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.     

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.     

Social anxiety and fear of bodily sensations in panic disorder and agoraphobia: A matched comparison

This study tests the hypothesis that social anxiety and fear of bodily sensations are associated with the development of agoraphobic avoidance behavior in panic disorder patients. Twenty patients with panic disorder were compared to 20 patients with panic disorder with agoraphobia, matched by sex and duration of disorder. The two groups did not differ on measures of fear and frequency of assertive social responses. However, the agoraphobics scored higher on measures of interpersonal sensitivity, depression, feelings of inadequacy, and hostility. They also reported higher fear of bodily sensations. Although definitive conclusions need to be postponed until prospective studies have been conducted, there is evidence suggesting that the development of agoraphobia in panic patients is associated with hypersensitivity to bodily sensations and interpersonal situations.This research was supported by Grant 560-268-009 of the Dutch Organization for Scientific Research.     

Personality in panic disorder with agoraphobia: a Rorschach study.

In this study, we tested several hypotheses derived from self psychology (Diamond, 1987) regarding personality features of patients suffering from panic disorder and agoraphobia (PDA). PDA patients are thought to suffer from a deficit in negative affect-regulating capacity, surrounded by defenses such as avoidance, repression, denial, and reaction formation against dependency needs. These defenses are thought to lead to a greatly impoverished affective life. The Rorschach Comprehensive System was used to assess the personality features of avoidance, restricted affective life, and reaction formation against dependency needs. We found evidence for the presence of a highly avoidant information-processing style (86% of protocols had lambda [L] greater than .99) and a constricted affective life (low weighted sum color [WSumC] and low affective ratio [Afr]). Our results were consistent with the hypothesis of reaction formation against dependency needs (low food content [Fd]). Findings are discussed in light of studies that found a high incidence of avoidant personality disorder in PDA patients.     

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.     

Patterns of personality pathology in patients with generalized anxiety disorder, panic disorder with and without agoraphobia, and social phobia

The relationship between co-occurring personality disorders and anxiety disorders (panic disorder with or without agoraphobia, social phobia, and generalized anxiety disorder) was examined, taking into account the effect of major depression. This article describes findings for 622 participants in the Harvard/Brown Anxiety Research Project, a longitudinal follow-up study of DSM-III-R-defined anxiety disorders. A total of 24% of participants had at least one personality disorder, with avoidant, obsessive compulsive, dependent, and borderline most common. Generalized anxiety disorder, social phobia, and major depression were positively associated with the occurrence of one or more personality disorders, whereas panic disorder with agoraphobia was not associated. Major depression was associated in particular with dependent, borderline, histrionic, and obsessive compulsive personality disorders and social phobia was associated with avoidant personality disorder. Whereas some of our findings confirm results from earlier studies, others are somewhat inconsistent with previous results and indicate the need for further investigation.     

Prediction of outcome in the behavioural treatment of panic disorder with agoraphobia

Outcome was predicted from pre-treatment characteristics for 62 patients with a primary diagnosis of panic disorder with agoraphobia of moderate to severe magnitude who were treated with 16 sessions of behavioural therapy. Two approaches to the task of prediction was compared: (i) predicting class membership as clinically significantly improved at post-test and at 1-year follow-up on a composite score; and (ii) predicting individual change from the same variable. Agoraphobic severity was found to be a significant predictor of clinically significant improvement at both post-treatment and follow-up. It was also found to be a significant predictor of change at post-treatment, but not at follow-up. Instead the duration of the disorder was found to be a significant predictor of change at follow-up. Perceived treatment credibility, motivation, anxious cluster personality disorder or trait anxiety were not identified as significant predictors of outcome.     

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.     

Preattentive bias for emotional information in panic disorder with agoraphobia.

