Patient dropout from a couples' group treatment for panic disorder with agoraphobia.

This study examined premature termination from couples' group treatment for panic disorder with agoraphobia. Patients were classified as either treatment noncompleters or treatment completers. Comparisons of pretreatment self-report and clinician-rated measures of anxiety and depression indicated no differences between groups. On communication measures, however, partners of noncompleters rated themselves as less communicative about panic-related issues. Of noncompleters, the majority reported "getting to treatment sessions" as problematic and indicated dissatisfaction with the cognitive-behavioral treatment approach. Results are discussed in terms of these issues and their impact on the treatment of these patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Recognition bias for safe faces in panic disorder with agoraphobia

Panic patients with agoraphobia were compared with normal controls on tasks of face recognition. The subjects were presented with 20 photos, and were required to make a judgement of the persons on the photos; shortly afterwards they were unexpectedly presented with a recognition task. In the first study, one task was to judge whether the persons on the photos were critical or accepting: unlike social phobics (Lundh and Ost, 1996b, Behaviour Research and Therapy, 34, 787-794), panic patients showed no bias for critical vs accepting faces on the recognition task. In a secondary study, the task was to judge whether the persons on the photos were 'safe' or 'unsafe', i.e. whether they could be relied on if the subject would need help in some situation. The results showed a recognition bias for safe vs neutral faces in panic patients. The index of recognition bias for safe faces correlated with avoidance of feared situations when accompanied by others, as measured by the Mobility Inventory. The possibility that memory bias in emotional disorders is a function of basic concern, or functional importance, rather than positive/negative valence is discussed. The results are also discussed in terms of degree of elaboration, exposure duration of the stimuli, and the generality of the findings.     

Minnesota Multiphasic Personality Inventory correlates of panic disorder with agoraphobia: changes with treatment

Granulocytes, monocytes, and T- and B-lymphocytes were separated from 28 blood samples collected from 5 bone marrow transplant (BMT) recipients. About 40% of granulocyte, monocyte, and B-lymphocyte samples were CMV DNA-positive by polymerase chain reaction in recipients with cytomegalovirus (CMV) infection. CMV DNA was rarely detected in separated T-lymphocytes. Within each of the simultaneously separated paired samples, there were several with single positive cell subtypes. Monocytes, granulocytes, and B-lymphocytes were the single positive samples in some instances. Thus, it is important to have all of the different cell subtypes present in samples for detection of CMV DNA in peripheral blood. We also studied the appearance of CMV DNA in plasma and peripheral blood leukocytes (PBLs) from 351 blood samples collected from 30 BMT recipients during a follow-up period of at least 3 months after BMT. All cell subtypes were represented in the PBL samples. In the 13 recipients who developed symptoms possibly associated with CMV infection or CMV disease, a correlation with the detection of CMV DNA in < or = 2 x 10(5) PBLs was found. In PBLs from 11 of the 13 BMT recipients, CMV DNA was detected before the onset of symptoms. CMV DNA was not detected in < or = 2 x 10(5) PBLs from recipients without CMV infection. The virus load in PBLs decreased during ganciclovir treatment. Nine of the 13 recipients displayed PCR-positive plasma samples, and CMV DNA was detected frequently after the onset of symptoms.     

Catastrophic cognitions in panic disorder with and without agoraphobia

The cognitive models of panic disorder with (PDA) or without (PD) agoraphobia are now widely recognised. These models propose that patients misinterpret external or internal cues in a catastrophic manner and as a result of these catastrophic cognitions the symptoms are maintained. There is now a large body of empirical evidence for this proposal and the aim of this paper is to systematically review the literature to evaluate whether the empirical evidence supports the contribution of catastrophic cognitions to PD and PDA. Empirical studies using different methodologies, such as interview, questionnaire, self-monitoring, and in vivo techniques are reviewed. The results indicate there is substantial empirical evidence in support of the central role of catastrophic cognition in cognitive models. Different methodologies provided convergent support for the importance of catastrophic cognitions in the maintenance of panic disorder and agoraphobia. Limitations in the interpretation of the existing research are highlighted and future research directions are proposed.     

