A Look At Panic Disorder with Agoraphobia

1. A Look At Panic Disorder with Agoraphobia Jennifer A. Roorda Laura Portman

2. HISTORY • Symptoms are mentioned as early as the 1600’s (Clarke & Wardman, 1985) • First coined its name by Westphal in Germany during the 1870’s (Clarke & Wardman, 1985) • The name was used to describe an intense dread or anxiety from having to walk in certain outdoor locations

3. HISTORY • In 1959 Klein studies effects of imipramine (McNally, 1994) • He finds it is effective against spontaneous panic attacks, but not against chronic anxiety • This implied a distinction between acute panic attacks and chronic anticipatory anxiety • This also prompted him to conceptualize agoraphobia as a consequence of panic

4. More HISTORY • Drafts of ICD-10 treat agoraphobia as an independent disorder rather than a complication of panic disorder (Horwath, 1993) • First included in DSM III (Clarke & Wardman, 1985) • DSM-III-R puts agoraphobia in a larger category of panic disorder (Horwath, 1993)

5. SYMPTOMS • Uncomfortable feelings growing into fear (Clarke & Wardman, 1985) • After succumbing to fears the day is spent feeling helpless and depressed • awareness of a “web of fear & a trap of unreason (Clarke & Wardman, 1985)

6. SYMPTOMS- continued • Seven domains of Panic- agoraphobic symptoms (Cassano, et al., 1997) • panic symptoms • anxious expectation • phobic features • sensitivity to: reassurance, substances, general stress, separation

7. SYMPTOMS- continued • Panic symptoms • panic attacks • according to DSM-IV, at least 4 out of 13 symptoms are required for diagnosis of panic attacks • limited symptom panic attacks may produce impairment similar to that of full-blown attacks • experiences most often associated with acute and intense anxiety: • unstable balance, sudden numbness, disorientation, “jelly legs,” tiredness, hypersensitivity to light, noise or heat

8. SYMPTOMS- continued • Anxious expectation • the following may be experienced in the absence of panic attacks: • anticipatory anxiety • focused on the occurrence of typical or atypical panic symptoms • a persistent general state of alertness • associated with a sense of insecurity, impotence, or impending menace with respect to physical and psychic integrity

9. SYMPTOMS- continued • Phobic and avoidant features • Avoidance • the attempt to cope with distress related to panic symptoms and anticipatory anxiety • this has temporary success in blocking panic • Illness phobia • misinterpretation of bodily sensations • fear and avoidance of medications • sleep phobia • fear of bad weather

10. SYMPTOMS- continued • Sensitivity to reassurance • reliance on others as a means of coping with insecurity • lack of a well-developed capacity for autonomous action • leads to the continuous desire for help from others • may cause peculiar interpersonal behavior • repeated requests for medical examinations and tests

11. SYMPTOMS- continued • Sensitivity to substances • chemicals and psychotropic medications • caffeine, recreational drugs, tricyclic antidepressants • these may trigger a full-blown panic attack • withdrawal symptoms may occur

12. SYMPTOMS- continued • Sensitivity to general stress • stressful life events • symptoms may occur in relation to minor stressors, such as day to day family problems, sleep deprivation, or overwork • onset may occur even after the relief of tension

13. SYMPTOMS- continued • Sensitivity to separation • dramatic reaction to loss (or the anticipation of it) • the end of a friendship or partnership, news of severe illness, sudden death of a loved one or pet. • Development of close and emotionally intense relationships characterized by dependence • often choose a partner on the basis of his or her high reliability as a companion.

14. DIAGNOSIS - DSM IV • Dominated by recurrent unexpected Panic Attacks • At least one attack is followed by 1 mo. (or more) of one (or more) of the following: • persistent concern about having additional attacks • worry about the implications of the attacks or their consequences • a significant change in behavior related to the attacks

15. DIAGNOSIS - DSM IV • It has been shown that panic attacks are not due to the direct physiological effects of a substance (drug abuse, medication) • The attacks are not better accounted for by another mental disorder, such as Social Phobia, Specific Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, or Separation Anxiety Disorder

16. DIAGNOSIS - DSM IV • The presence of Agoraphobia is evident when: • There is anxiety about being in places or situations from which escape might be difficult or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack. • Fears include being outside the home alone; being in a crowd or standing in line; being on a bridge; & traveling in a bus, train, or car. • Situations that have potential for causing attacks are avoided, or endured with great anxiety about having a panic attack

17. DIAGNOSIS- continued • There tends to be a phobic dependency on special people • this makes it easier to enter public arenas; fears are eased (Clarke & Wardman, 1985) • Some believe that agoraphobia precedes the onset of panic disorder • this is due to reports of patients who had their first attack in an agoraphobic situation • this was found more often in patients with panic disorder without agoraphobia (Fava, 1993).

