Agoraphobic Patients Research Articles

Virtual Reality Exposure Therapy Does Not Provide Any Additional Value in Agoraphobic Patients: A Randomized Controlled Trial

Background: A number of studies have demonstrated the efficacy of virtual reality exposure therapy (VRET) in specific phobias, but research in seriously impaired patients with agoraphobia is lacking. In this randomized controlled trial with patients with agoraphobia and panic disorder, VRET and exposure in vivo were compared in terms of outcome and processes involved. Methods: Patients with panic disorder with agoraphobia (n = 55) were randomly assigned to receive 4 sessions of cognitive behavioral therapy (CBT) followed by either 6 sessions of VRET or 6 sessions of exposure in vivo or to a waiting list control condition. Results: Analyses showed that both active treatment packages were significantly more effective than no treatment and that no differences between VRET and exposure in vivo were found in three out of four outcome measures. On the panic disorder severity scale, however, CBT plus exposure in vivo was more effective than CBT plus VRET. The results show clear synchrony of temporal processes involved in VRET and exposure in vivo on weekly avoidance measures and cognitive measures. Further, it was shown that initial changes in agoraphobic cognitions during the CBT phase predicted later changes in agoraphobic avoidance behavior. Conclusion: These data support the notion that therapeutic processes involved might be the same in VRET and exposure in vivo. However, given the slight superiority of exposure in vivo above VRET, the costs involved in the implementation of VRET and the lack of long-term follow-up, VRET cannot yet be recommended for patients with agoraphobia.

633 – Integrative psychotherapy model of anxiety disorders

At the present time in Ukraine the special priority has the problem of somatoform disorders. A prevalence of clinical somatization neurotic disturbances and necessity of differential diagnostics with somatic diseases were the precondition for studying this area. At the same time, in Ukraine the diagnosis “Vegetative-vascular dystonia” which is ciphered G 90.8, according to ICD-10 instead of “Somatoform disoders” F40.0-F48 is used. It leads unreasonable treatment significant contingents of neurotic patients in neurological departments. The 60 agoraphobia patients and 40 panic disorder (PD) patients were examined. The emotional disturbances of all thease patients were investigated with the clinic and pathopsychological methods. The high level of anxiety was shown. Pathopsychologically the high level of personality anxiety and low level of neurotism and depression were indentified. The system of psychotherapy correction was established, with high efficacy in 68% cases. On that ground has been developed complex differential system of medical- psychological and psychotherapy correction of agoraphobia, PD and somatoform disorders with the - 80% high efficasy. Our experience showed the necessity of the integrative models of psychotherapy provided, parted on stage. On the first stage - sedative-adapting the receptions of cognitive and suggestive psychotherapy are used. There is groupe therapy on second-main-stage. On the third stagetupesupportive elements of the autogenic training mastered.

Dynamics of Defensive Reactivity in Patients with Panic Disorder and Agoraphobia: Implications for the Etiology of Panic Disorder

The learning perspective of panic disorder distinguishes between acute panic and anxious apprehension as distinct emotional states. Following animal models, these clinical entities reflect different stages of defensive reactivity depending upon the imminence of interoceptive or exteroceptive threat cues. The current study tested this model by investigating the dynamics of defensive reactivity in a large group of patients with panic disorder and agoraphobia (PD/AG). Three hundred forty-five PD/AG patients participated in a standardized behavioral avoidance test (being entrapped in a small, dark chamber for 10 minutes). Defense reactivity was assessed measuring avoidance and escape behavior, self-reports of anxiety and panic symptoms, autonomic arousal (heart rate and skin conductance), and potentiation of the startle reflex before and during exposure of the behavioral avoidance test. Panic disorder and agoraphobia patients differed substantially in their defensive reactivity. While 31.6% of the patients showed strong anxious apprehension during this task (as indexed by increased reports of anxiety, elevated physiological arousal, and startle potentiation), 20.9% of the patients escaped from the test chamber. Active escape was initiated at the peak of the autonomic surge accompanied by an inhibition of the startle response as predicted by the animal model. These physiological responses resembled the pattern observed during the 34 reported panic attacks. We found evidence that defensive reactivity in PD/AG patients is dynamically organized ranging from anxious apprehension to panic with increasing proximity of interoceptive threat. These data support the learning perspective of panic disorder.