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. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Explicit and implicit memory bias in panic disorder with agoraphobia

Thirty patients with a diagnosis of panic disorder with agoraphobia and 30 normal controls were compared on explicit memory (cued recall) and implicit memory (word stem completion) for positive, neutral, social threat, and physical threat words. The panic patients showed an explicit memory bias, but no implicit memory bias, for physical threat words. The index of explicit memory bias for physical threat words was found to correlate with anxiety sensitivity and degree of agoraphobic fear and avoidance. The index of baseline bias for threat words on the word completion task, on the other hand, correlated with trait anxiety. Although there were no correlations between explicit and implicit memory bias for physical threat words, explicit memory bias for physical threat words correlated with explicit memory bias indexes for positive words and social threat words. The results are discussed in terms of the functional role of an explicit memory bias for physically threatening events in panic disorder. The negative results on implicit memory bias are discussed in relation to earlier studies, the use of different implicit memory tasks, and the role of baseline bias on implicit memory tasks. Finally, the hypothesis is suggested that explicit and implicit memory bias for emotional information may represent two different styles of information processing, which serve as vulnerability factors for different emotional disorders.     

Personality disorders and the outcome of cognitive–behavioural treatment of panic disorder with agoraphobia.

In recent years, cognitive–behavioural interventions have proven to be effective in the treatment of Panic Disorder with Agoraphobia (PDA). However, there is controversy concerning treatment efficacy of PDA for patients with a comorbid diagnosis of Personality Disorder (PD). This study evaluates the impact of a PD on PDA treatment response. 81 patients suffering from PDA were recruited from a cognitive–behavioural group treatment program. Diagnoses on Axis I (N?=?81) and Axis II (N?=?36) were made at treatment onset according to Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) criteria. Validated questionnaires were used to assess agoraphobia at treatment onset, following treatment, and at the 3 mo follow-up. All patients improved markedly from pretest to posttest and at the 3 mo follow-up. Grouping of patients according to the presence or absence of a personality disorder revealed significant differences between the groups on pre- and posttreatment scores on agoraphobia. Results also reveal that patients with a personality disorder improve more slowly than patients without a personality disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Confirmatory factor analysis of the Fear Questionnaire in panic disorder with agoraphobia.

The Fear Questionnaire responses of 390 patients with panic disorder with agoraphobia were used in a confirmatory factor analysis. The results provide strong support for the 3-factor model of this scale (agoraphobia, social phobia, blood/injury phobia) and the multidimensional model of fears proposed by W. A. Arrindell (1980). The presence of fear clusters other than agoraphobia existing in panic disorder is also discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Panic disorder and agoraphobia with panic attacks: Covariation along the dimensions of panic and agoraphobic fear.

Tested the validity of the distinction made in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) between the diagnoses of "panic disorder" and "agoraphobia with panic attacks" by examining the pattern of covariation between panic symptoms and agoraphobic fear in a group of individuals presenting with panic attacks as a prominent symptom. Ss were 17 patients (mean age 34.4 yrs) who had been diagnosed as having panic disorder and 56 patients (mean age 36.4 yrs) diagnosed as having agoraphobia with panic attacks, and who had completed at the time of diagnosis both the Fear Survey Schedule and the SCL-90-R. Analyses of the panic-related items and the agoraphobia-related items of these 2 inventories revealed that irrespective of diagnosis, the degree of panic was highly correlated with the degree of agoraphobic fear. Although panic patients tended to experience more severe panic and milder agoraphobic fear than agoraphobics, the groups overlapped with respect to both kinds of symptoms. Findings are discussed in terms of whether panic disorder and agoraphobia should be classified as qualitatively distinct conditions. (10 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Convergent and divergent validity of the Beck Anxiety Inventory for patients with panic disorder and agoraphobia

Psychometric properties of the Beck Anxiety Inventory (BAI) (Beck and Steer, 1990) were investigated in a sample of 82 patients suffering from panic disorder with agoraphobia. Before and after brief treatment, patients completed a battery of questionnaires and, for 2-week periods, kept a daily panic diary in which they recorded panic attacks, fear of panic, and average anxiety. The BAI demonstrated excellent internal consistency and good test-retest reliability over a 5-week interval. A partial multitrait, multimethod correlation matrix provided evidence of convergent validity with other measures of anxiety and of divergent validity vis á vis measures of depression. Factor analyses of pretest scores and residual gain scores used to address criticism that the BAI is excessively panic-centric yielded mixed results. In one analysis, the BAI was loaded with multimethod measures of panic and anxiety and, in the other, with questionnaire methods of assessing anxiety and depression. However, the BAI was clearly distinguished from measures of fear of fear, a central construct in panic disorder, and agoraphobic avoidance. Finally, the BAI proved sensitive to change with treatment, yielding effect sizes for improvement comparable to those of other anxiety measures.     

The effects of extraverted temperament on agoraphobia in panic disorder.

