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PubMed1995

Assessing the efficacy of treatments for panic disorder and agoraphobia. II. The Panic and Agoraphobia Scale.

Despite the plethora of rating scales for anxiety disorders and agoraphobia, a qualified scale for assessing the severity of panic disorder and agoraphobia (PDA) is still lacking. The new Panic and Agoraphobia Scale (P&A) is presented in this paper. It was developed to assess the degree of severity of these disorders after a diagnosis has been made according to the criteria of the DSM-III-R/IV or the ICD-10. The P&A was specially developed for use in clinical drug trials. Factors which impair the quality of life in panic disorder and agoraphobia patients (panic attacks, phobic avoidance, anticipatory anxiety, impairment in social relationships and work, assumption of somatic disease) were considered in the development of this scale so that the efficacy of a certain drug therapy on each of these factors can be assessed separately. Both an observer rating and a self-rating with matching items are available. The observer rating only takes about 10 minutes to complete. Translation into many European languages is planned so that it can be used in multicentre trials. Satisfactory results of item analysis, inter-rater reliability, objectivity, external validity and factor structure are presented. The P&A should be a useful tool for assessing the severity of PDA and may solve some of the methodological problems that have arisen in former PDA studies.

Adult↗
PubMed1994

Exposure reduced agoraphobia but not panic, and cognitive therapy reduced panic but not agoraphobia.

Earlier studies showed that cognitive therapy has anti-panic effects and exposure has anti-agoraphobic effects while other studies suggest that agoraphobia is a secondary complication of panic disorder. It was therefore hypothesized that cognitive therapy not only reduces panic but also agoraphobia and that it potentiates the effects of exposure in vivo. Two groups of 12 severe agoraphobics were treated with 4 sessions of cognitive therapy followed by 8 sessions of cognitive therapy combined with in vivo exposure. The other 12 received 4 sessions of 'associative therapy', a presumably inert treatment that controls for therapist attention, followed by 8 sessions of in vivo exposure that was framed in common behavioral terms. The initial cognitive therapy produced a significant reduction in panic frequency, while associative therapy did not affect panic. Neither cognitive therapy alone, nor associate therapy alone significantly reduced depression, state or trait anxiety, self-rated agoraphobia or behavioral avoidance. After adding exposure however, these parameters were clearly and significantly reduced. Cognitive therapy did not potentiate exposure effects. The results are discussed.

Adult↗
PubMed1994

Panic, agoraphobia, and panic disorder with agoraphobia. Data from a multicenter anxiety disorders study.

In a cross-sectional investigation of the properties of DSM-III-R panic disorder (PD), panic disorder with agoraphobia (PDA), and agoraphobia without history of panic disorder (AWOPD), we analyzed demographic, descriptive, comorbidity, treatment, and course data for 562 subjects with PD, PDA, or AWOPD in a multicenter anxiety-disorders study. In general, AWOPD subjects had the worst functioning and PD subjects the best, as measured by length of intake episodes, education attained, likelihood of receiving financial assistance, depressive comorbidity, and likelihood of having experienced 8 weeks symptom-free. Panic disorder with agoraphobia was the most common disorder and emerged as a condition intermediate in severity between the other two. Treatments received varied little by diagnosis. Most subjects received medication, usually benzodiazepines. Psychodynamic psychotherapy was the most frequently received psychosocial treatment; cognitive and behavioral approaches were less common. Subjects classified with AWOPD were the most likely to have received exposure therapies.

Adult↗
PubMed1998

Characteristics of agoraphobia in women and men with panic disorder with agoraphobia.