The use of VR in the treatment of panic disorders and agoraphobia.

Panic disorder with agoraphobia (PDA) is considered an important public health problem. The efficacy of cognitive-behavioral therapy (CBT) for PDA has been widely demonstrated. The American National Institute of Health recommended Cognitive-Behavioral programs as the treatment of choice for this disorder. This institution also recommended that researchers develop treatments whose mode of delivery increases the availability of these programs. Virtual Reality based treatments can help to achieve this goal. VR has several advantages compared with conventional techniques. One of the essential components to treat these disorders is exposure. In VR the therapist can control the feared situations at will and with a high degree of safety for the patient, as it is easier to grade the feared situations. Another advantage is that VR is more confidential because treatment takes place in the therapist's office. It is also less time consuming as it takes place in the therapist's office. Considering the wide number of situations and activities that agoraphobic patients use to avoid, VR can save time and money significantly. Another advantage in treating PDA using VR is the possibility of doing VR interoceptive. VR could be a more natural setting for interoceptive exposure than the consultation room because we can elicit bodily sensations while the patient is immerse in VR agoraphobic situations. Finally, we think that VR exposure can be a useful intermediate step for those patients who refuse in vivo exposure because the idea of facing the real agoraphobic situations is too aversive for them. In this chapter we offer the work done by our research team at the VEPSY-UPDATED project. We describe the VR program we have developed for the treatment of PDA and we summarize the efficacy and effectiveness data of a study where we compare a cognitive-behavioral program including VR for the exposure component with a standard cognitive-behavioral program including in vivo exposure and with a waiting list control condition. Our findings support the efficacy and effectiveness of VR for the treatment of PDA.

Panic agoraphobic spectrum in psychiatrically healthy subjects: Impact on quality of life

Several studies have evaluated the quality of life (QOL) in patients with Panic Disorder (PD). For instance, the Epidemiological Catchment Area Study (ECA) assessed the quality of life (QoL) using the subjective evaluation of health, psychosocial functioning and financial status as parameters (Regier et al., 1984). Among the general population, people with PD or panic attacks reported a low level of physical health in 35% of cases and a low degree of mental health in 38% of cases, similarly to people suffering from Major Depressive Disorder (29% and 39% respectively), but more frequently than the in individuals not affected by any disorder (24% and 12% respectively). Furthermore, 27% of patients with PD were in need of some form of social or financial support in contrast to 16% of people suffering from depression and 12% of unaffected people. The National Comorbidity Survey (NCS) (Magee et al., 1996) found serious interference in activities in 27% of agoraphobic patients. For instance, the agoraphobic subjects reported an average of 1.1 days of work lost in the previous month due to their psychopathology. Several Authors have studied the relationship between PD and a worse quality of life and/or a worse ability to function. In a review on the topic, Mendlowicz & Stein (2000) provided an integrated view of the issue of quality of life in patients with anxiety disorders and concluded that the existing studies almost uniformly show a marked impairment of quality-of-life and psychosocial functioning in individuals with anxiety disorders. However, as noted by the Authors above, “despite the growing number of studies undertaken during the past 15 years, the investigation of quality of life in individuals with anxiety disorders is still in its infancy.” Rucci et al. (1993) evaluated the prevalence of subthreshold psychiatric disorders in primary care and their association with the patients health perception, disability in daily activities and psychological distress Subjects with subthreshold disorders reported levels of psychological distress, disability in daily activities and perceived health comparable to those of patients with full-fledged ICD-10 disorders. Despite the scientific and clinical importance of the topic, relatively few studies have evaluated the prevalence and impact of subthreshold affective disorders in general (Schotte & Cooper, 1999) and panic symptoms in particular (for instance Bellini & Galverni, 2003) in non psychiatric populations. Moreover, the literature on the relationship between sub-threshold or residual PD and quality of life is scant. To this end, we decided to investigate the impact of panic-agoraphobic “spectrum” on the quality of life of subjects who did not meet the criteria for a full blown PD. We adopted the definition of “spectrum” developed by Cassano and colleagues (Cassano & Pini, 2000; Rucci & Maser, 2000), which refers to a dimensional view of psychopathology that includes a broad array of manifestations of the target disorder, including its most severe symptoms as well as a range of more subtle features related to the core condition, which may include temperamental traits, prodromal indicators, or residual symptoms. Although they are frequently associated with specific DSM-IV disorders, these conditions are also found in individuals who have never met full DSM-IV diagnostic criteria. Our hypothesis for this study was that the presence of subthreshold panic-agoraphobic symptomatologies in otherwise healthy individuals would significantly impair the quality of life despite the absence of a full-blown PD diagnosis.

