Panic control treatment for agoraphobia

The goal of the present study was to compare the efficacy of cognitive-behavioral treatment for panic control alone versus this treatment containing an additional in vivo exposure component. The sample was comprised of 68 individuals who met diagnosis for panic disorder with agoraphobia. Participants were randomly assigned to one of two 16-week treatment conditions, panic control only and panic control with in vivo exposure. Assessments were repeated at baseline, mid-treatment, posttreatment, and 6-month follow-up using diagnostic and behavioral measures. Results indicated that the two treatment conditions were equally efficacious for both panic disorder and agoraphobia. The intervention explicitly targeting agoraphobia appeared superfluous given the efficacy of panic control alone. On the other hand, reduction in panic frequency predicted reduction in agoraphobic avoidance overall. The practical and theoretical implications are discussed, as are limitations and directions for future research.     

Behavioural and combined therapy in panic states

This review will focus only on those paradigms for treatment of panic states with agoraphobia. Until recently the behaviour therapy literature has completely ignored panic disorder and has focused exclusively on the agoraphobic aspect of this syndrome. To summarize the behavioural therapy of panic disorder and agoraphobia, it appears that exposure is in the short run the most effective behavioural paradigm in agoraphobia. However, when contrasted with cognitive approaches it does not appear to be as effective in the treatment of panic disorder. In conclusion, it is unclear whether we can speak of antiphobic medications. Certainly studies of imipramine, chlomipramine, monoamine oxidase inhibitors, and alprazolam have demonstrated an anti-panic affect of medications and a subsequent improvement in phobic avoidance. However, when exposure is not made a part of the treatment, there is a much poorer resolution and a tendancy for the patient to relapse.     

The diagnosis and management of panic disorder

The diagnosis of panic disorder without agoraphobia can very often be quite difficult because of the similarity with physical disorders particularly in the cardiac, gastrointestinal or neurological systems. The distinction must be made between panic attacks appearing as medical problems and medical problems appearing as panic attacks. Sometimes the diagnosis of panic attacks is made only after the medical diagnoses have been excluded. Panic disorder with agoraphobia however is much easier to detect if one carefully traces the historical development of agoraphobia and carefully distinguishes between the anxiety produced by agoraphobia and the panic attacks related to panic disorder. Panic disorder must also be distinguished from other anxiety disorders since the treatment for panic disorder still is quite specific. Once diagnosed however, the treatment of panic disorder without agoraphobia is rather simple. It involves the use of a benzodiazepine, either alprazolam or clonazopam, and perhaps the concomitant use of either imipramine or phenelzine sulfate for the rapid control of anxiety symptoms and continued treatment of the disorder. It is also very helpful to have the patient in psychotherapy either using a supportive or cognitive approach. If the patient has a panic disorder with agoraphobia, the pharmacological approach is the same, with the initiation of treatment using either alprazolam or clonazopam, but the psychotherapeutic approach is somewhat different in that behavioral therapy is emphasized rather than purely supportive or cognitive approaches. Given the fact that 1%-2% of the population is at risk for panic disorder, it is important that the condition be rapidly recognized and treated effectively since the currently available modalities of treatment result in almost total resolution of symptoms. Some individuals will remain on medication for several years while others will find it possible to decrease and/or discontinue their medications after only a few months or a few years. There is little excuse at this point for this disorder to be ineffectively diagnosed or treated.     

Brief treatment of emergency room patients with panic attacks.

OBJECTIVE: Most research on treatment for panic disorder has involved chronic forms of the illness. To determine the efficacy of early intervention, the authors examined the effects of treatment for patients with panic attacks who were seen in the emergency room, which is the first point of contact with the health delivery system for many persons with panic attacks. METHOD: The subjects were 33 patients with panic attacks seen in two emergency rooms. The presence of panic attacks was confirmed with a modified version of the Structured Clinical Interview for DSM-III-R; approximately 40% of the patients met the DSM-III-R criteria for panic disorder with agoraphobia. The patients were randomly assigned to groups receiving reassurance (N = 16) or exposure instruction (N = 17). Scores on the Fear Questionnaire agoraphobia subscale, Mobility Inventory, and Beck Depression Inventory and the frequency of panic attacks were determined at baseline, 3 months, and 6 months. RESULTS: The subjects who received exposure instruction significantly improved over the 6-month period on depression, avoidance, and panic frequency. The reassurance subjects did not improve on any measure and eventually reported more agoraphobic avoidance. CONCLUSIONS: These results suggest that early intervention with exposure instruction may reduce the long-term consequences of panic attacks. The exposure instruction was of value even though the subjects had relatively low levels of avoidance at the outset of the study.     