We compared female and male patients with panic disorder with agoraphobia (PDA) in terms of characteristics of agoraphobia (AG). Ninety-five patients (73 women and 22 men) with the SCID-based diagnosis of PDA were administered the National Institute of Mental Health Panic Questionnaire (NIMH PQ), and women and men were compared on the items of the NIMH PQ that pertain to AG and symptoms of panic attacks. Male and female patients did not differ significantly with respect to demographic characteristics, age of onset of panic disorder and AG, duration of PDA, and severity and frequency of symptoms experienced during panic attacks. Women avoided more situations than did men, but this difference was not statistically significant. Women avoided buses and being in unfamiliar places alone significantly more often. The only situation that was avoided more often by men, although not significantly, was staying at home alone. Women were significantly more likely to stay at home to avoid agoraphobic situations and significantly less likely to go outside of home alone. When going outside, women required a companion significantly more often. There were significantly more married women than married men who required a spouse as a companion, and significantly more women with children than men with children who required a child as a companion. Women thought that AG had affected the overall quality of their lives significantly more adversely. Whereas the overall "profile" of agoraphobic situations does not seem to distinguish between female and male patients with AG, females may be more impaired and appear more dependent than men in terms of requiring companions to move outside of the home. Cultural and psychological factors may be most likely to account for these findings.

Adult↗
PubMed2002

Assessing the severity of panic disorder and agoraphobia: validity, reliability and objectivity of the Turkish translation of the Panic and Agoraphobia Scale (P&A).

The aim of the present study was to determine the psychometric properties of the Turkish translation of both the observer-rated (P&Ao) and self-rated (P&As) versions of the Panic and Agoraphobia Scale (P&A). Discriminant and convergent validity of P&A were assessed in patients with panic disorder with or without agoraphobia (n = 119), by comparing the P&A with the Clinical Global Impression Scale (CGI), Hamilton Anxiety Scale (HAMA), Phobia and Anxiety sub-scales of Symptom Check List, Spielberger State and Trait Anxiety Inventory and the Beck Depression Inventory (BDI). Inter-rater and test-retest reliability were determined. Correlation coefficients between the CGI and the P&Ao and the P&As were .85 and .74, respectively, and .85 between the two versions of the P&A. Cronbach's alpha for the P&Ao, and the P&As was .88 and .86, respectively. The Turkish version of the P&A has yielded good psychometric properties and was found to be a reliable instrument for assessing severity in panic disorder.

Adult↗
PubMed1994

Relationship of panic, anticipatory anxiety, agoraphobia and global improvement in panic disorder with agoraphobia treated with alprazolam and exposure.

In a controlled trial of alprazolam and exposure in 154 patients with panic disorder with agoraphobia, relations between panic, anticipatory anxiety, and phobic avoidance were examined. The three symptoms were independent of one another at baseline and improved largely independently during treatment; only early improvement in avoidance predicted global improvement after treatment. Global improvement was more related to reduction of avoidance than a decrease in panics. Panic was not a valuable outcome measure in panic disorder with agoraphobia.

Adult↗
PubMed1998

The relationship of agoraphobia and panic in a community sample of adolescents and young adults.

BACKGROUND: Data are presented on the prevalence of DSM-IV panic and agoraphobia in a community sample of adolescents and young adults in Munich, Germany. METHODS: A total of 3021 respondents aged 14 to 24 years were assessed with a revised version of the Composite International Diagnostic Interview (CIDI). Respondents classified as having agoraphobia without panic were subtyped by number of agoraphobic trigger situations and subjected to a clinical review. RESULTS: Lifetime prevalence of DSM-IV agoraphobia in the revised CIDI was higher (8.5%) than that of panic attack (4.3%) or panic disorder with (0.8%) or without (0.8%) agoraphobia. Marked differences in symptomatology, course, and associated impairments between panic disorder and agoraphobia were found. Most patients with agoraphobia reported neither full nor limited attacks or uncued paniclike experiences. Clinical review revealed that many respondents classified by the CIDI as having agoraphobia actually have specific phobia, resulting in a corrected agoraphobia prevalence of 3.5%. Number of agoraphobia trigger situations was identified as a useful way of differentiating patients with true agoraphobia from those with simple phobia. Even after correcting for overdiagnosis, however, the majority of respondents with confirmed agoraphobia were found not to have a prior history of panic. CONCLUSIONS: The results call into question the assumed key pathogenic role of panic attacks in the onset of agoraphobia. Consistent with findings that agoraphobia without panic is rarely seen in clinical settings, we find that such patients seldom seek professional treatment.