Interpersonal Aspects of Agoraphobia:: Therapeutic Implications

Evidence that interpersonal, marital, and family variables are significant factors in the onset and maintenance of Panic Disorder with Agoraphobic symptoms is reviewed. The implications of this evidence for the evaluation of therapy outcome studies are discussed and questions are raised about the interpretation of results of previous studies. Attempts to integrate cognitive-behavioral with marital interventions in the treatment of agoraphobia are described. It is suggested that attempts to broaden the focus of therapy with agoraphobic patients to include dyadic interactions, while helpful, may be insufficient because they ignore cross generational triadic patterns observed to be of significance in agoraphobic problems. Aspects of a multi-level systems approach to information gathering and the design of therapeutic interventions with agoraphobic patients are described and discussed.

Change in interpersonal problems after cognitive agoraphobia and schema‐focused therapy versus psychodynamic treatment as usual of inpatients with agoraphobia and Cluster C personality disorders

The aim was to study whether patients with panic disorder with agoraphobia and co-occurring Cluster C traits would respond differently regarding change in interpersonal problems as part of their personality functioning when receiving two different treatment modalities. Two cohorts of patients were followed through three months' in-patient treatment programs and assessed at follow-up one year after end of treatment. The one cohort comprised 18 patients treated with "treatment as usual" according to psychodynamic principles, the second comprised 24 patients treated in a cognitive agoraphobia and schema-focused therapy program. Patients in the cognitive condition showed greater improvement in interpersonal problems than patients in the treatment as usual condition. Although this quasi-experimental study has serious limitations, the results may indicate that agoraphobic patients with Cluster C traits should be treated in cognitive agoraphobia and schema-focused programs rather than in psychodynamic treatment as usual programs in order to reduce their level of interpersonal problems.

Emptiness in Agoraphobic Patients: Commentary On Milrod

Emptiness in Agoraphobic Patients: Commentary On Milrod

Emptiness in Agoraphobia Patients

In light of new research findings about the efficacy of psychodynamic treatment for panic disorder and agoraphobia, it seems a prudent time to carefully address psychoanalytic thinking about the treatment of agoraphobia. The literature has highlighted oedipal contributions to its genesis and clinical unraveling in psychoanalysis. While those contributions are indeed central to the disorder, structural deficits in the self-representation often become a central focus of treatment once symptomatic remission has been achieved in psychoanalytic treatment. This aspect of the clinical presentation of agoraphobia has not yet been specifically addressed in the psychiatric literature. Some aspects of the phenomenon have been described by psychoanalysts. It is more difficult to treat this "emptiness" than the overt symptoms of agoraphobia, as described in DSM-IV. Nonetheless, this phenomenon may be one of the contributors to the chronicity of the disorder. Two clinical cases illustrate these points.

