Assessment of agoraphobia and panic disorder

1. 1. Phobia and panic are defined by the measures used.

2. 2. Rating scales, diaries, global measures, physiological measures, behavioural assessment.

3. 3. Three fear systems: physiological, cognitive and behavioral

4. 4. Concordance and discordance.

5. 5. Synchrony and desynchrony

6. 6. The Behavioural Approach Test at the Calgary General Hospital.

Hyperventilation-induced panic attacks in panic disorder with agoraphobia

Eight minutes of hyperventilation to an end-tidal PCO2 of less than 20 mmHg led to a panic attack in 7 of 12 patients with panic disorder with agoraphobia and only 1 of 12 normal controls. Patients experienced greater increases in panic symptoms than controls during hyperventilation. Patients who reported more distress from somatic symptoms of hyperventilation during the preceding week were more likely to panic during hyperventilation. Patients who panicked during hyperventilation exhibited a delayed recovery of normocapnia following hyperventilation. Hyperventilation by this protocol is an effective means of inducing panic attacks in the laboratory. A hyperventilation challenge may identify a subgroup of patients for whom hyperventilation symptoms are frequently associated with panic.     

Panic disorder with and without agoraphobia: comorbidity within a half-year of the onset of panic disorder

The present study was performed to compare the clinical features of patients with panic disorder with and without agoraphobia. The subjects were 233 outpatients with panic disorder (99 males and 134 females) diagnosed according to DSM-IV criteria. Sixty-three patients met the criteria for panic disorder without agoraphobia, and 170 met the criteria for panic disorder with agoraphobia. Patients with agoraphobia showed a significantly longer duration of panic disorder and higher prevalence of generalized anxiety disorder. However, there were no significant differences in prevalence of major depressive episodes, in current severity of panic attacks, or in gender ratio between the two groups. The second aim of the present study was to investigate the effects of onset age and sex differences on the development of agoraphobia within a half-year. The subjects were divided into two groups according to their self-report: patients who did or did not develop agoraphobia within 24 weeks of onset of panic disorder. A total of 40.6% of the patients developed agoraphobia within 24 weeks of the onset of panic disorder, and onset age and sex differences had no robust effect on the development of agoraphobia within 24 weeks.     

Paroxetine in panic disorder with agoraphobia

A case of a panic disorder patient treated successfully in the long term with a selective serotonin re-uptake inhibitor, paroxetine, is reported. Based on this case, the relationship between pharmacotherapy and psychotherapy is discussed.     

Residual symptoms and comorbidity in panic disorder.

Background: The aim of this study was to assess the outcome of the comorbid conditions of panic disorder after 1 year of treatment, emphasizing the detection of residual symptoms and their relationship to other clinical variables. Methods: Subjects (N = 64) were assessed by the Structured Clinical Interview for DSM-III-R and the Eysenck Personality Questionnaire. Comorbidity with other disorders, scores on Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale were assessed at baseline and after 12 months. Criteria for residual anxiety/somatic symptoms were defined. Results: Reduction in generalized anxiety disorder rates accounted for a significant decrease in comorbidity at 1-year follow-up, with regard to baseline assessment. When the more severe symptoms of the disorder had remitted, a third of the patients referred physical symptoms with some concern over a fluctuating state of anxiety. The said symptoms were neither a recurrence of panic disorder nor did they account for other anxiety or somatoform disorders. Lower scores on extraversion predict higher risk of residual symptoms. Discussion: The persistence of residual anxiety/somatic symptoms in a third of the patients who apparently achieved a good response to treatment of panic disorder might characterize a minor form of chronic persistence of this condition. Conclusions: The subgroup of patients with residual symptoms would not be detectable by follow-up studies, which focus on the assessment of relapse of panic disorder by means of strictly defined diagnostic criteria.     

Correlates of DSM-III personality disorder in panic disorder and agoraphobia

One hundred eighty-seven patients meeting DSM-III criteria for panic disorder (n = 26) or agoraphobia with panic (n = 161) were assessed with the Personality Diagnostic Questionnaire (PDQ), a self-rating scale designed to assess Axis II personality disorders and traits. Results replicated our earlier findings of a preponderance of dependent, avoidant, and histrionic features and the finding that patients exhibiting a greater number of personality traits were also significantly more symptomatic. Patients with the diagnosis of panic disorder did not differ on any personality disorder variables from patients with the diagnosis of agoraphobia with panic. Furthermore, none of the specific symptom dimensions, i.e., panic, anxiety, or agoraphobia, was selected as a unique predictor of any personality variables in the regression analyses. Rather, the most important correlates of personality disorder in these patients consisted of general factors such as dysphoric mood, social phobia, or interpersonal sensitivity, and Eysenck's neuroticism dimension. The results are discussed in light of recent findings suggesting a nonspecific link between panic disorder or agoraphobia and personality disorder.     