18. ETIOLOGY • Agoraphobia is one of the most prevalent of all clinical phobias (Pollard, 1989) • Occurs at a frequency of 6 in 1000; makes up 50-80% of phobics seeking assistance (Goldstein, 1982) • Begins suddenly between the ages of 18 and 31 (thirteen percent of cases begin after age 40; it is least common at age 65 and above) (Clarke & Wardman, 1985; McNally, 1994)

19. ETIOLOGY- continued • 95% of unexpected attacks start after a great stress occurs (Clarke & Wardman, 1985) • 75% of cases are women; men are less likely to admit to weakness (Clarke & Wardman, 1985) • in addition, men must leave home to work (can act as therapy), while many married women can stay home or rely on a friend

20. ETIOLOGY- DSM IV • Lifetime prevalence: 1.5% - 3.5% One year prevalence: 1 - 2% • Development of agoraphobia is usually within one year of the occurrence of recurrent panic attacks • 1st degree biological relatives have a 4-7x’s greater chance of developing agoraphobia • Major depression often occurs in panic disorder patients (50-60%)

21. ETIOLOGY- continued • 70% of 130 patients at an anxiety disorders research clinic were also diagnosed with at least one additional but secondary axis I diagnoses (Sanderson, et al., 1990) • The most common additional diagnoses are simple and social phobia • Most patients report that onset occurs most often during stressful life events

22. ETIOLOGY- continued • Socioeconomic status of sufferers tends to be low • the less educated receive lower level jobs and are thus poorer financially. This leads to more serious symptoms (Chambless &Goldstein, 1982). • Personality type tends to be dependent • this can be caused by either: • growing up in an overprotective family or • having an unstable family life (Lilienferd, 1997)

23. ETIOLOGICAL THEORIES • Biological theory (Davison & Neale, 1998) • overactivity in the noradrenergic system, specifically in a nucleus in the pons called the locus ceruleus • yohimbine, a drug, can stimulate activity in the locus ceruleus and can elicit panic attacks in patients with panic disorder • however, recent research is not consistent with this view. Drugs that block firing in the locus ceruleus are not effective treatments.

24. ETIOLOGICAL THEORIES-cont • Panic disorder is linked to hyperventilation due to activated autonomic nervous system • lactate can also produce panic; the level may become elevated in patients with panic disorder and chronic hyperventilation • labs have found that increased levels of CO2 can cause a panic attack: thus oversensitive CO2 receptors could stimulate hyperventilation. • These findings occurred in 1 out of every 24 attacks • This is not a concrete theory

25. ETIOLOGICAL THEORIES-cont • Physiological theory (Davison & Neale, 1998) • fear-of-fear hypothesis • a fear of having an attack in public • unexplained physiological arousal in someone who is fearful of such sensations leads to panic attacks • control hypothesis • fear of losing control in public • fear of embarrassment

26. TREATMENTS • Drugs (Davison & Neale, 1998) • Benzodiazepines • example: alprazolam • these have been found to have some success, but must be continued otherwise symptoms will return if stopped • However, studies show that these have less long lasting effects on patients than cognitive-behavioral treatments (Brown & Barlow, 1995).

27. TREATMENTS- continued • Tricyclic antidepressants (Chambless & Goldstein, 1982) • antidepressants block spontaneous panic attacks • as of 1982, the FDA had not accepted panic attacks as an indication for antidepressants • Example: imipramine (Mavissakalian, 1992) • dosage should be carefully monitored since panic disorder patients are sometimes very sensitive to drug use (Swinson, 1992) • Along with use of this drug, persuasion, support, or minor tranquilizers are often required to help extinguish anticipatory anxiety.

28. TREATMENTS- continued • Systematic desensitization (Chambless & Goldstein, 1982) • patients are trained in muscular relaxation • they gradually move up a hierarchy of anxiety arousing situations while remaining relaxed • Either imagination or in vivo can be used • in vivo tends to be most successful • Flooding (Chambless & Goldstein, 1982) • maximize anxiety throughout treatment • this leads to extinction

29. TREATMENTS- continued • Self-management Procedure (Jacobson and Hollon, 1996) • a combination of flooding followed by self-observation • this is more effective than any single treatment • a viable alternative to drugs • Relaxation Training (Barlow, 1988) • combination of cognitive and behavioral intervention and exposure to internal cues that trigger panic • After two years, this was shown to have great success

30. PROGNOSIS • 60% of patients completing behaviorally based treatment show signs of improvement (Wade, et al., 1993) • According to DSM-IV, 6 - 10 years after treatment: • 30% are well • 40 - 50% are improved but symptomatic • 20 - 30% have symptoms that are the same or slightly worse

31. REFERENCES • American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.) Washington, D.C.: Author. • Describes the criteria for selecting agoraphobia as a diagnosis.

32. REFERENCES • Barlow, D.H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and panic. New York: Guilford. • Includes various disorders and describes their symptoms and what treatments are most successful. In particular relaxation training is recommended for agoraphobia.

33. REFERENCES • Brown, T.A. & Barlow, D.H. (1995).Long-term outcome in cognitive behavioral treatment of panic disorder: clinical predictors and alternative strategies for assessment. Journal of Consulting and Clinical Psychology,63, 754-765. • A discussion of the prognosis for panic disorder patients given cognitive behavioral treatment. Discusses the research that shows advantages to pyschosocial treatments.

