The relationships among impulsivity, anxiety sensitivity and nonsuicidal self-injury characteristics in patients with phobias

Abstract Background: The relationship between impulsivity and nonsuicidal self-injury (NSSI) has been revealed in several mental disorders other than phobias. Objectives: The purpose of this study was to examine the relationships among impulsivity, anxiety sensitivity, and NSSI characteristics in patients with phobias, and to compare these relationships with healthy controls. Methods: The sample of this study consisted of outpatients (n = 109) who had been diagnosed with social phobia, agoraphobia or simple phobia in addition to healthy individuals (n = 51) serving as the control group. Data collection tools were the socio-demographic form, the Barratt Impulsivity Scale (BIS-11), the Inventory of Statements About Self-Injury (ISAS), and the Anxiety Sensitivity Index (ASI-3). Results: Mean BIS-11 and ASI-3 scores in the social phobia and agoraphobia groups were found to be significantly higher than those in the control group. In addition, a positive correlation was found between ISAS and cognitive anxiety sensitivity scores in the agoraphobia and simple phobia groups. Discussion: The study revealed a positive correlation between cognitive anxiety sensitivity and NSSI in both the agoraphobia and simple phobia groups. The results of this study indicate that anxiety sensitivity may play a regulatory role between impulsivity and NSSI in some sub-groups of phobia.

Association between COMT and 5-HTTLPR Polymorphisms in Korean Patients with Panic Disorder : A Replication Study

OBJECTIVES: We investigated whether the catechol-O-methyltransferase (COMT) and serotonin related gene polymorphisms may be associated with agoraphobia in patients with panic disorder in Korea. METHODS: The COMT gene (rs4680), 5-hydroxytryptamine (serotonin) transporter linked polymorphic region (5-HTTLPR) gene (rs25531), serotonin receptor 1A (HTR1A) gene (rs6295) genotypes were analyzed in 406 patients with panic disorder and age-sex matched 206 healthy controls. Patients with panic disorder were dichotomized by the presence of agoraphobia. The following instruments were applied : the Beck Depression Inventory, the Beck Anxiety Inventory, the Panic Disorder Severity Scale. RESULTS: There was a significant difference in the distribution of 5-HTTLPR genotype between panic patients with agoraphobia and without agoraphobia (p = 0.024). That is, the panic patients with agoraphobia had a significant excess of the less active 5-HTTLPR allele (S allele). (p = 0.039) Also, we replicated previous western reports which indicated a significant difference in the distribution of COMT genotype between the patients with panic disorder and the healthy controls (p = 0.040). However, no significant associations of agoraphobia or panic disorder with HTR1A gene polymorphisms were found. CONCLUSIONS: This result supports that the COMT polymorphisms may be associated with panic disorder and suggests that the 5-HTTLPR polymorphisms may play a role in the pathogenesis of agoraphobia in the Korean patients with panic disorder.

A study of phenomenology of panic disorder & assessment of severity & comorbidity of panic disorder.

Background : Panic disorder with or without agoraphobia is one of the common anxiety disorder. Panic disorder patient seeking medical help with different presenting complains & many patients also suffer from other anxiety / psychiatric or substance use disorders. Objectives: Study sociodemographic characteristics, phenomenology, and assessment of co morbidity and severity of Panic disorder. Material & methods : This is a cross sectional study conducted using DSM-IV-TR criteria for the Panic disorder. Then the patients with the diagnosis of Panic disorder were subjected to 7-item Panic Disorder severity scale (PDSS) for assessing the severity of panic disorder. Evaluated clinically for having agoraphobia or not. Particular attention was paid to check whether patients having any co morbid psychiatric illness. Result : Majority of patients 65% were female, 52.5% were in age group of 15-24 years & mean age of patients was 23.82 years . Mean age of onset of symptoms of Panic disorder was 21.3 years. Most common substance use tobacco in 30% of patients. Most common co morbidity was Major Depressive Disorder in 40% of patients. Agoraphobia was present in 24(60%) patients. Mean duration of PA was 22.37 minutes. 60% had PD moderate. symptoms pattern majority patients 67.5% had Cardio Vascular System (CVS) symptoms. Conclusion: Panic disorder commonly seen in age group 15 – 24 years . Commonly presenting symptoms are CVS related need caution to differentiate. High rate of co morbid substance use & psychiatric illness need attention in Panic disorder patients.

The Effect of Agoraphobia on Oxidative Stress in Panic Disorder

We aimed to investigate whether agoraphobia (A) in panic disorder (PD) has any effects on oxidative and anti-oxidative parameters. We measured total antioxidant capacity (TAC), paraoxonase (PON), arylesterase (ARE) antioxidant and malondialdehyde (MDA) oxidant levels using blood samples from a total of 31 PD patients with A, 22 PD patients without A and 53 control group subjects. There was a significant difference between the TAC, PON, ARE and MDA levels of the three groups consisting of PD with A, PD without A and the control group. The two-way comparison to clarify the group creating the difference showed that the TAC, PON, and ARE antioxidants were significantly lower in the PD with A group compared to the control group while the MDA oxidant was significantly higher. There was no significant difference between the PD without A and control groups for TAC, PON, ARE and MDA levels. We clearly demonstrated that the oxidative stress and damage to the anti-oxidative mechanism are significantly higher in the PD group with A. These findings suggest that oxidative/anti-oxidative mechanisms may play a more important role on the pathogenesis of PB with A.

Are patients with panic disorder respiratory subtype more vulnerable to tobacco, alcohol or illicit drug use? / Pacientes com subtipo respiratório do transtorno de pânico são mais vulneráveis ao uso de tabaco, álcool ou outras substâncias?