Frequency of panic as an outcome measure in agoraphobia research: Latent effects of exposure on panic

The frequency of panic attacks during treatment of patients with panic disorder and agoraphobia was studied with an event sampling method. Treatment comprised panic management techniques followed by exposure in vivo. Results revealed that the frequency of panic attacks varied considerably across patients. There was a group of patients that responded to treatment with a decrease in both panic attacks and avoidance. Another group of patients, however, experienced little panic in the initial phase of treatment, but during the exposure phase they evidenced an increase in the frequency of panic attacks along with a decrease in avoidance. Consequently, merely focusing on panic frequency could lead to considering some patients as treatment failures, while in fact they did respond to the treatment. Recommendations for the use of panic attack frequency as an outcome measure in the evaluation of treatment for panic disorder with agoraphobia are discussed.     

Inpatient treatment of complicated agoraphobia and panic disorder

Despite recent advances in the treatment of agoraphobia and panic disorder, some patients do not respond to standard outpatient regimens of biological and psychosocial intervention and may require more intensive, closely supervised care. The authors describe a specialized inpatient program that integrates pharmacotherapy, intensive levels of exposure and other behavioral therapies, a structured and strategically reinforcing environment, panic and anxiety management strategies, and other interventions designed specifically for patients with complicated panic-based disorders. Outcome data for 25 patients indicate that after a mean stay of 35 days, 19 patients were significantly improved. These preliminary results suggest that appropriately designed inpatient programs offer an effective treatment option for some patients with refractory conditions of agoraphobia or panic disorder.     

Panic and avoidance in agoraphobia. Application of path analysis to treatment studies

We explored a causal sequence between panic and avoidance to provide recommendations for psychotherapy, pharmacotherapy, and their combination in treating agoraphobia. We produced a two-way [( imipramine hydrochloride vs placebo] by [office-based behavioral therapy vs in vivo exposure]) design by amalgamating two studies. We assessed agoraphobic patients for panic and avoidance at these time points: baseline (week 0), midcourse (week 13), and termination (week 26). The causal sequence model was tested by path analysis. Imipramine was superior to placebo in lowering panic and avoidance at both postbaseline time points. Exposure was superior to office-based treatment in lowering avoidance only at week 13. Exposure appeared to produce quicker improvement of avoidance than office-based therapy, but relapse occurred if this improvement was not supported by medication. Exposure did not benefit panic. We believe patients should be informed that imipramine is superior to exposure in inducing a panic-free state. Exposure without imipramine is of benefit only in reducing avoidance, but adding imipramine to exposure is necessary for panic control and substantially improves exposure and exposure maintenance.     

Sequential combination of imipramine and self-directed exposure in the treatment of panic disorder with agoraphobia

Thirty-eight patients who had panic disorder with agoraphobia completed 8 weeks of treatment with imipramine followed by 8 weeks of treatment with imipramine combined with behavior therapy consisting of self-directed exposure. Sixty-three percent (24) of the patients responded markedly to this cost-effective combined pharmacologic and behavioral approach. Results also revealed that most of the improvement in panic occurred during the first 8 weeks of treatment when imipramine treatment alone was used, whereas improvement in severity, anxiety, depression, and phobias, in particular, continued to be significant between midtreatment and end of study. Further analysis revealed that improvement in phobic anxiety and avoidance in the first 8 weeks of treatment, rather than improvement in panic, predicted final outcome. Implications of these findings on the complex issue of differential antipanic and antiphobic effects of imipramine are briefly discussed.     

Panic disorders and agoraphobia: Freudian concepts and DSM IV

This paper refers to the relationship between panic and agoraphobia, regarding Panic Disorder and Agoraphobia (DSM IV), from two different points of view coming from Psychoanalysis and Psychiatry. Psychoanalysis (S. Freud) considers agoraphobia as a defensive organization to avoid anxiety, not bound to the original conflict, but to substitutive formation. The exposure to space (its unconscious significance) provokes panic attack. The psychiatric approach considers agoraphobia, meaningless by its own, as a consequence of spontaneous panic attacks. The etiology is referred to neurophysiological mechanisms. The authors reviewd D Klein's hypothesis about panic and Freud's theories on anxiety, partiularly Anxiety Neurosis.     

Behavioral aspects of panic disorder

The behavioral approach to panic disorder distinguishes between agoraphobia and nonsituational panic and emphasizes the handicap to the patient caused by avoidance of agoraphobic situations. Agoraphobia is a more viable label than panic disorder. Behavioral treatment consists of delineating the patient's agoraphobic avoidance and panic profile and developing a self-exposure program to produce habituation. Systematic exposure to agoraphobic situations is usually of durable efficacy, and the treatment requires little time from clinicians. Antidepressant drugs, which do not interfere with exposure, are a useful addition when dysphoria is present, but they can have troublesome side effects.     