A combined emotional Stroop and implicit memory (tachistoscopic identification) task with 3 types of words (panic-related, interpersonal threat, and neutral words) and 2 exposure conditions (subliminal, supraliminal) was administered to 35 patients with panic disorder and 35 age- and sex-matched controls. The patients showed Stroop interference for panic-related words both sub- and supraliminally and a similar but not equally robust effect on interpersonal threat words. On the tachistoscopic identification task, the patients identified more panic-related words than the controls did but showed no implicit memory bias effect. The patients' subliminal Stroop interference for panic-related words was found to correlate with trait anxiety and depression, although not with anxiety sensitivity.     

Perfectionism and self-consciousness in social phobia and panic disorder with agoraphobia.

Social phobics were compared to patients with panic disorder with agoraphobia and normal controls on perfectionism and self-consciousness. On concern over mistakes and doubts about action, social phobics scored higher than patients with panic disorder. Social phobics also demonstrated a higher level of public self-consciousness than patients with panic disorder and when this difference was controlled for the significant differences on perfectionism disappeared. Within each patient group, however, perfectionism was more robustly related to social anxiety than was public self-consciousness, which replicates the findings of Saboonchi and Lundh [Saboonchi, F. & Lundh, L. G. (1997). Perfectionism, self-consciousness and anxiety. Personality and Individual Differences, 22, 921-928.] from a non-clinical sample. The results are discussed in terms of public self-consciousness being a differentiating characteristic of the more severe kind of social anxiety which is typical of social phobia.     

Long-term stability of cognitive behavioral therapy effects for panic disorder with agoraphobia: A two-year follow-up study

Objective

Cognitive-behavioral therapy (CBT) aims to help patients establish new behaviors that will be maintained and adapted to the demands of new situations. The long-term outcomes are therefore crucial in testing the durability of CBT.

Method

A two-year follow-up assessment was undertaken on a subsample of n = 146 PD/AG patients from a multicenter randomized controlled trial. Treatment consisted of two variations of CBT: exposure in situ in the presence of the therapist (T+) or on their own following therapist preparation (T−).

Results

Both variations of CBT had high response rates and, overall, maintained the level of symptomatology observed at post-treatment with high levels of clinical significance. Effect sizes 24 months following treatment were somewhat lower than at the 6-month follow up. Once patients reached responder status, they generally tended to remain responders at subsequent assessments. Differences were observed for patients that obtained additional treatment during the follow-up period. Expert opinion and subjective appraisal of treatment outcome differed. No robust baseline predictors of 2-year outcome were observed.

Conclusion

Most patients maintain clinically meaningful changes two years following treatment across multiple outcome measures. Approximately 1/3 of patients continued to experience meaningful residual problems.     

Acceptability of virtual reality interoceptive exposure for the treatment of panic disorder with agoraphobia

Interoceptive exposure (IE) is a standard component of cognitive-behavioural therapy (CBT) for panic disorder and agoraphobia. The virtual reality (VR) program ‘Panic-Agoraphobia’ has several virtual scenarios designed for applying exposure to agoraphobic situations; it can also simulate physical sensations. This work examines patients' acceptability of the IE component as applied in two different ways: using VR versus traditional IE. Additionally, it explores the relationship between users' treatment expectations and satisfaction and clinically significant change. Results showed that VR and traditional IE were well accepted by all participants. Furthermore, treatment expectations predicted efficacy.     

Effects of group experiential cognitive therapy for the treatment of panic disorder with agoraphobia.

A treatment protocol, called experiential cognitive therapy (ExCT), was developed. It integrated traditional cognitive behavior therapy (CBT) with virtual reality exposure for the treatment of panic disorder with agoraphobia (PDA). The objective of this study was to test the efficacy of short-term (four sessions) ExCT compared with a traditional 12-session panic control program (PCP) for the treatment of PDA. Forty patients diagnosed as having PDA by the diagnostic criteria of DSM-IV were randomly assigned to ExCT and PCP groups of 20 patients each. The treatment effects were measured with self-report questionnaires, including the BDI, STAI, ASI, PBQ, ACQ, and BSQ. The authors also assessed high end-state functioning (HES), including the success rate of stopping or reducing medication at post-treatment and 6-month follow-up. In all ratings, both ExCT and PCP groups showed significant improvement post-treatment compared with pre-treatment scores. There were no significant differences between the two treatment groups in HES and medication discontinuation at post-treatment, but there was a significant difference in medication discontinuation at 6-month follow-up. These results suggested that although short-term effectiveness of ExCT might be comparable to the effectiveness of PCP, long-term effectiveness of ExCT might be relatively inferior to the effectiveness of PCP.     