Diazepam and propranolol in panic disorder and agoraphobia

The response to diazepam and propranolol hydrochloride was compared in 21 patients who (with one exception) met DSM-III criteria for panic disorder and agoraphobia. Each drug was administered for two weeks in double-blind fashion according to a crossover design. The response to diazepam was significantly superior on all measures. By observer rating, 18 patients showed at least moderate improvement with diazepam compared with seven receiving propranolol. Panic attacks and phobic symptoms responded to diazepam, but not to propranolol. The results suggest that benzodiazepines constitute effective short-term treatment for these newly defined disorders.     

Prodromal symptoms in panic disorder with agoraphobia

Of 20 patients suffering from panic disorder with agoraphobia, 18 reported experiencing agoraphobic avoidance, generalized anxiety, and/or hypochondriacal fears and beliefs before the first panic attack. The prevalence of these symptoms in the patients was significantly higher than the prevalence in 20 healthy control subjects. The results indicate that phobic avoidance in panic disorder with agoraphobia may not be secondary to the panic attacks, a finding that runs counter to the current DSM-III-R classification of anxiety disorders.     

NAG level differences in panic disorder and agoraphobia

It is not clear if panic disorder (PD) and agoraphobia are variants of the same disorder or distinct diseases. A laboratory test could help resolve this issue. Research has shown that levels of the urinary lysosomal enzyme N-acetyl-beta-glusosaminidase (NAG) differ between patients with various psychiatric disorders. This study examined whether NAG levels would be similar in PD and agoraphobia, suggesting the two disorders may be the same disorder, or different, suggesting they may be distinct diseases. Differences found could suggest either qualitative or quantitative distinctions between these disorders. Ninety-one agoraphobics were compared to 24 patients with panic disorder. NAG levels were significantly lower in panic patients compared to agoraphobic patients 9.7+/- 8 versus 22+/- 21; P< .005. These data provide limited support for the hypothesis that PD and agoraphobia may be distinct diseases.     

Characteristics of agoraphobia in women and men with panic disorder with agoraphobia

We compared female and male patients with panic disorder with agoraphobia (PDA) in terms of characteristics of agoraphobia (AG). Ninety-five patients (73 women and 22 men) with the SCID-based diagnosis of PDA were administered the National Institute of Mental Health Panic Questionnaire (NIMH PQ), and women and men were compared on the items of the NIMH PQ that pertain to AG and symptoms of panic attacks. Male and female patients did not differ significantly with respect to demographic characteristics, age of onset of panic disorder and AG, duration of PDA, and severity and frequency of symptoms experienced during panic attacks. Women avoided more situations than did men, but this difference was not statistically significant. Women avoided buses and being in unfamiliar places alone significantly more often. The only situation that was avoided more often by men, although not significantly, was staying at home alone. Women were significantly more likely to stay at home to avoid agoraphobic situations and significantly less likely to go outside of home alone. When going outside, women required a companion significantly more often. There were significantly more married women than married men who required a spouse as a companion, and significantly more women with children than men with children who required a child as a companion. Women thought that AG had affected the overall quality of their lives significantly more adversely. Whereas the overall “profile” of agoraphobic situations does not seem to distinguish between female and male patients with AG, females may be more impaired and appear more dependent than men in terms of requiring companions to move outside of the home. Cultural and psychological factors may be most likely to account for these findings. Depression and Anxiety 8:8–13, 1998. © 1998 Wiley-Liss, Inc.     

Thyroid hormones in panic disorder, panic disorder with agoraphobia, and generalized anxiety disorder

Fifty-two patients with generalized anxiety disorder who had symptoms persisting for at least 6 months, 41 patients suffering from either panic disorder (32 patients) or panic disorder with agoraphobia (9 patients), and 14 control subjects were screened for thyroid disease. Total serum thyroxine (TT4), serum-free thyroxine index (FT4I), and triiodothyronine resin uptake (T3RU), were examined for the entire sample, using a one-way analysis of variance (ANOVA). No significant differences were found in TT4 (p = .24), FT4I (p = .24), and T3RU (p = .19). Thyroid-stimulating hormone (TSH) was examined in a subsample of 10 patients with generalized anxiety disorder, 11 with panic disorder or panic disorder with agoraphobia, and 10 controls. One-way ANOVA again showed no significant differences, although there was a trend (p = .07). This is the first report that compares generalized anxiety disorder patients, panic disorder patients, and patients with panic disorder and agoraphobia with controls on measures of thyroid function. It is also the first to report normal values in the thyroid indices of generalized anxiety disorder patients.     

