Panic Disorder With Agoraphobia Patients Research Articles

Panic attack provocation in panic disorder patients with a computer simulation

BackgroundComputer simulations (CS) and virtual reality exposure are promising techniques for research and treatment of panic disorder with agoraphobia (PDA). The objective of this study was to ascertain whether a given CS was a stimulus capable of producing panic attacks (PAs), anxiety and psychophysiological changes in patients with PDA. MethodsThirty PDA patients and 30 healthy subjects were recruited for this study. Subjects were exposed to a 3-min CS of a situation relevant to agoraphobic patients. Anxiety, panic symptoms, PAs, heart rate, skin conductance and respiration were recorded before, during and after the CS exposure. ResultsThe CS effectively induced anxiety, hyperventilation and electrodermal responses in PDA patients but not in healthy subjects. Forty percent of PDA patients had a PA while none of the control subjects had a PA. A subgroup of patients who were less sensitive to the CS than the other subgroup of PDA patients and did not present full-blown PAs still had more panic symptoms, higher anxiety levels and more respiratory irregularities than the controls. LimitationsLow immersion and low sense of presence, lack of interaction with the environment. ConclusionsExposure to the CS produced effects similar to in vivo exposure, respiratory and caffeine challenges. Subsequent studies should: make direct comparisons between CS and other challenges for PDA; investigate if CS can be a tool for predicting effects of medication; determine the potential of CS as a desensitization technique for situational PAs.

Cognitive models for panic disorder with agoraphobia: A study of disaggregated within-person effects.

The purpose of this study was to test 2 cognitive models of panic disorder with agoraphobia (PDA)-a catastrophic cognitions model and a low self-efficacy model-by examining the within-person effects of model-derived cognitive variables on subsequent anxiety symptoms. Participants were 46 PDA patients with agoraphobic avoidance of moderate to severe degree who were randomly allocated to 6 weeks of either cognitive therapy, based on the catastrophic cognitions model of PDA, or guided mastery (guided exposure) therapy, based on the self-efficacy model of PDA. Cognitions and anxiety were measured weekly over the course of treatment. The data were analyzed with mixed models, using person-mean centering to disaggregate within- and between-person effects. All of the studied variables changed in the expected way over the course of therapy. There was a within-person effect of physical fears, loss of control fears, social fears, and self-efficacy when alone on subsequent state anxiety. On the other hand, within-person changes in anxiety did not predict subsequent cognitions. Loss of control and social fears both predicted subsequent self-efficacy, whereas self-efficacy did not predict catastrophic cognitions. In a multipredictor analysis, within-person catastrophic cognitions still predicted subsequent anxiety, but self-efficacy when alone did not. Overall, the findings indicate that anxiety in PDA, at least in severe and long-standing cases, is driven by catastrophic cognitions. Thus, these cognitions seem to be useful therapeutic targets. (PsycINFO Database Record

Functional MRI activation in response to panic-specific, non-panic aversive, and neutral pictures in patients with panic disorder and healthy controls.

There is evidence that besides limbic brain structures, prefrontal and insular cortical activations and deactivations are involved in the pathophysiology of panic disorder. This study investigated activation response patterns to stimulation with individually selected panic-specific pictures in patients with panic disorder with agoraphobia (PDA) and healthy control subjects using functional magnetic resonance imaging (fMRI). Structures of interest were the prefrontal, cingulate, and insular cortex, and the amygdalo-hippocampal complex. Nineteen PDA subjects (10 females, 9 males) and 21 healthy matched controls were investigated using a Siemens 3-Tesla scanner. First, PDA subjects gave Self-Assessment Manikin (SAM) ratings on 120 pictures showing characteristic panic/agoraphobia situations, of which 20 pictures with the individually highest SAM ratings were selected. Twenty matched pictures showing aversive but not panic-specific stimuli and 80 neutral pictures from the International Affective Picture System were chosen for each subject as controls. Each picture was shown twice in each of four subsequent blocks. Anxiety and depression ratings were recorded before and after the experiment. Group comparisons revealed a significantly greater activation in PDA patients than control subjects in the insular cortices, left inferior frontal gyrus, dorsomedial prefrontal cortex, the left hippocampal formation, and left caudatum, when PA and N responses were compared. Comparisons for stimulation with unspecific aversive pictures showed activation of similar brain regions in both groups. Results indicate region-specific activations to panic-specific picture stimulation in PDA patients. They also imply dysfunctionality in the processing of interoceptive cues in PDA and the regulation of negative emotionality. Therefore, differences in the functional networks between PDA patients and control subjects should be further investigated.