Cross-sectional and longitudinal confirmatory factor models for the german test anxiety inventory: A construct validation

Construct validity of the German Test Anxiety Inventory (TAI-G) was tested in two respects. Firstly, the purported four-dimensional structure of the TAI-G (comprising subscales Emotionality, Worry, Interference, and Lack of Confidence) as well as relations of the test anxiety dimensions to self-efficacy were tested. Secondly, the trait conception of the TAI-G was tested within the framework of Latent State-Trait theory. The TAI-G was given to a student sample (N=302) on three occasions with a time interval of 2 weeks along with a study-specific self-efficacy scale on occasion 1. Dimensionality assumptions as well as relations with self-efficacy were tested using cross-sectional second-order confirmatory factor analysis. The trait conception was tested separately for TAI-G subscales by specifying longitudinal confirmatory factor models (Latent State-Trait models) and by calculating variance proportions of manifest variables (Latent State-Trait coefficients) referring to different sources of systematic variance (person, situation, and method) based on parameter estimates of the models. Results were supportive of both the purported four-dimensional structure and hypothesized relationships to self-efficacy (i.e., acceptable model fit) as well as of the trait conception of test anxiety (i.e., acceptable model fit and high proportion of variance due to person component). Implications for further validation studies were discussed.     

Belief disconfirmation versus habituation approaches to situational exposure in panic disorder with agoraphobia: a pilot study

Exposure therapy and cognitive behaviour therapy (CBT) are both effective in the treatment of panic disorder with agoraphobia. Cognitive theories suggest that the way in which exposure to avoided situations is implemented in either treatment may be crucial. In particular, it is suggested that clinical improvement will be greatest if opportunities for disconfirmation of feared catastrophes are maximized. In a small pilot study, 16 patients with panic disorder and (moderate or severe) agoraphobia were randomly allocated to either habituation based exposure therapy (HBET) or exposure planned as a belief disconfirmation strategy and accompanied by dropping of safety-seeking behaviours. Both treatments were brief (total of 3.25 h of exposure) and were similar in terms of expectancy of change. Patients in the CBT condition showed significantly greater improvements in self-report measures of anxiety, panic and situational avoidance. They also completed significantly more steps in a standardized behavioural walk, during which they experienced significantly less anxiety. The controlled effect sizes for CBT were substantial (range 1.7-2.7), which suggests it may be a particularly efficient way of managing therapeutic exposure to feared situations in panic disorder with agoraphobia. Further research is needed to clarify the mechanism of change involved.     

Cognitions in generalized anxiety disorder and panic disorder patients. A prospective approach.

Self-observations of cognitions during episodes of anxiety were examined in 38 patients with generalized anxiety disorder and 36 patients with panic disorder. Two independent observers who where blind to the diagnoses categorised the cognitions. The inter-rater reliability was high (mean kappa 0.82). The GAD-patients had significantly more cognitions in the following categories: interpersonal confrontation, competence, acceptance, concern about others and worry over minor matters, while the PD-patients had significantly more cognitions in the physical catastrophe category. Furthermore, GAD-patients with a comorbidity of social phobia reported more cognitions regarding social embarrassment than did GAD-patients with other or no (axis-I) comorbidity. The results of this study support the cognitive theory regarding the cognitive specificity of anxiety disorders. The implications of these results are discussed, along with the issues of reliability and validity of the instrument used.