Adolescent↗
PubMed1993

Agoraphobia without panic: clinical reappraisal of an epidemiologic finding.

OBJECTIVE: In the United States, the consensus among clinicians and researchers, reflected in DSM-III-R, is that agoraphobia is a conditioned response to panic attacks and almost never occurs without panic attacks. The predominant view in the United Kingdom is that agoraphobia frequently occurs in the absence of panic. While clinicians report that they rarely see patients with agoraphobia who have no history of panic disorder, community studies report that agoraphobia without panic disorder is common. For example, the Epidemiologic Catchment Area (ECA) study found that 68% of 961 persons with agoraphobia had no history of panic attacks or disorder. METHOD: To understand this discrepancy, 22 subjects who had been diagnosed as having agoraphobia without panic disorder or panic attacks in the ECA study were blindly reinterviewed 7-8 years later with the Schedule for Affective Disorders and Schizophrenia--Lifetime Version Modified for the Study of Anxiety Disorders; data from these interviews were blindly reviewed by a research psychiatrist who was not involved in the original data collection or the reinterview process. RESULTS: On reappraisal, 19 of the 22 subjects had simple phobias or fears but not agoraphobia. One subject had probable agoraphobia without panic attacks, one had definite panic disorder with agoraphobia, and one had probable agoraphobia with limited symptom attacks. CONCLUSIONS: Epidemiologic studies that used the Diagnostic Interview Schedule and lay interviewers, such as the ECA study, may have over-estimated the prevalence of agoraphobia without panic. Agoraphobia without panic attacks occurs but is uncommon, and the diagnostic boundary between agoraphobia and simple phobia is unclear.

Aged↗
PubMed2006

Prevalence and correlates of agoraphobia in older adults.

OBJECTIVE: Agoraphobia has been previously found to be a relatively prevalent disorder in the older adult. However, little is known about the nature of this disorder in the elderly population. The purpose of this study was to identify risk factors, illness characteristics, and comorbidity of agoraphobia in the elderly. METHODS: This was a national community mental health survey that included 12,792 individuals > or = 55 years. Agoraphobia was assessed using the World Mental Health Composite International Diagnostic Interview. Social, demographic, psychiatric, and physical variables previously found to be associated with agoraphobia in the adult population were measured. Bivariate and logistic regression analyses were used to examine these associations. RESULTS: The prevalence of agoraphobia in adults over 55 was 0.61% (95% confidence interval [CI]: 0.40-0.82). In bivariate analysis, the condition was more common in the younger age groups, women, and those widowed or divorced. It was also more common in individuals with chronic health conditions and those with comorbid psychiatric disorders. However, in the multivariate model, chronic health conditions and panic disorder were no longer significant. Most cases of agoraphobia in the elderly were of early onset (age <55 years). The majority of patients with agoraphobia did not have concurrent panic disorder. CONCLUSION: Lower prevalence rates of agoraphobia in the elderly were found compared with previous studies. The degree to which this is a measurement issue is discussed. The low correlation between agoraphobia and panic disorder raises further questions about the nature and etiology of agoraphobia in the elderly. Implications for future research and clinical practice are discussed.

Adolescent↗
PubMed2006

Agoraphobia in adults: incidence and longitudinal relationship with panic.