FC25-02 - Functional MRI activation in response to panic-specific, non-panic aversive, and neutral imagery in patients with panic disorder and healthy controls

IntroductionThere is evidence that, besides limbic brain structures, prefrontal and insular cortical activations and deactivations are involved in the pathophysiology of panic disorder.Objectives and aimsUsing fMRI, this study investigated BOLD response patterns to stimulation with individually selected panic-specific pictures in patients with panic disorder with agoraphobia (PDA) and healthy controls. Structures of interest were the prefrontal, cingulate, and insular cortex, and the amygdalo-hippocampal complex.Methods21 PDA subjects (12 female, 9 male) and 21 matched controls were investigated using a Siemens 3 T scanner. Before, PDA subjects gave ratings on 120 pictures showing characteristic panic/agoraphobia situations (PA). 20 pictures with the individually highest ratings were selected. 20 matching pictures showing aversive but not panic-specific stimuli (A) and 80 neutral pictures (N) from the International Affective Picture-System (IAPS) were chosen for each subject. Anxiety and depression ratings were recorded.ResultsGroup comparisons revealed a significantly greater BOLD response in PDA subjects than in controls in the insular cortices, left inferior frontal gyrus, dmPFC, the left hippocampal formation, and left caudatum (p < .005), when PA and N responses were compared. Group comparisons for stimulation with A compared to PA showed activation of similar brain regions in both groups but with different peak coordinates.ConclusionsResults indicate specific activation patterns to panic-specific picture stimulation in PDA patients. Distinct peak coordinates between PA and A differ between groups. This might implicate that the brain circuits underlying processing of aversive stimuli might differ in their function in PDA patients compared to healthy subjects.

Marital Interactions in Predicting Treatment Outcome in Panic Disorder with Agoraphobia

Abstract — T his study had two goals. First, it investigated marital interaction variables as predictors of treatment outcome in panic disorder with agoraphobia (PDA) in sixty-five couples with one spouse suffering from PDA. Second, it analyzed the impact of PDA improvement, following therapy, on marital interaction patterns of both spouses. The partners were observed during a problem-solving task, before and after treatment. Negative behaviors at the outset of therapy, both in the PDA and the NPDA partners, predicted less improvement at post-test. It also appears that improvement in some PDA symptoms following therapy is linked to increase in the dominant behavior of the NPDA spouse and to an improvement in terms of his intrusiveness. Keywords — Communication and problem-solving skills, Emotional overinvolvement, Marital relationship, Panic disorder with agoraphobia, Treatment outcome. . I. I NTRODUCTION ANIC disorder with agoraphobia (PDA) afflicts 1.5 to six percent of the population yearly [1], [2] and causes severe limitations to the individual and high costs for society [3]. When compared to individuals without PDA, PDA patients tend to be more dependent, less self-confident, more submissive, and more demanding towards their spouses and to generate fewer effective solutions during problem-solving tasks [4]-[7]. They are more likely to have the impression of being criticized and are more irritable and hostile [8]-[10]. Several studies link the onset, severity and evolution of PDA following treatment to interpersonal conflicts, marital stress, family problems, poor problem-solving skills, and expressed emotions in non-PDA spouses [6], [11]-[15]. Although PDA seems to negatively affect the couple, the marital relationship can contribute to the development and maintenance of the disorder.