Although situational avoidance is viewed as the most disabling aspect of panic disorder, few studies have evaluated how dimensions of neurotic (i.e., neuroticism, behavioral inhibition) and extraverted (i.e., extraversion, behavioral activation) temperament may influence the presence and severity of agoraphobia. Using logistic regression and structural equation modeling, we examined the unique effects of extraverted temperament on situational avoidance in a sample of 274 outpatients with a diagnosis of panic disorder with and without agoraphobia. Results showed low extraverted temperament (i.e., introversion) to be associated with both the presence and the severity of situational avoidance. Findings are discussed in regard to conceptualizations of conditioned avoidance, activity levels, sociability, and positive emotions within the context of panic disorder with agoraphobia. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical features in panic disorder with agoraphobia: a comparison of men and women

This study compared 96 women and 58 men suffering from panic disorder with agoraphobia. Participants completed questionnaires assessing various clinical features associated with panic disorder with agoraphobia (PDA), general adjustment, and drug/alcohol use. Results showed that PDA is a more severe condition in women. Women reported more severe agoraphobic avoidance when facing situations or places alone, more catastrophic thoughts, more body sensations, and higher scores on the Fear Survey Schedule. Also, women more often had a comorbid social phobia or posttraumatic stress disorder. The lower agoraphobic avoidance of men was associated with their alcohol use. However, there were no differences between genders in other dimensions, including depression, situational and trait anxiety, stressful life events, social self-esteem, marital adjustment, and drug use.     

EMDR for panic disorder with agoraphobia: Comparison with waiting list and credible attention-placebo control conditions.

In a randomized controlled trial, eye movement desensitization and reprocessing (EMDR) for panic disorder with agoraphobia (PDA) was compared with both waiting list and credible attention-placebo control groups. EMDR was significantly better than waiting list for some outcome measure, (questionnaire, diary, and interview measures of severity of anxiety, panic disorder, and agoraphobia) but not for others (panic attack frequency and anxious cognitions). However, low power and, for panic frequency, floor effects may account for these negative results. Differences between EMDR and the attention placebo control condition were not statistically significant on any measure, and, in this case, the effect sizes were generally small (η?=?.00–.06), suggesting the poor results for EMDR were not due to lack of power. Because there are established effective treatments such as cognitive–behavior therapy for PDA, these data, unless contradicted by future research, indicate EMDR should not be the first-line treatment for this disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comorbidity of panic disorder with agoraphobia and specific phobia: relationship with the subtypes of specific phobia

The study objectives were to determine comorbidity rates for various subtypes of specific phobia (SP) in a sample of patients with the principal diagnosis of panic disorder with agoraphobia (PDA) and to examine the possible etiologic relatedness of these SP subtypes to PDA. Ninety consecutive day clinic patients with PDA were administered the Structured Clinical Interview for DSM-III-R (SCID) modified for DSM-IV. The overall comorbidity rate for SP was 65.6%. The most frequent subtypes of SP were situational phobia and dental phobia, followed by natural environment phobia, phobia of funerals, cemeteries, dead bodies, and other death-related phenomena and objects (referred to as death-related phobia), and blood-injection-injury phobia. Except for death-related phobia, other subtypes of SP clearly tended to precede the onset of PDA, often by many years. The smallest difference between the age of onset for PDA and particular subtypes of SP (temporal distance) was found for death-related phobia, whereas the temporal difference was longer for situational phobia, hospital phobia, and blood-injection-injury phobia. The frequency and temporal distance data suggest that death-related phobia may constitute a risk factor for developing PDA or that it is a prodrome of PDA, whereas situational phobia, hospital phobia, and blood-injection-injury phobia appear to predispose to PDA to a lesser degree. Of the three broadly conceived groups of SP, mutilation phobias (which include death-related phobia, hospital phobia, blood-injection-injury phobia, and dental phobia) appear most etiologically relevant for PDA, with the group of situational phobias (which also includes the natural environment subtype of SP) being less relevant, and animal phobias showing a negligible etiologic relatedness to PDA.     

The role of trauma and dissociation in cognitive-behavioral psychotherapy outcome and maintenance for panic disorder with agoraphobia

The relationship between traumatic experiences and dissociation with pretreatment psychopathology and rates of recovery, relapse and maintenance for patients receiving cognitive-behavioral treatments for panic disorder with agoraphobia (PDA) were investigated. One-hundred and forty-seven subjects who met DSM-III criteria for agoraphobia with panic attacks and who completed participation in one of two previously conducted treatment outcome studies were mailed packets containing measures to assess history of trauma, victimization and dissociation. Eighty-nine of these were returned and completed sufficiently to be included in the present study. It was hypothesized that a variety of trauma-related variables (e.g. history of traumatic experience, type of trauma, age at which the trauma first occurred, perceived responsibility, social supports available, self-perceived severity, level of violence, and whether or not the traumatic event was followed by self-injurious or suicidal thoughts and/or behaviors) and dissociative symptomatology would be predictive of (1) greater psychopathology at pretreatment, (2) poorer treatment response and (3) higher relapse rates and poorer maintenance over a 1 year longitudinal follow-up. These hypotheses were supported by the findings and the theoretical, empirical and clinical implications are discussed.     