Panic disorder subtypes: further clinical differences

Panic disorder (PD) is a heterogeneous phenomenon with respect to symptom profile. Most studies agree that a group of patients with prominent respiratory symptoms emerged as a distinct PD subtype. In this study we compared a range of clinical features associated with PD and agoraphobia in patients with respiratory (RS) and nonrespiratory (NRS) subtypes of PD. The participants were 124 patients with PD (79 women and 45 men), with or without agoraphobia, diagnosed by DSM-IV criteria. Following the observer-rated Panic Disorder Severity Scale assessment, subjects completed self-report measures, including the Anxiety Sensitivity Index (ASI), Panic-Agoraphobia Scale; the Beck Anxiety Inventory; and the Panic-Agoraphobic Spectrum Scale (PAS-SR). Multivariate analysis of variance (MANOVA) showed significant group differences [Pillai's trace = 0.95, F (5, 118)(=)2.48, P = .036]. Patients in RS group had higher mean total scores on the ASI (F = 5.00, df = 1, P = .027) and PAS-SR (F = 11.23, df = 1, P = .001) than patients in NRS group. Also, patients with RS attained higher scores than patients with NRS on four domains of PAS-SR (panic-like symptoms, agoraphobia, separation sensitivity, and reassurance seeking). A descriptive discriminant analysis of the data correctly identified 69.4% of the patient group in general and 86.1% of RS group (Wilks's lambda = 0.87, df = 8, P = .048). The significant discriminating factors of the RS and NRS groups were domains of panic-like symptoms, agoraphobia, separation sensitivity, and reassurance seeking. Our findings suggest that anxiety sensitivity and panic-agoraphobic spectrum symptoms might be particularly relevant to understanding subtypes of PD.

The role of parenting experiences in the development of social anxiety and agoraphobia in the eating disorders

While social anxiety and agoraphobia are commonly observed in patients with eating disorders, little is known about the types of family environment that may predispose patients to the development of these types of comorbid anxiety problem. The present study investigated whether social anxiety and agoraphobia in patients with eating disorders are linked to different types of parenting experiences. A sample of 70 women meeting DSM-IV criteria for an eating disorder completed self-report measures of social anxiety, agoraphobia and perceived parenting experiences. Social anxiety in patients with eating disorders is associated with emotionally inhibited parenting by fathers (i.e., parenting that reflects a lack of ability to share feelings with the child), while agoraphobia is associated with anxious/fearful parenting by mothers (i.e., parenting that reflects anxious, fearful traits in the parent and a pessimistic outlook on life). Specific parenting experiences may contribute to the development of comorbid social anxiety and agoraphobia in patients with eating disorders. Implications for future research and clinical practice are discussed.

High sensitivity to multisensory conflicts in agoraphobia exhibited by virtual reality

The primary aim of this study was to evaluate the effect of auditory feedback in a VR system planned for clinical use and to address the different factors that should be taken into account in building a bimodal virtual environment (VE). We conducted an experiment in which we assessed spatial performances in agoraphobic patients and normal subjects comparing two kinds of VEs, visual alone (Vis) and auditory–visual (AVis), during separate sessions. Subjects were equipped with a head-mounted display coupled with an electromagnetic sensor system and immersed in a virtual town. Their task was to locate different landmarks and become familiar with the town. In the AVis condition subjects were equipped with the head-mounted display and headphones, which delivered a soundscape updated in real-time according to their movement in the virtual town. While general performances remained comparable across the conditions, the reported feeling of immersion was more compelling in the AVis environment. However, patients exhibited more cybersickness symptoms in this condition. The result of this study points to the multisensory integration deficit of agoraphobic patients and underline the need for further research on multimodal VR systems for clinical use.