Nonhomogeneous results in place learning among panic disorder patients with agoraphobia

Patients affected by panic disorder with agoraphobia (PDA) often suffer from visuo-spatial disturbances. In the present study, we tested the place-learning abilities in a sample of 31 PDA patients compared to 31 healthy controls (CTR) using the computer-generated arena (C-G Arena), a desktop-based computer program developed at the University of Arizona (Jacobs et al 1997, for further detail about the program, see http://web.arizona.edu/~arg/data.html). Subjects were asked to search the computer-generated space, over several trials, for the location of a hidden target. Results showed that control subjects rapidly learned to locate the invisible target and consistently returned to it, while PDA patients were divided in two subgroups: some of them (PDA-A) were as good as controls in place learning, while some others (PDA-B) were unable to learn the correct strategies to find the target. Further analyses revealed that PDA-A patients were significantly younger and affected by panic disorder from less time than PDA-B, indicating that age and duration of illness can be critical factors that influence the place-learning abilities. The existence of two different subgroups of PDA patients who differ in their spatial orientation abilities could provide new insight into the mechanisms of panic and open new perspectives in the cognitive–behavioral treatment of this diffuse and disabling disorder.

Anxiogenic properties of a computer simulation for panic disorder with agoraphobia

BackgroundThere are several useful methods to induce anxiety in patients with panic disorder with agoraphobia (PDA). Our aim was to ascertain if a computer simulation (CS) could induce anxiety and physiologic alterations in PDA patients. Methods10 healthy controls (HC) and 10 patients who fulfilled DSM-IV criteria for PDA were recruited for this study. The anxiety level was measured with the Subjective Units of Distress Scale (SUDS) and the Diagnostic Symptom Questionnaire (DSQ) was used to ascertain panic attack (PA) symptoms. The heart rate, skin conductance and respiration were monitored during exposure to the CS. The CS was a 3D computer animation of a short bus trip, from a first person perspective. ResultsIn PDA patients CS exposure increased anxiety levels, they also had higher scores in the DSQ and two of them had PA. Compared to the HC, the PDA patients had higher skin conductance level, electrodermal response magnitude, respiratory rate, tidal volume, and respiratory rate irregularities. The heart rate means were higher for PDA patients who had PA, followed by HC and PDA patients who did not have PA. There were no significant differences between the two groups regarding the sense of presence. LimitationsThe main limitations were the small sample size, and some PDA patients under medications. ConclusionsThis study indicated that CS exposure may induce anxiety, electrodermal and respiratory alterations in patients with PDA. CS exposure may be a useful tool in the research and treatment of PD patients.

P01-135 - Anxiogenic properties of a virtual reality simulation for panic disorder with agoraphobia

ObjectivesThere are several useful methods to induce anxiety in patients with panic disorder with agoraphobia (PDA). Our aim was to ascertain if a virtual reality simulation could induce anxiety and physiologic alterations in PDA patients.Methods10 healthy controls (HC) and 10 patients who fulfilled DSM-IV criteria for PDA were recruited for this study. Before and after the experiment the anxiety level was measured with the Subjective Units of Distress Scale (SUDS), the Diagnostic Symptom Questionnaire (DSQ) was used to ascertain panic attack symptoms. The heart rate, skin conductance and respiration parameters were monitored during the exposure to the VR. The virtual reality simulation was a 3D computer animation of a short bus trip, from a first person perspective. The Igroup Presence Questionnaire (IPQ) was used to measure the sense of presence.ResultsPDA patients had higher familial history of panic disorder. From the 10 PDA patients only 3 were not taking medications. In PDA patients the VR exposure increased anxiety levels, they also had higher scores in the DSQ and two of them had panic attacks. Compared to the HC, the PDA patients had higher skin conductance levels, electrodermal response magnitude, respiratory rate, tidal volume, and respiratory rate irregularities. The heart rates were higher for patients who had panic attacks, followed by the HC and the non-panicking patients. Regarding the sense of presence the two groups were similar.ConclusionThis study indicated that VR exposure may induce anxiety, electrodermal and respiratory alterations in patients with PDA.

