Overcoming Agoraphobia and Extreme Anxiety Disorders
A subsequent study, using an anxiety clinic sample and an expanded array of measures, yielded similar results. (17 In this case, five primary factors (corresponding to panic, agoraphobia, social anxiety, obsessions compulsions, and general anxiety) and a higher-order factor (negative affect) were identified. Again, patients with GAD had a unique factor profile.
Both genetic and environmental factors contribute to the emergence of social phobia. Studies of first-degree relatives of probands with social phobia have clearly established that it runs in families. One of the first proband studies interviewed 83 first-degree relatives of individuals with social phobia and 231 first-degree relatives of individuals with no psychiatric history to assess their lifetime history of DSM-IIIR disorders. Of relatives of individuals with social phobia, 16 per cent met the criteria for social phobia compared with only 5 per cent of relatives of individuals with no psychiatric history. Rates for all other anxiety disorders were similar among relatives of the two proband groups. Similarly, first-degree relatives of probands with DSM-IIIR simple phobia, social phobia, and panic disorder with agoraphobia most frequently met the criteria for the proband's anxiety disorder, but were not more likely to meet the criteria for the other disorders. (33) Further, in a...
Certainly the preponderance of evidence suggests there is a genetic contribution to the predisposition to develop panic attacks and agoraphobia. There are increased rates of panic disorder in first-degree relatives with 7.9 to 41 per cent versus 8 per cent or less in control populations. The overall increased risk in first-degree relatives ranges from two- to 20-fold with the median seven- to eightfold. Overall, studies suggest that another affected relative can be found 25 to 50 per cent of the time, two times as commonly in female relatives. The increased familial aggregation is specific for panic disorder. (43) These findings are certainly consistent with a modest genetic transmission with relatively high specificity. There are also many studies suggesting that traumatic early events may figure in the vulnerability leading to panic disorder. The majority of children in some studies have experienced early parental separation.(42) A traumatic event in childhood has been...
As previously mentioned, the Klein model suggests that spontaneous panic attacks are the first manifestation of the illness, followed by anticipatory anxiety, and agoraphobia in some individuals. However, for most panic disorder patients examined closely, a panic attack is rarely the first symptom. In some studies, over 90 per cent of patients have had mild phobic or hypochondriacal, milder symptoms prior to the onset of their first panic attack.
Multiple effective treatments have been developed since the early 1960s and include both psychological and pharmacological treatments. Both exposure-based treatments and imipramine were shown to be effective in treating panic disorder and agoraphobia in the early 1960s. (3,74) Psychological-based treatments have moved increasingly toward cognitive-behavioural therapy with efficacy roughly comparable to pharmacological treatments.
There are now a series of studies utilizing antidepressants or benzodiazepines as maintenance treatment for 6 and 12 months for panic disorder and agoraphobia. In each trial to date, treatment gains from acute treatment are almost always maintained, and generally are extended while the medication is continued. After treatment with clomipramine for 6 months, 93 per cent of patients became panic free, compared with 60 per cent on placebo. In a 12-month trial comparing clomipramine and placebo, the clomipramine group continued to improve and tolerated the medication well. On various outcome measures, there was 82 to 100 per cent improvement. Placebo patients who were switched to active medication matched the good responses of the clomipramine group.
The other major aetiological consideration for panic disorder and agoraphobia has been the evidence of negative traumatic events occurring in the childhood of adults with panic disorder. Preventative efforts need to be aimed at these issues through public education and education of caregivers of children. Also, one of the intervention goals in helping a traumatized child should be to prevent future development of anxiety disorders and other problems.
There is evidence that patients with secondary hypochondriasis respond to drug therapy for the primary disturbance. Noyes et al.(64) measured hypochondriacal symptoms in patients who received pharmacotherapy for panic disorder and agoraphobia. After 6 weeks, a significant reduction in Whiteley Index scores was observed among patients whose panic symptoms had improved. Similar observations have been made with respect to hypochondriasis in depression.
The base for exposure treatment in agoraphobia, some indications for nurse therapists and community psychiatric nurses. Journal of Advanced Nursing, 16, 82-91. 24. Gournay, K. (1991). The failure of exposure treatment in agoraphobia, implications for the practice of nurse therapists and community psychiatric nurses. Journal of Advanced Nursing, 16, 1099-109.