Sex differences in panic disorder with agoraphobia

Two hundred seventy-two patients (68 males and 204 females) with DSM-III diagnosis of Agoraphobia with Panic Attacks (300.21) were used in the present study to investigate sex differences in these patients. Discriminant analysis showed that female agoraphobics can be significantly differentiated from male agoraphobics on their responses to the Fear Survey Schedule (FSS), the clinicians ratings on the Hamilton Anxiety Scale (HAM-H), and Hamilton Depression Scale (HAM-D), indicating the expression of more severe symptomatology amongst the female agoraphobics. Female and male agoraphobics could not, however, be differentiated using the Fear Questionnaire (FQ), Hostility and Direction of Hostility Questionnaire (HDHQ), Maudsley Personality Inventory (MPI), and the State-Trait Anxiety Inventory (STAI), panic symptoms, and cognitions associated with panic attacks. The paper concluded that there were no real differences between the male and female agoraphobics with panic attacks.     

Characteristics and course of panic disorder and panic disorder with agoraphobia in primary care patients

Objective: To examine the course of panic disorder (PD) and panic disorder with agoraphobia (PDA) in 235 primary care patients during a 3-year period.Method: Patients were recruited from primary care waiting rooms and diagnosed using the Structured Clinical Interview for DSM-IV. They were reassessed at 6 months, 1 year, and annually thereafter for diagnosis, treatment, and other clinical and demographic variables. Recruitment occurred between July 1997 and May 2001.Results: At intake, 85 patients were diagnosed with PD and 150 were diagnosed with PDA. Patients with PD were significantly more likely to achieve recovery (probability estimate, 0.75) from their disorder than patients with PDA (0.22) at the end of 3-year follow-up (p < .0001). There was no difference in recurrence rates between the 2 disorders. Women were more likely to recover from PD (p = .001). At intake, comorbid generalized anxiety disorder (p = .004), higher Global Assessment of Functioning score (p = .0003), and older age at panic onset (p = .05) were related to recovery from PDA, and comorbid major depressive disorder (p = .05) and psychosocial treatment (p = .002) predicted remaining in an episode of PDA. The relationship between psychosocial treatment and poor recovery must be interpreted with caution and is most likely due to the treatment bias effect.Conclusion: Primary care patients with PDA have a chronic course of illness, whereas those with PD have a more relapsing course. Given the significant burden of PD and PDA in primary care, attention to factors relevant to the course of these disorders is important for recognition and for continued improvement of treatment interventions in this setting.     

The relationship of panic disorder to agoraphobia

Twenty patients with agoraphobia or panic disorder were compared to each other using multiple variables of clinical illness. No differences were found. Only one of thirteen agoraphobic patients did not experience panic attacks. The agoraphobia symptoms never preceded the panic attacks in those twelve patients experiencing both agoraphobia and panic attacks. This study data and that of others is most consistent with the hypothesis that agoraphobia is a secondary manifestation of panic disorder.     

Patterns of axis II comorbidity in early-onset versus late-onset panic disorder in Japan

Early onset of psychiatric disorders has been reported to be associated with increased familial risk or more severe clinical symptoms. In this study, we specifically examine the association between clinical severity and early versus late onset in panic disorder. We hypothesize the existence of differences in rates of axis II disorders in these two groups that will relate to clinical severity. Subjects were a consecutive clinical case series of 105 panic disorder patients (age, 18.3 to 70.9 years). Thirty-one panic disorder patients were classified as early onset (age of onset < or = 25 years) and 74 as late onset (age of onset >25). We compared symptomatology and rates of comorbid axis II disorders (diagnosed by structured clinical interview) between the early- and the late-onset groups. We found a statistically significant increase in the number of suicide attempts and likelihood of comorbid axis II disorders in the early-onset group compared to the late-onset group. In logistic regression analyses, cluster B personality disorders (PDs), especially borderline and histrionic, were statistically significantly associated with the presence of suicide attempts. The following limitations are present: first, we have not taken into consideration comorbidity of other axis I disorders, especially major depression. Second, there is imprecision associated with efforts to date the onset of panic disorder retrospectively. We conclude that comorbid axis II disorders are more likely to occur in early-onset panic disorder patients. Cluster B PDs, especially borderline or histrionic, may be associated with a high frequency of suicide attempts in this group. In clinical practice, efforts to aggressively detect and treat axis II disorders in early-onset panic disorder patients are warranted.