The Shocking Story of Azimilide

Initially tested for the secondary prevention of life-threatening ventricular arrhythmias in survivors of cardiac arrest,1 the effectiveness of implantable cardioverter-defibrillator (ICD) therapy has recently been validated for the primary prevention of sudden cardiac death in high-risk patients with left ventricular (LV) dysfunction.2,3 Despite an improvement in survival (30% relative risk reduction) comparable to that of β-blockers4 or angiotensin-converting enzyme (ACE) inhibitors,5 ICD therapy remains limited by impairment in quality of life in some of its recipients. As may be expected, the psychosocial consequences of device implantation, including anxiety disorders, depression, phobias, and sexual and employment problems, have been linked to the frequency of ICD discharges.6 In a recent publication, Godemann et al7 demonstrated a 3-fold increase in panic disorders and agoraphobia in patients with ≥2 ICD shocks annually. When severe enough, these symptoms necessitate psychiatric intervention8 or, in extreme cases, even device explantation. See p 3646 Enhancements in detection algorithms have reduced the rate of inappropriate shocks for supraventricular arrhythmias,9 and the empirical programming of antitachycardia pacing (ATP) has proved effective in reducing the frequency of shocks for conversion of ventricular tachycardia (VT). Nevertheless, ATP has been routinely programmed only in patients with slower VTs, despite recent data suggesting its effectiveness as an initial therapy in faster VTs up to 250 bpm. In the PainFREE Rx (Does PA c IN g F ast VT RE duc E Shock Rx ) trial, this strategy of “aggressive” programming resulted in a significant improvement in quality of life without compromising patient safety,10 further confirming the negative impact of recurrent shocks on psychosocial functioning. Regardless of programming preferences, ATP therapy is ineffective in some patients, particularly those with polymorphic VT or ventricular fibrillation (VF). Radiofrequency catheter ablation of recurrent symptomatic monomorphic VT is an alternative form …

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-β-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.

Panic disorders and agoraphobia: side effects of treatment with an implantable cardioverter/defibrillator.

Implantable cardioverter/defibrillator (ICD) treatment has reduced the mortality of patients with a high risk of sudden cardiac death. However, ICD discharges may cause anxiety with respect to new discharges and lead to preventive, for example, phobic, behavior. This study evaluated the frequency of panic disorders and agoraphobia in patients with ICD and assessed the risk factors in their development. Treatment with ICD represents a risk factor in the development of anxiety disorders. Ninety patients with ICD were examined using a standardized lifetime Diagnostic Interview of Psychiatric Syndromes (DIPS). This interview makes it possible to estimate the incidence of panic disorders and agoraphobia. The impact of the severity of the underlying cardiac disease, the number of ICD discharges, and the subjective appraisal of the shock experience on the development of panic disorders and agoraphobia was assessed. Fifteen patients (16.7%) developed anxiety disorders after ICD implantation. The incidence was 21% in patients with and 6.9% in patients without ICD discharge. In patients with two or more ICD discharges annually, the incidence of panic disorders and agoraphobia was higher than that in patients with a single ICD discharge annually (62 vs. 10%, p<0.01). The intensity of self-observation of their body was significantly related to the development of anxiety disorders (p<0.001). Panic disorders and agoraphobia are frequent side effects of ICD treatment. Risk factors in the development of these disorders are two or more ICD discharges annually and a negative cognitive appraisal of ICD discharges. Therapeutic efforts should aim at reducing the number of ICD discharges and provide early psychological treatment.

Coping behavior in patients with panic disorder.

The purpose of the present paper was to investigate the role of coping behavior in patients with panic disorder (PD). This was done by evaluating three items of coping behavior (seeking of social support, wishful thinking and avoidance) in the Ways of Coping Checklist. The subjects consisted of 30 patients with PD (26 with agoraphobia). Coping behavior and the severity of PD was investigated at baseline and at 24 months (the final outcome). At baseline there were no gender differences in coping behavior. The severity of panic attacks significantly correlated with that of agoraphobia. The baseline severity of PD (panic attacks and agoraphobia) did not correlate with coping behavior. At the outcome assessment there was no significant correlation between the severity of panic attack and coping behavior. The severity of agoraphobia at final outcome and the coping behavior (seeking of social support) at baseline were significantly correlated. In the group that had remission in agoraphobia (the good outcome group), the severity of agoraphobia at baseline was significantly lower and the seeking of social support coping behavior was significantly higher than that of the poor outcome group. No significant difference in panic attack severity was noted between the good and poor outcome groups. Discriminant analysis revealed that seeking of social support coping behavior was a significant discriminant factor of agoraphobia. Although these are preliminary data, special coping behavior might be related to improvement of agoraphobia in patients with PD.