BACKGROUND: Theories regarding how spontaneous panic and agoraphobia relate are based mostly on cross-sectional and/or clinic data. AIMS: To determine how spontaneous panic and agoraphobia relate longitudinally, and to estimate the incidence rate of and other possible risk factors for first-onset agoraphobia, using a general population cohort. METHOD: A sample of 1920 adults in east Baltimore were assessed in 1981-1982 and the mid-1990s with the Diagnostic Interview Schedule (DIS). Psychiatrist diagnoses were made in a subset of the sample at follow-up (n = 816). RESULTS: Forty-one new cases of DIS/DSM-III-R agoraphobia were identified (about 2 per 1000 person-years at risk). As expected, baseline DIS/DSM-III panic disorder predicted first incidence of agoraphobia (OR = 12, 95% CI 3.2-45), as did younger age, female gender and other age, female gender and other phobias. Importantly, baseline agoraphobia without spontaneous panic attacks also predicted first incidence of panic disorder (OR=3.9, 95% CI1.8-8.4). Longitudinal relationships between panic disorder and psychiatrist-confirmed agoraphobia were strong (panic before agoraphobia OR=20, 95% CI 2.3-180; agoraphobia before panic OR=16, 95% CI 3.2-78). CONCLUSIONS: The implied one-way causal relationship between spontaneous panic attacks and agoraphobia in DSM-IV appears incorrect.

Adolescent↗
PubMed2005

Panic disorder with and without agoraphobia: comorbidity within a half-year of the onset of panic disorder.

The present study was performed to compare the clinical features of patients with panic disorder with and without agoraphobia. The subjects were 233 outpatients with panic disorder (99 males and 134 females) diagnosed according to DSM-IV criteria. Sixty-three patients met the criteria for panic disorder without agoraphobia, and 170 met the criteria for panic disorder with agoraphobia. Patients with agoraphobia showed a significantly longer duration of panic disorder and higher prevalence of generalized anxiety disorder. However, there were no significant differences in prevalence of major depressive episodes, in current severity of panic attacks, or in gender ratio between the two groups. The second aim of the present study was to investigate the effects of onset age and sex differences on the development of agoraphobia within a half-year. The subjects were divided into two groups according to their self-report: patients who did or did not develop agoraphobia within 24 weeks of onset of panic disorder. A total of 40.6% of the patients developed agoraphobia within 24 weeks of the onset of panic disorder, and onset age and sex differences had no robust effect on the development of agoraphobia within 24 weeks.

Adult↗
PubMed2002

Agoraphobia without a history of panic disorder may be part of the panic disorder syndrome.

Agoraphobia without a history of panic attacks is a disorder lacking strong support. Data from the Australian National Survey were explored in respect to panic disorder with or without agoraphobia (PDA, PD), and agoraphobia without a history of panic disorder (AG). Panic disorder, agoraphobia, and panic disorder with agoraphobia occurred in 3.5% of the adult population. People with this group of disorders were more likely to be female and more likely to seek help than people with other anxiety disorders. Significant anxiety symptoms and unease about safety when out and about occur in all three disorders. People with the double disorder PDA report more comorbid disorders, are more disabled, and have higher neuroticism scores than people with PD or AG. People with AG are older and consult less than people with PD or PDA. Agoraphobia has been devalued as a cause of human suffering. This idea is wrong. Agoraphobia is as common, comorbid, and disabling as PD, but less disabling than the double disorder of PDA.

Adolescent↗
PubMed1995

DSM-IV and the disappearance of agoraphobia without a history of panic disorder: new data on a controversial diagnosis.

OBJECTIVE: This analysis describes subjects who met rigorous criteria for DSM-III-R agoraphobia without a history of panic disorder and makes inferences from these data regarding relationships among agoraphobia without a history of panic disorder, panic disorder, and panic disorder with agoraphobia. METHOD: Twenty-six subjects (seven men and 19 women) with agoraphobia without a history of panic disorder were identified from among 711 subjects recruited for a multicenter, longitudinal anxiety disorder study. Narrative transcripts prepared by raters from study evaluations were coded for limited symptom attacks, situational panic, catastrophic cognitions, and possible precipitants and stressors, course, and somatic and psychosocial treatments received. RESULTS: Sixty-five percent of the subjects reported experiences consistent with situational panic attacks, and 57% had definite or probable limited symptom attacks; these attacks usually preceded or appeared at the same time as avoidance behavior. Eighty-one percent had catastrophic cognitions associated with agoraphobia. Twenty-six percent reported a likely precipitating factor for symptom onset, and 30% reported a definite or probable major life stressor within 6 months before symptom onset. Cognitive-behavioral treatments were relatively infrequently used. Course was relatively unchanged across the follow-up period. CONCLUSIONS: These data support a view of agoraphobia without a history of panic disorder on a continuum with uncomplicated panic disorder and with panic disorder and agoraphobia, rather than as a separate diagnosis.