Psychological treatment for panic disorder with agoraphobia: A randomized controlled trial to examine the role of therapist-guided exposure in situ in CBT.

[Correction Notice: An erratum for this article was reported in Vol 79(5) of Journal of Consulting and Clinical Psychology (see record 2011-21293-002). In the article, the name of author Georg W. Alpers was misspelled as George W. Alpers. In Table 2, in the footnote, line two, the criteria should read “MI≤1.8”. The online versions of this article have been corrected.] Objective: Cognitive–behavioral therapy (CBT) is a first-line treatment for panic disorder with agoraphobia (PD/AG). Nevertheless, an understanding of its mechanisms and particularly the role of therapist-guided exposure is lacking. This study was aimed to evaluate whether therapist-guided exposure in situ is associated with more pervasive and long-lasting effects than therapist-prescribed exposure in situ. Method: A multicenter randomized controlled trial, in which 369 PD/AG patients were treated and followed up for 6 months. Patients were randomized to 2 manual-based variants of CBT (T+/T?) or a wait-list control group (WL; n = 68) and were treated twice weekly for 12 sessions. CBT variants were identical in content, structure, and length, except for implementation of exposure in situ: In the T+ variant (n = 163), therapists planned and supervised exposure in situ exercises outside the therapy room; in the T? group (n = 138), therapists planned and discussed patients' in situ exposure exercises but did not accompany them. Primary outcome measures were (a) Hamilton Anxiety Scale, (b) Clinical Global Impression, (c) number of panic attacks, and (d) agoraphobic avoidance (Mobility Inventory). Results: For T+ and T? compared with WL, all outcome measures improved significantly with large effect sizes from baseline to post (range = ?0.5 to ?2.5) and from post to follow-up (range = ?0.02 to ?1.0). T+ improved more than T? on the Clinical Global Impression and Mobility Inventory at post and follow-up and had greater reduction in panic attacks during the follow-up period. Reduction in agoraphobic avoidance accelerated after exposure was introduced. A dose–response relation was found for Time × Frequency of Exposure and reduction in agoraphobic avoidance. Conclusions: Therapist-guided exposure is more effective for agoraphobic avoidance, overall functioning, and panic attacks in the follow-up period than is CBT without therapist-guided exposure. Therapist-guided exposure promotes additional therapeutic improvement—possibly mediated by increased physical engagement in feared situations—beyond the effects of a CBT treatment in which exposure is simply instructed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Cognitive-behavioral treatment of panic disorder.

Cognitive-behavioral therapy can be effective for many clients with panic disorder. Therapy can be conceptualized in terms of four central components. First, the initial preparation for therapy involves establishing a working alliance, educating the client about panic symptoms and treatments, and conducting a diagnostic assessment. Second, skills training is used to cultivate active coping skills that the client can use to tolerate symptoms of emotional distress. Third, exposure is used to encourage clients to test and refine their newly developed coping skills. Fourth, relapse prevention is used to help clients discontinue psychological and biological treatments without suffering lasting setbacks. Through the use of cognitive-behavioral therapy, most clients can learn to control their symptoms of panic and reduce their anticipatory anxiety. Treatment gains can be maintained after therapy is discontinued. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of a safe person on induced distress following a biological challenge in panic disorder with agoraphobia.

This study examined the effect of having a safe person present on artificially induced anxiety following a biological challenge among panic-disordered patients. Anxiety symptoms were induced using a 5.5% CO?-inhalation procedure. Panic patients underwent the inhalation procedure either in the presence or absence of their safe person. Nonanxious controls underwent the procedure without a safe person. Panic patients exposed to CO? without their safe person present reported greater distress, a greater number of catastrophic cognitions, and a greater level of physiological arousal than did panic patients exposed with their safe person. The latter group did not differ from controls on most measures at postexposure. The attenuation of self-reported anxiety and catastrophic cognitions is consistent with the safety-signal theory and the cognitive model of panic, respectively. The results, however, are inconsistent with a biological model of panic. (PsycINFO Database Record (c) 2010 APA, all rights reserved)