Styles of adaptation in panic disorder with and without agoraphobia.

Two groups of women with a main DSM-IV diagnosis of panic disorder, one with and one without agoraphobia (respectively, n = 26 and n = 14) were compared on several clinical variables. Forward logistic regressions were run for the presence of agoraphobia. Age of onset, duration of illness, presence of major depressions, and cluster classification on Axis II did not predict the criterion variable. Diagnosis and scores on avoidant personality disorder led, respectively, to 65% and 72.5% rates of correct classifications. Among panic symptoms, fear of going crazy and palpitations significantly predicted agoraphobia (75% of correct allocations). Three adaptive variables assessed by the Serial Color-Word Test (a serial version of the Stroop task) led to a 90% rate of correct classification. Agoraphobic patients were mainly characterized by an anxious or over-controlling style, which permitted a pseudo-objective mastery of the conflict situation. The findings seem to support the clinical relevance of the Serial Color-Word Test.

Sympathetic reactivity in agoraphobic patients with and without personality disorders

Objective: To compare sympathetic activity in agoraphobic patients with and without personality disorders before and after 11 weeks inpatient treatment. Methods: Agoraphobic patients ( n=38), 84% with panic disorder and 47% with personality disorders underwent cold pressure test (CPT), mental stress test (MST), and a specific anxiety test (SAT). Psychological assessments were done by the Bodily Sensations Questionnaire (BSQ), the Agoraphobic Cognitions Questionnaire (ACQ), Spielberger STAI-1 and -2, and a Stress Test Anxiety (STA) questionnaire. Sympathetic activity was measured by blood pressure, heart rate, epinephrine, and norepinephrine. Results: The sympathetic activity did not differ significantly between patient groups, and the reactivity to stress was very low. The sympathetic reactivity remained unchanged after treatment, whereas psychiatric symptoms decreased. Correlations between sympathetic activity and psychological distress were not significant. Conclusion: Interpretation of bodily signals seems to be more important than the actual sympathetic activity in agoraphobic patients.

Relationship Between Perfectionism and Agoraphobia in Patients with Panic Disorder

We investigated the relationship between perfectionism and agoraphobia in 59 panic disorder patients with agoraphobia, 44 panic disorder patients without agoraphobia and 35 healthy controls using Frost's Multidimensional Perfectionism Scale. The panic disorder with agoraphobia group scored significantly higher than the panic disorder group or the healthy controls on the Frost's Multidimensional Perfectionism Scale subscales regarding concern over mistakes, personal standards, parental criticism and on the total Frost's Multidimensional Perfectionism Scale score. In logistic regression analyses, the Frost's Multidimensional Perfectionism Scale total score was the only predictor variable that made a significant unique contribution to the prediction of agoraphobia. These results suggest that perfectionistic beliefs and tendencies may be involved in the development and maintenance of agoraphobia in patients with panic disorder and thus should be considered as a target for cognitive behavioural therapy.

Comparisons of Different Measures for Cognitions in Agoraphobic Patients

According to the cognitive models of panic disorder with and without agoraphobia, patients engage in catastrophic cognitions when anxious. An important question to address is the relationship between measures used in previous research. The present study compares different measures of cognitive material from the same sample of 70 patients with panic disorder with agrophobia. Cognitions were assessed through questionnaires, interview and self-monitoring during a behavioural avoidance test. No congruence between the different measures of cognitive material was found. Furthermore, cognitions collected through interview were more in line with the assumptions derived from the cognitive model, than were cognitions reported through self-monitoring. To answer the question whether this is due to methodological inadequacy or whether it reflects the state of affairs requires future research.