A transdiagnostic comparison of trauma and panic memories in PTSD, panic disorder, and healthy controls

Inadequate processing of trauma information is considered to lead to particularly vivid recollections and disorganized memories of the trauma. Although trauma memories have mainly been investigated in PTSD, memories in other psychiatric disorders may actually share some characteristics. This may particularly be true for patients with panic disorder with agoraphobia (PDA) as a first panic attack resembles trauma. To test this hypothesis, PTSD trauma memories ( n = 59) were compared with PDA panic memories ( n = 58), and trauma memories of healthy trauma victims ( n = 135) on self-reported re-experiencing and disorganization. PTSD trauma memories had more re-experiencing elements than memories of the other two groups, although PDA memories had more re-experiencing elements than the controls' trauma memories. Relative to the controls, PTSD and PDA memories were disorganized. Peritraumatic dissociation and current memory-associated dissociation were also high in PTSD and PDA patients compared to the controls. Implications of these results are discussed.

Marital predictors of symptom severity in panic disorder with agoraphobia

Twenty-six to forty percent of individuals suffering from panic disorder with agoraphobia (PDA) do not benefit significantly from cognitive-behavior therapy. Marital problems are among risk factors that may explain this limited impact. Some studies suggest that PDA treatment outcome is related to the couple’s ability to communicate and solve problems during and after treatment. It may be also useful to further clarify the interplay of marital interpersonal variables with PDA severity before any intervention. This study aims at specifying the links between PDA symptom severity on the one hand and, on the other hand, marital adjustment, attachment style and personal problem-solving skills in both spouses. Results obtained from a group of 67 PDA patients (44 women and 23 men) and their partners showed that some PDA symptoms or comorbid depressive symptoms were more severe when both spouses independently scored low on problem-solving skills or marital adjustment, and when attachment style of PDA patients was insecure. Marital adjustment and difficulties in problem-solving, more specifically, avoidance of problem-solving activities in PDA patients, were the best predictors of PDA symptom severity. In light of these findings, a more complete program of problem-solving and acceptance strategies could be developed as part of a cognitive-behavior treatment of PDA. Other theoretical and clinical implications are discussed.

Clinical and psychosocial outcome of patients affected by panic disorder with or without agoraphobia: results from a naturalistic follow-up study

Objective: A clinical and psychosocial follow-up study of a cohort of 85 patients affected by panic disorder (PD) with or without agoraphobia was performed an average of 40 months after initial observation and following a mean duration of illness of 8 years. Methods: Eighty-five out of 130 patients affected by PDs with or without agoraphobia according to DSM-III R criteria, examined between 1990 and 1995 at an outpatient clinic were re-examined in 1997/1998 using the same standardized clinical evaluation performed on admission. Patients also underwent a structured diagnostic interview (Mini International Neuropsychiatric Interview, MINI) and psychosocial evaluation (Scale of Sheehan’s Disability Scale, DISS, Baker and Intagliata’s Satisfaction with Life Domains Scale, SLDS). Results: At follow-up, the percentage of patients who had either improved or were in remission was considerably higher among those initially diagnosed as PD with respect to those diagnosed as panic disorder with agoraphobia (PDA): Thirty-eight percent of PD and 20.6% of PDA patients were in clinical remission. Mild panic symptoms and phobic avoidance were found in the majority of patients who were still symptomatic (respectively 71% and 57%). Approximately 60% of patients reported a significant difficulty in performing daily activities and 40% expressed dissatisfaction in at least 50% of life domains considered. Seventy-two percent of subjects examined were still undergoing pharmacological treatment at the time of follow-up. Conclusions: The findings of the study are suggestive of a chronic illness with a significant impact on everyday quality of life of patients.

Does expressed emotion predict behaviour therapy outcome at follow‐up for obsessive‐compulsive disorder and agoraphobia?

AbstractThe relationship of expressed emotion (EE) to outcome of behaviour therapy at 1‐year follow‐up was examined in a sample of patients with obsessive‐compulsive disorder (OCD) or panic disorder with agoraphobia (PDA). Included were 54 subjects who were reliably changed after outpatient treatment via in vivo exposure (plus response prevention for OCD). Perhaps because few clients relapsed (11%), EE variables assessed by the Camberwell Family Interview and perceived criticism ratings, although successful in predicting drop‐out and posttest outcome in this sample, were not significantly related to regression during the follow‐up period. The sole exception, critical comments from the CFI, predicted worsened social adjustment at follow‐up, but only for PDA patients. The experience of stressful life events did not interact with EE variables to predict outcome. Copyright © 2001 John Wiley & Sons, Ltd.

