisting of exposure and cognitive restructuring while subjects walked, or in one case, were driven along a standard 1.2 km course leading away from the treatment setting. Self-reports of anxiety were collected simultaneously. Despite substantial behavioral improvement in all cases, markedly different patterns of synchrony or desynchrony were noted between heart rate and self-reports of anxiety and substantial increases in heart rate were noted in one subject.     

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.     

Couples treatment of agoraphobia: changes in marital satisfaction

Six agoraphobic women and their husbands participated in a group therapy program consisting of exposure and cognitive restructuring. The husbands acted as co-therapists. Ratings of marital satisfaction as well as severity of phobia were filled out independently by both clients and their husbands throughout the course of therapy and at follow-up. Two patterns of relationships among marital satisfaction and severity of phobia emerged. For four couples a parallel relationship was observed in that as phobia improved marital satisfaction increased. For two couples the inverse relationship was noted where improvements in phobia were correlated with decreases in marital satisfaction. The importance of the interpersonal context of agoraphobia and implications for treatment are suggested.