A pilot study of sensation-focused intensive treatment for panic disorder with moderate to severe agoraphobia: preliminary outcome and benchmarking data

This report presents results of a treatment for panic disorder with moderate to severe agoraphobia (PDA-MS) called sensation-focused intensive treatment (SFIT). SFIT is an 8-day intensive treatment that combines features of cognitive- behavioral treatment for panic disorder, such as interoceptive exposure and cognitive restructuring with ungraded situational exposure. SFIT focuses on feared physical sensations as well as agoraphobic avoidance. Preliminary data support the utility of SFIT in improving PDA-MS. The goal of this exploratory study was to further investigate the effectiveness of SFIT and evaluate factors related to treatment outcome, including severity of panic symptoms, gender, comorbidity, self-efficacy, and place of residence (local vs. remote). SFIT was found to be effective in decreasing panic symptoms from pre- to posttreatment, with treatment gains maintained at follow-up. The implications of these findings for the treatment of PDA are discussed.     

The utility of the panic disorder concept

Summary In this paper we discuss the theory that agoraphobic avoidances are central and spontaneous panics an epiphenomenon to the development of agoraphobia. Moreover we discuss the theory that posits a fixed cognitive-catastrophizing set as causal for panic. We conclude these theories do not fit the facts. We argue that it is important to distinguish between spontaneous panic and chronic or anticipatory anxiety and avoidance. Such a distinction allows for an understanding of the roles of anti-spontaneous panic medications such as tricyclics and MAOI's, as well as exposure therapy, in the treatment of panic disorder with agoraphobia. The former serves the purpose of blocking panic attacks while the latter undermines phobic avoidance, but only after the panic attacks have ceased through proper medication. We conclude that recognizing the key role of spontaneous panic and its variants in anxiety nosology is a necessary guide for etiological, psychophysiological and therapeutic research in this rapidly developing area.Parts of this article were presented on the occasion of the inauguration ceremony of the Department of Psychiatry of the University of Mainz on April 2 and 3, 1987     

Low dose desipramine treatment of cocaine-related panic attacks.

Thirteen patients meeting DSM-III-R criteria for panic disorder with or without agoraphobia that started during or shortly after cocaine exposure were treated in the UCLA Anxiety Disorders Program (Los Angeles, CA). Low starting doses (ranging from 2.5 to 10 mg/day) of desipramine were used. Doses were then slowly increased to an average daily dose of 25 mg. Eleven patients who were able to tolerate an initial increase in panic anxiety responded to this treatment strategy with almost full resolution of panic attacks. The authors discuss the possible value and mechanisms of low dose treatment of cocaine-related panic attacks.     

Protective effects of imipramine maintenance treatment in panic disorder with agoraphobia.

OBJECTIVE: This study was designed to assess and compare the differential relapse rates of patients with panic disorder and agoraphobia after discontinuation of acute treatment (6 months) or acute plus maintenance treatment (18 months) with imipramine. METHOD: Sixteen patients with panic disorder and agoraphobia who had shown marked and stable response to 6 months of acute imipramine treatment and a comparable group of 14 patients who had been in remission during an additional year of half-dose imipramine maintenance treatment entered a 3-month, double-blind discontinuation study followed by a 3-month drug-free period. Assessments of the patients were made according to operationalized response/relapse criteria, and plasma drug concentrations were monitored. RESULTS: Survival analysis revealed significantly different cumulative probabilities of continued response 6 months after discontinuation of imipramine treatment between the patients who had received only acute treatment and those who had received acute and maintenance treatment. CONCLUSIONS: The results support the hypothesis that successful imipramine maintenance treatment of patients with panic and agoraphobia can have protective effects against relapse, at least in the first 6 months after the maintenance treatment period.     

Clinical characteristics and treatment outcomes of patients with major depressive disorder and comorbid anxiety disorders - results from a European multicenter study