Predictors of comorbid personality disorders in patients with panic disorder with agoraphobia

The aim of this study was to ascertain predictors of comorbid personality disorders in patients with panic disorder with agoraphobia (PDAG). Sixty consecutive outpatients with PDAG were administered the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) for the purpose of diagnosing personality disorders. Logistic regressions were used to identify predictors of any comorbid personality disorder, any DSM-IV cluster A, cluster B, and cluster C personality disorder. Independent variables in these regressions were gender, age, duration of panic disorder (PD), severity of PDAG, and scores on self-report instruments that assess the patient's perception of their parents, childhood separation anxiety, and traumatic experiences. High levels of parental protection on the Parental Bonding Instrument (PBI), indicating a perception of the parents as overprotective and controlling, emerged as the only statistically significant predictor of any comorbid personality disorder. This finding was attributed to the association between parental overprotection and cluster B personality disorders, particularly borderline personality disorder. The duration of PD was a significant predictor of any cluster B and any cluster C personality disorder, suggesting that some of the cluster B and cluster C personality disorders may be a consequence of the long-lasting PDAG. Any cluster B personality disorder was also associated with younger age. In conclusion, despite a generally nonspecific nature of the relationship between parental overprotection in childhood and adult psychopathology, the findings of this study suggest some specificity for the association between parental overprotection in childhood and personality disturbance in PDAG patients, particularly cluster B personality disorders.

Axis I and Axis II comorbidity in panic/agoraphobic patients with and without suicidal ideation

In view of the controversial relationship between certain aspects of panic disorder with agoraphobia (PDA), suicidal ideation and comorbidity, the purposes of this study were to compare severity of PDA and Axis I and Axis II comorbidity in PDA patients with and without suicidal ideation, and to examine predictors of suicidal ideation in these patients. Eighty-eight consecutive outpatients with PDA were administered structured diagnostic interviews for the DSM-IV Axis I and Axis II disorders (SCID-I and SCID-II), while the severity of PDA was assessed by means of the Panic Disorder Severity Scale. Of the patients, 25 (28.4%) reported suicidal ideation in past years (‘ideators’). The severity of PDA was greater among ideators, and they were significantly more likely to have a personality disorder and more than one comorbid Axis I and Axis II disorder. There were no ideators without either Axis I or Axis II comorbidity. Univariate logistic regression identified several predictors of suicidal ideation: any DSM-IV Cluster C personality disorder, any DSM-IV Cluster B personality disorder, any comorbid mood disorder, and severity of PDA. With multivariate logistic regression, a combination of any Cluster C personality disorder and severity of PDA emerged as the most significant predictor of suicidal ideation. These findings have implications for clinical practice in that PDA patients should be carefully assessed for the severity of their illness and presence of certain personality disorders and comorbid mood disorders, because they may all increase the risk for suicidal ideation.

The overprediction of fear and panic in panic disorder

The present study examined changes in the prediction of fear and panic in a clinical sample of patients ( N = 25) meeting DSM-III-R criteria for panic disorder with agoraphobia (PDA). Data were collected for approx. 2000 trials of in vivo exposure. As expected, PDA patients displayed a bias for overpredicting both the level of fear and the likelihood of panic during an exposure trial. This overprediction bias was evidenced across several domains including heights, transportation and social situations. Although patients learned to make more accurate predictions within an exposure session, the level of overprediction remained relatively stable after the third trial within a session. Changes in fear overprediction differed across fear domains. Patients showed significant reductions in overprediction during exposure to transportation and social situations, but failed to show reductions in overprediction during exposure to heights. Unexpectedly, patients did not show increased prediction accuracy across sessions. These findings concur with earlier laboratory studies indicating that anxiety patients show an overprediction bias for panic and fear which decreases with practice. However, our findings indicate that the overprediction bias does not remit even after significant practice. The persistence of the overprediction bias is discussed within an evolutionary context.