34. REFERENCES • Cassano, G.B.; Michelini, S.; Shear, M.K. (1997). The panic-agoraphobic spectrum: A descriptive approach to the assessment and treatment of subtle symptoms. The American Journal of Psychiatry, 154, 26-38. • Provides an extensive look at panic-agoraphobia and proposes seven domains of symptoms to guide diagnosis.

35. REFERENCES • Chambless, D.L. & Goldstein, A.J. (1982). Agoraphobia: multiple perspectives on theory and treatment. New York: John Wiley & Sons. • Another full look at agoraphobia with descriptions of symptoms, etiology, prevelance, and multiple treatments including drug therapy, and in vivo exposure.

36. REFERENCES • Clarke, J.C., & Wardman, W. (1985). Agoraphobia: a clinical & personal account. New York: Pergamon Press. • The second author, Wardman, is a sufferer of agoraphobia and Clarke is the therapist. Together they constructed a book that describes the history, symptoms, etiology, and treatment of agoraphobia while also telling Wardman’s story of how he successfully got his life back.

37. REFERENCES • Davison, G.C. & Neale, J.M. (1998) Abnormal Psychology (7th ed.). New York: John Wiley & Sons, Inc. • Our class text, which provides an overview of agoraphobia; the sypmtoms, the etiology, and possible treatments.

38. REFERENCES • Fava, G.A. (1993). Assessment of onset of panic disorder in relation to onset of agoraphobia. The American Journal of Psychiatry, 150, 1436-1437. • Discusses the debate over the issue of whether agoraphobia precedes panic disorder, or if panic disorder comes first.

39. REFERENCES • Horwath, E., Lish, J.D., & Johnson, J. (1993). Agoraphobia without panic: clinical reappraisal of an epidemiologic finding. The American Journal of Psychiatry, 150, 1496-1501. • A look at whether agoraphobia can exist on its own with out panic disorder. Discusses the effects this might have on the classification of agoraphobia.

40. REFERENCES • Jocobson, N.S. & Hollon, S.D. (1996). Cognitive-behavior therapy versus pharmacotherapy: now that the jury’s returned its verdict, it’s time to present the rest of the evidence. Journal of Consulting and Clinical Psychology, 64, 74-80. • evidence from recent studies that pharmocotherapy is superior to cog-behavior therapy in treating depressed patients. However, cog-behavior therapy is a promising intervention for panic disorder.

41. REFERENCES • Lilienferd, S.O. (1997). The relation of anxiety sensitivity to higher and lower order personality dimensions: implications for the etiology of panic attacks. Journal of Abnormal Psychology, 106, 539-544. • Discusses the effects personality types might have on the likeliness of developing a panic disorder.

42. REFERENCES • Mavissakalian, M. (1992). Protective effects of imipramine maintenance treatment in panic disorder with agoraphobia. The American Journal of Psychiatry, 149, 1053-1057. • Discusses imipramines ability to block spontaneous panic attacks and its success rate of treating agoraphobia patients.

43. REFERENCES • McNally, R.J. (1994). Panic disorder: a critical analysis. New York: The Guilford Press. • McNally looks at Klein’s studies and discusses his findings in relation to imipramine (effective against spontaneous panic attacks, but not chronic anxiety). The article also describes Klein’s three types of panic (spontaneous, stimulus-bound, & situationally predisposed)

44. REFERENCES • Pollard, C.A., Pollard, H. J., & Corn, K.J. (1989). Panic onset and major events in the lives of agoraphobics: a test of contiguity. The Journal of Abnormal Psychology, 98:3, 318-321. • A study of the hypothesized temporal relationship between life events and panic onset in agoraphobic patients. Results showed a high percentage of agoraphobics experience at least one major life event during onset of panic.

45. REFERENCES • Sanderson, W.C., DiNardo, P.A., Rapee, R.M., & Barlow, D.H. (1990). Syndrome cormorbidity in patients diagnosed with a DSM III-R anxiety disorder. The Journal of Abnormal Psychology, 99:3,308-312. • 70% of patients with an anxiety disorder are diagnosed with at least one additional but secondary Axis I disorder; the most common is simple & social phobia.

46. REFERENCES • Swinson, R.P., Soulios, C., & Cox, B.J. (1992). Brief treatment of emergency room patients with panic attacks. The American Journal of Psychiatry, 149, 944-946. • A discussion of the special treatment required for panic attack patients in the emergency room; their fears can make it difficult. There is also a look at reasons for patients to arrive in the emergency room.

47. REFERENCES • Wade, S.L., Monroe, S.M., & Michelson, L.K. (1993). Chronic life stress and treatment outcome in agoraphobia with panic attacks. The American Journal of Psychiatry, 150, 1491-1495. • This article discusses the role chronic life stress has on recovery. Those who experienced chronic stressors in their life had less significant improvements than other patients; The level of chronicity makes the difference.