Adult↗
PubMed1996

Panic, agoraphobia, and vestibular dysfunction.

OBJECTIVE: Otoneurological abnormalities have been reported in panic disorder. The purpose of this investigation was to determine the prevalence of such findings in panic disorder with and without agoraphobia and to discern whether vestibular dysfunction was associated with specific symptoms. METHOD: Clinical audiological and vestibular tests were administered to 30 patients with uncomplicated panic disorder (without agoraphobia or with only mild agoraphobia), 29 patients with panic disorder with moderate to severe agoraphobia, 27 patients with anxiety but no history of panic attacks, 13 patients with depressive disorders but no history of anxiety or panic attacks, and 45 normal comparison subjects. Evaluators were blind to subjects' diagnostic group. Quantitative measures of subjects' discomfort with space and motion and of the frequency of certain symptoms between and during panic attacks were obtained. Anxiety state levels were measured during the vestibular tests. RESULTS: Vestibular abnormalities were common in all the groups but most prevalent in the patients with panic disorder with moderate to severe agoraphobia. Vestibular dysfunction was associated with space and motion discomfort and with frequency of vestibular symptoms between, but not during, panic attacks. There were no major differences between the two panic groups in anxiety levels during vestibular testing. There were no significant differences between groups on the audiological component of the test battery. Exploratory data analysis indicated that the constellation of vestibular tests most specific for agoraphobia was one indicating compensated peripheral vestibular dysfunction. CONCLUSIONS: Subclinical vestibular dysfunction, as identified by clinical tests, may contribute to the phenomenology of panic disorder, particularly to the development of agoraphobia in panic disorder patients.

Adult↗
PubMedDate not supplied

[Relationship of psychiatric comorbidity and treatment of panic disorder and agoraphobia].

INTRODUCTION: Besides numerous studies that examined various aspects of comorbidity in patients with panic disorder and agoraphobia and numerous studies that examined efficacy of different treatment modalities in these patients, there was no study that examined relationship of overall psychiatric comorbidity and treatment of patients with panic disorder and agoraphobia. OBJECTIVE: The objective of the study was to establish the effect of psychiatric comorbidity on treatment efficiency of patients with panic disorder and agoraphobia. METHOD: The sample of the study consisted of 119 patients with primary diagnosis of panic disorder and agoraphobia. The therapy of patients was based on the use of individual integrative model of treatment, which incorporated psycho-pharmaceuticals (benzodiazepines and antidepressants) and cognitive-behavior therapy. Symptom severity was estimated by Panic and Agoraphobia Scale before and after the completion of treatment. Patients with comorbidity and patients without any comorbidity were compared by MANOVA and ANOVA with repeated measures. RESULTS: The results of the study showed that 91% of patients met diagnostic criteria of comorbid psychiatric disorder and these patients had more severe clinical picture than patients without any comorbid disorder before the treatment. The results also showed that, after the completion of treatment, there was a significant reduction of all analyzed symptoms, that the effects of treatment were significantly better in patients with psychiatric comorbidity and that comorbid psychiatric disorders had no negative effect on the main goals of the treatment. CONCLUSION: Based on these results, it may be concluded that: in patients with panic disorder and agoraphobia and comorbid psychiatric disorders, the pharmacotherapy must be based on simultaneous use of antidepressants and benzodiazepines, while standard cognitive-behavior therapy of patients with panic disorder and agoraphobia must be modified in case of the existing comorbid psychiatric disorders.

Adult↗
PubMed1992

The genetic epidemiology of phobias in women. The interrelationship of agoraphobia, social phobia, situational phobia, and simple phobia.