Very few systematic data are available on the natural history course and outcome of separation anxiety disorder in childhood. There are no longitudinal prospective studies through into adult life. During childhood, the symptoms tend to wax and wane. Normal events, such as school transitions, as well as undesirable events may lead to a recurrence or exacerbation of symptoms. There is some suggestion of continuities between separation anxiety disorder in childhood and panic disorder and agoraphobia in adults.(89 and19 Identifying which subpopulations of children with separation anxiety disorder are at risk for persistent anxiety disorders into adult life is an important issue for further research. Current preliminary findings suggest that it is the early-onset separation anxiety disorder that may be the most persistent.
Phobias are inappropriate exagerated fears which are not under voluntary control, cannot be reasoned away, and entail avoidance behaviour. (4Z) The fears are kindled by particular stimuli. These may either be perceived objects, such as animals (animal phobia) or pustules (in some illness phobias), or situations such as open places (agoraphobia) or confined rooms (claustrophobia).
Individuals with this personality disorder may be at increased risk for agoraphobia, obsessive-compulsive disorder, and substance abuse or dependence. This personality disorder is often codiagnosed with schizoid, schizotypal, narcissistic, and avoidant personality disorders.
As usually in agoraphobia, or social phobia. The worry characteristic of generalized anxiety disorder, verging on panic, endless and fruitless, appears as a form of cognitive avoidance, in adults (Borkovec et al. 1991), and in children, once they develop the pre-requisite cognitive capacities (Vasey 1993). Avoidance is mandatory when situations are seen as really dangerous, as life-threatening, but for the very same reason they demand attention and vigilance paradoxical attempts to do both at the same time, in reality and in the imagination, are seen most clearly in post-traumatic stress disorder. Obsessive-compulsive disorder may represent a pre-rational coping style getting out of hand, exhibiting the characteristic, paradoxical combinations of coping and not coping, being in and out of control, and panic. The fundamental fear is being out of control where coping is essential, and this leads to excessive, out of control coping. In general, the problem and the solution become...
Most patients who require psychological testing present with one or more Axis I disorders. Traits refer to long-standing personality characteristics that endure over time and situations. In contrast, states refer to potentially short-lived conditions, usually emotional in nature. Anxiety, depression, and loss of reality contact can all affect the results of personality testing. J. Reich, Noyes, Coryell, and Gorman (1986), for example, obtained personality profiles on a group of persons with panic disorder and agoraphobia. Those judged improved six weeks later showed significantly increased emotional strength and extroversion and significantly decreased interpersonal dependence. Some disorders also have a motivational or cognitive dimension that can affect the validity of test results. Depressed individuals report increased feelings of worthlessness and shame, which can lead to overendorsement of items intended to assess low self-esteem as a personality trait, for example. Research on...
Agoraphobia usually accompanies panic disorder. Agoraphobia refers to avoidance behavior motivated by fear of having another panic attack. It may consist of avoidance of activities that patients fear could provoke an attack, situations where escape may not be readily available, or activities during which patients are not accompanied by a person whom they believe could help in case of an attack.
Panic disorder is characterized by a fear of an immediately impending internal disaster (for example heart attack, cessation of breathing, mental derangement) and a sense of loss of control over physical and mental functions. Many of panic patients' negative thoughts can be viewed as misinterpretations of normal bodily sensations (such as palpitations or a slight feeling of breathlessness). Indeed, cognitive theorists (8.,9) argue that panic attacks result from a vicious circle in which catastrophic misinterpretations of body sensations lead to an increase in anxiety and associated sensations, which are in turn interpreted as further evidence of impending, internal disasters (e.g. heart attack, fainting, going mad). Panic disorder with agoraphobia is often also accompanied by fear of the interpersonal consequences of attacks (e.g. 'I'll make a fool of myself').
When one main diagnosis clearly applies yet does not account for some symptoms which, although a significant part of the clinical picture, still fall short of fulfilling the criteria for another disorder, it is useful to record these simply as 'additional symptoms' (for instance, depressive disorder with some obsessional symptoms agoraphobia with some depressive symptoms, etc.). Neither ICD-10 nor DSM-IV mention this way of recording symptoms 'left over' after the main disorder has been accounted for, even though it is a useful clinical custom familiar to many generations of clinicians in a variety of countries. However, omission from formal classifications should not be allowed to inhibit clinicians from following clinical habits they find useful.