This naturalistic European multicenter study aimed to elucidate the association between major depressive disorder (MDD) and comorbid anxiety disorders. Demographic and clinical information of 1346 MDD patients were compared between those with and without concurrent anxiety disorders. The association between explanatory variables and the presence of comorbid anxiety disorders was examined using binary logistic regression analyses. 286 (21.2%) of the participants exhibited comorbid anxiety disorders, 10.8% generalized anxiety disorder (GAD), 8.3% panic disorder, 8.1% agoraphobia, and 3.3% social phobia. MDD patients with comorbid anxiety disorders were characterized by younger age (social phobia), outpatient status (agoraphobia), suicide risk (any anxiety disorder, panic disorder, agoraphobia, social phobia), higher depressive symptom severity (GAD), polypsychopharmacy (panic disorder, agoraphobia), and a higher proportion receiving augmentation treatment with benzodiazepines (any anxiety disorder, GAD, panic disorder, agoraphobia, social phobia) and pregabalin (any anxiety disorder, GAD, panic disorder). The results in terms of treatment response were conflicting (better response for panic disorder and poorer for GAD). The logistic regression analyses revealed younger age (any anxiety disorder, social phobia), outpatient status (agoraphobia), suicide risk (agoraphobia), severe depressive symptoms (any anxiety disorder, GAD, social phobia), poorer treatment response (GAD), and increased administration of benzodiazepines (any anxiety disorder, agoraphobia, social phobia) and pregabalin (any anxiety disorder, GAD, panic disorder) to be associated with comorbid anxiety disorders. Our findings suggest that the various anxiety disorders subtypes display divergent clinical characteristics and are associated with different variables. Especially comorbid GAD appears to be characterized by high symptom severity and poor treatment response.     

Chronology of panic and avoidance,age of onset in panic disorder,and prediction of treatment response

Summary The relevance of the chronology between panic disorder and avoidance behavior and of an early, medium or late onset of panic disorder was tested. Groups from the sample of the cross-national collaborative panic study (CNCPS) were compared for differences in basic characteristics and for the ability to predict treatment response. Patients who developed avoidance behavior before the full syndrome of panic disorder had less often a full agoraphobia but were not different in their response to treatment. Patients with an early onset of panic disorder suffered more often from agoraphobia. The treatment response was similar in the groups with early, medium or late onset of panic disorder. Neither the chronology between panic disorder and avoidance behavior nor the age of onset of panic disorder predicted outcome in short-term treatment with alprazolam or impiramine.     

Cognitive-behavioral treatment for panic disorder with gastrointestinal symptoms: A case study

A 25-year-old woman with a 12-year history of panic disorder with agoraphobia and gastrointestinal symptoms was treated using a cognitive-behavioral program which included: (a) correcting misconceptions about normal bowel functioning, (b) graduated in vivo exposure to internal stimuli which she misinterpreted as precursors of loss of bowel control, (c) graduated in vivo exposure to external stimuli associated with fears of loss of bowel control, (d) establishment of regular eating patterns, and (e) bowel control training. Self-ratings of avoidance and distress, frequency of panic attacks, diazepam use, and negative cognitions decreased with treatment. Treatment gains were maintained at 18-month follow-up. Tailoring of cognitive-behavioral treatment to panic with fears of loss of bowel control was emphasized.     

Alprazolam in the treatment of panic attack patients with and without major depression

Sixteen patients with panic attacks were treated with alprazolam at an anxiety clinic between March 1982 and April 1983. For all patients charts were reviewed for baseline data and treatment results at 1 and 6 months. Quantitated self-rating scales and the Clinical Global Impressions scale were used to assess progress. Alprazolam appeared effective for panic, agoraphobia, and depressive symptoms in 7 of 11 patients with either panic disorder or agoraphobia with panic attacks (DSM-III-defined diagnoses); side effects occurred in 4 of the 11 patients, were limited to oversedation, and resulted in no discontinuations of drug. However, alprazolam was ineffective in controlling panic, agoraphobia, and depression in 5 patients with panic attacks and secondary major depressive episode; for this group of patients, side effects were apparently paradoxical and required drug discontinuation in 3 of these 5 patients.     

Pharmacologic treatment of anxiety disorders

The benzodiazepines and the beta-adrenergic blockers are effective in the treatment of anxiety neurosis (generalized anxiety disorder and panic disorder) but offer little help in the treatment of agoraphobia and obsessive-compulsive disorders. The antidepressants are often effective in agoraphobia and obsessive-compulsive disorders, and the evidence suggests that their antipanic and antiobsessional effects may be independent of their antidepressant properties. There is suggestive evidence linking the antiobsessional effect to a specific neurotransmitter (serotonin) system.     

Cognitive-behavioural group treatment of panic disorder and agoraphobia in a psychiatric setting: A naturalistic study of effectiveness

The purpose of the present study was to investigate the effectiveness of cognitive-behavioural group treatment of panic disorder and agoraphobia in a clinical setting. Fifty-three patients were offered treatment and assessed before, after and at follow-up 1 1/2-2 years after treatment. The study included an informal waiting-list control group of 40 patients. The investigation group achieved better outcome on most analyses with 47.2% found to be panic-free after treatment compared with 12.5% in the control group. Treatment gains were durable with 66.7% without panic attacks at follow-up. Most patients, however, still had major psychological problems after treatment. The outcomes of cognitive-behavioural group treatment of panic disorder in this study were modest compared with most controlled studies, possibly due to an unselected patient group with a high degree of agoraphobia.