In 2163 personally interviewed female twins from a population-based registry, the pattern of age at onset and comorbidity of the simple phobias (animal and situational)--early onset and low rates of comorbidity--differed significantly from that of agoraphobia--later onset and high rates of comorbidity. Consistent with an inherited "phobia proneness" but not a "social learning" model of phobias, the familial aggregation of any phobia, agoraphobia, social phobia, and animal phobia appeared to result from genetic and not from familial-environmental factors, with estimates of heritability of liability ranging from 30% to 40%. The best-fitting multivariate genetic model indicated the existence of genetic and individual-specific environmental etiologic factors common to all four phobia subtypes and others specific for each of the individual subtypes. This model suggested that (1) environmental experiences that predisposed to all phobias were most important for agoraphobia and social phobia and relatively unimportant for the simple phobias, (2) environmental experiences that uniquely predisposed to only one phobia subtype had a major impact on simple phobias, had a modest impact on social phobia, and were unimportant for agoraphobia, and (3) genetic factors that predisposed to all phobias were most important for animal phobia and least important for agoraphobia. Simple phobias appear to arise from the joint effect of a modest genetic vulnerability and phobia-specific traumatic events in childhood, while agoraphobia and, to a somewhat lesser extent, social phobia result from the combined effect of a slightly stronger genetic influence and nonspecific environmental experiences.

Adolescent↗
PubMedDate not supplied

Familial analysis of panic disorder and agoraphobia. Gruppo Italiano Disturbi d'Ansia.

In this paper we studied the distribution of age at onset in 144 patients with panic disorder (PD) and/or agoraphobia (according to DSM-III criteria). We also investigated the incidences in their first-degree relatives of PD, agoraphobia, affective disorders, other anxiety disorders and alcoholism. Our aim was to detect the existence of a specific susceptibility system in these families, considering a wide spectrum of disorders. We found an earlier onset of PD and agoraphobia in the subgroup of our probands who previously met criteria for a separation anxiety disorder in childhood. The presence of both separation anxiety disorder and agoraphobia in the probands increased the familial risk for PD and agoraphobia. Nevertheless, the main finding appeared to be the specific familial concentration of agoraphobia, a disorder exclusively clustered in families of agoraphobic patients.

Adult↗
PubMed1993

Evidence that decreased function of lymphocyte beta adrenoreceptors reflects regulatory and adaptive processes in panic disorder with agoraphobia.

OBJECTIVE: This study was designed to clarify the nature of the reduced function of the peripheral beta adrenoceptor system observed in panic disorder with agoraphobia. The authors hypothesized that this phenomenon reflected a regulatory and adaptive process. METHODS: Lymphocyte beta adrenoreceptor density and affinity, basal lymphocyte cAMP level, and isoproterenol-stimulated cAMP generation were measured in 27 untreated outpatients with panic disorder with agoraphobia and 24 healthy comparison subjects. Lymphocyte beta receptor attributes were again assessed in patients after 4 weeks of double-blind treatment with adinazolam (slow-release form) or placebo. Panic frequency, agoraphobic symptoms, overall anxiety, and improvement with treatment were assessed with standard rating instruments. RESULTS: Multivariate statistics revealed significantly lower beta receptor density and isoproterenol-stimulated cAMP generation in patients than in comparison subjects. beta receptor density tended to normalize after adinazolam but not after placebo. Pretreatment beta receptor density was lower in treatment responders than nonresponders. Patients with mild agoraphobia had lower cAMP responsivity than patients with moderate or severe agoraphobia. CONCLUSIONS: Decreased function of lymphocyte beta receptors in panic disorder with agoraphobia is expressed as both decreased density and decreased cAMP responsivity. This pattern of changes, and the tendency for receptor density to normalize with treatment, is consistent with an active, regulatory process rather than a structural deficit in the beta receptor system. Preliminary clinical findings suggest that these changes may reflect adaptive processes associated with a favorable clinical course in panic disorder with agoraphobia.

Adult↗