Social phobia may increase the risk for other psychiatric disorders. (9,2 21. In the National Comorbidity Survey (NCS), 81 per cent of persons with primary social phobia met the criteria for at least one other lifetime psychiatric disorder.(22) Odds ratios for other DSM-IIIR disorders given social phobia were 7.75 for simple phobia, 7.06 for agoraphobia, 4.83 for panic disorder, 3.77 for generalized anxiety disorder, 2.69 for post-traumatic stress disorder, 3.69 for major depression, 3.15 for dysthymia, and 2.01 for substance abuse 22) In persons with comorbid diagnoses in the Epidemiological Catchment Area Study (ECA), social phobia preceded the comorbid disorder in 76.8 per cent and onset in the same year in 7.2 per cent of cases.(9) Panic disorder with agoraphobia (PDA) can be differentiated from social phobia in several ways. While many individuals with social phobia experience panic attacks, their anxiety occurs in anticipation of being evaluated negatively by others for persons...
The culture of any scientific discipline, memory research no exception, could be depicted as a collection of conceptual, pragmatic, and ritualistic attributes that are partially shared with other scientific disciplines. They range from the philosophical to the mundane. The philosophical include, among others, the elementary, universal sets of the scientific methods and criteria. These themselves are cognitive + cultural constructs. Being so, and to the justified dismay of scientists, these tenets of the scientific culture are a recurrent target for vicious attacks by the so-called 'postmodernists', who seem to capitalize on the inherent fallibility of the senses and the cognition of the human individual, yet utterly ignore the built-in safeguards that the scientific system as a whole has painstakingly devised to hold a grip on reality, as well as the great successes of science and technology (for minute glimpses into these issues, see Midgley 1992 Gottfried and Wilson 1997). Other...
Anxiety is a prominent and expected reaction to conditions leading to intensive care (e.g. myocardial infarction). Most patients develop anxiety which lasts for only a few days. However, some do not return to a normal level of concern and psychomotor activity. A thorough review of the patient's medical history, with emphasis on previous panic attacks, agoraphobia, or generalized anxiety, is then crucial. Weaning from chronic ventilatory support often generates considerable anxiety which can be minimized with skillful weaning techniques.
The most definitive trial in the field involved 39 centres in 13 countries, mostly in Europe. A sample of 367 were randomly assigned to paroxetine, clomipramine, and placebo. Beginning at a dose of 10 mg with ultimate dosing of 20 to 60 mg day of paroxetine and 50 to 100 mg day of clomipramine, paroxetine was significantly superior to placebo at weeks 6, 9, and 12 for percentage of patients having no panic attacks (50.9 per cent paroxetine, 36.7 per cent clomipramine, 31.6 per cent placebo at week 12). Paroxetine's effect was significantly greater on several measures than clomipramine at weeks 6 and 9. Measures of other symptomatic domains (anxiety, agoraphobia, functional disability) all improved on paroxetine and clomipramine greater than on placebo. There were significantly greater side-effects from clomipramine than paroxetine, especially gastrointestinal and central nervous system side-effects.
Antidepressant drugs, such as the tricyclic antidepres-sants and the selective serotonin reuptake inhibitors (SSRIs), are very important for the treatment of psychotic depression (see Chapter 34). They have been shown to be effective when used in the treatment of several anxiety disorders, including general anxiety, obsessive-compulsive disorder, and several phobias, including agoraphobia. Because the SSRIs are less toxic than the tricyclic antidepressants, their use in the treatment of anxiety is safer and less likely to produce serious side effects.
Neurotic illness, more especially anxiety and depression, largely account for the increased psychiatric morbidity that is to be found in patients with epilepsy. These disorders have few distinctive characteristics. They may be explained by the adverse social, educational, and economic disadvantages that confront people with epilepsy. A phobic anxiety akin to agoraphobia may be seen in some individuals who fear the onset of a seizure in public places. Obsessive-compulsive disorder does not seem to occur more commonly in epilepsy.