BACKGROUND: Studies have documented high use of tobacco, alcohol and illicit drugs in patients with panic disorder (PD). The comorbid substance use disorders worsen the prognosis of mood and anxiety disorders. The respiratory subtype (RS) of PD seems to represent a more severe and distinct form of this disorder associated with higher familial history of PD and more comorbidity with other anxiety disorders. OBJECTIVES: Describe the patterns of tobacco, alcohol or illicit drug use in PD patients, and also to ascertain if patients with the RS use these substances more than those of the non-respiratory subtype. METHODS: This is a cross-sectional study with 71 PD patients. The Alcohol Use Disorders Identification Test and Fagerstrom Tobacco Questionnaire were used in the evaluation. Patients with four or five respiratory symptoms were classified in the RS, the remaining patients were classified as non-respiratory subtype. RESULTS: In our sample 31.0% were smokers, 11.3% were hazardous alcohol users and none of them was using illicit drugs. There were no differences between the respiratory and non-respiratory subtypes regarding the use of tobacco, alcohol, cannabis, cocaine, stimulants and hallucinogens. DISCUSSION: The RS was not correlated to the use of tobacco, alcohol and illicit drugs. Additional epidemiological and clinical studies focusing the relationship between PD and substance use are warranted.

CONTEXTO: Estudos anteriores têm mostrado associações entre o transtorno de pânico (TP) e o uso de tabaco, álcool e substâncias ilícitas. É conhecido que transtornos de uso de substâncias interferem negativamente no prognóstico de transtornos de ansiedade e depressão. No subtipo respiratório (SR) do TP há mais história familiar de TP e maior risco de comorbidades com transtornos de ansiedade. OBJETIVOS: Descrever os padrões de uso de tabaco, álcool e outras substâncias em pacientes com TP. Além disso, analisar se pacientes do SR usam mais essas substâncias do que os pacientes do subtipo não respiratório. MÉTODOS: Esse foi um estudo transversal com 71 pacientes com TP. As escalas Alcohol Use Disorders Identification Test e Fagerstrom Tobacco Questionnaire foram aplicadas. Pacientes com quatro ou cinco sintomas respiratórios foram considerados no SR, e os demais pacientes foram considerados como do subtipo não respiratório. RESULTADOS: Na amostra estudada, 31,0% dos pacientes eram fumantes, 11,3% faziam uso perigoso de álcool e nenhum fazia uso de substâncias ilícitas. Não houve diferença entre os subtipos respiratório e não respiratório em relação a tabagismo, uso de álcool, cannabis, cocaína, estimulantes e alucinógenos. CONCLUSÃO: O SR não foi correlacionado com o uso de tabaco, álcool ou drogas ilícitas. Mais estudos clínicos e epidemiológicos focando a relação entre o TP e uso de substâncias são necessários.

Intervenção baseada na psicoterapia analítica funcional em um caso de transtorno de pânico com agorafobia / Intervention based on functional analytic psychotherapy in a case of panic disorder with agoraphobia

Estratégias terapêuticas descritas como eficazes em transtornos de ansiedade envolvem procedimentos comportamentais e cognitivo-comportamentais de exposição a enfrentamento de situações aversivas. Entretanto, considerando-se que o padrão comportamental comum a estes transtornos é a esquiva fóbica, o uso de tais estratégias pode dificultar a adesão ou promover fuga/esquiva do e no processo terapêutico. A Psicoterapia Analítica Funcional surge como alternativa para manejo dos comportamentos de esquiva e para promoção de respostas de enfrentamento. Este estudo apresenta a análise da relação terapêutica de um caso de Transtorno de Pânico com Agorafobia. A intervenção baseada na FAP foi adotada para auxiliar no manejo do padrão de esquiva do processo terapêutico apresentado pela cliente. Os resultados demonstram a efetividade dos procedimentos adotados e confirmam a possibilidade de utilização da FAP para aumento da eficácia de terapias empiricamente baseadas.

Therapeutic strategies described as effective for anxiety disorders include behavioral and cognitive-behavioral procedures of exposure and coping of aversive situations. However, considering that the behavioral pattern common in anxiety disorders is the phobic avoidance, the application of these strategies may difficult the adhesion or promote escape and avoidance of the therapeutic process. The Functional Analytic Psychotherapy is an alternative for dealing with these avoidance/escape behaviors and it can promote coping responses. This case report describes an analysis of the therapeutic relationship of a client with Panic Disorder and Agoraphobia. The intervention based on FAP was considered to help dealing with the avoidance behavior in the therapeutic process. Results show the efficacy of the procedures adopted and confirm the possibility of using FAP for improving the effectiveness of the empirically based psychotherapies.

Legrand du saulle: da agorafobia ao medo dos espaços / Legrand du saulle: from agoraphobia to fear of open spaces / Legrand du saulle: de l'agoraphobie à la peur des espaces / Legrand du saulle: de la agorafobia al miedo a los espacios

Henri Legrand du Saulle, célebre alienista francês do século XIX, escreve em 1878 "Estudo clínico do medo dos espaços (a agorafobia dos alemães) - neurose emotiva". Constituindo uma abrangente recapitulação crítica dos trabalhos psiquiátricos do século XIX concernentes à agorafobia, assim como uma ótima compilação de descrições clínicas, esse texto situa os fundamentos dessa psicopatologia, os quais serão posteriormente desenvolvidos tanto pela psiquiatria como pela psicanálise.

In 1878 Henri Legrand du Saulle, a famous 19th-century French psychiatrist, wrote "Clinical study of the fear of spaces (the Germans' agoraphobia) - emotional neurosis." This text is a comprehensive critical summary of all work on existing psychiatric agoraphobia at the time, and an excellent compilation of clinical studies. Above all it offers us the foundations for psychopathology, which was further developed by psychiatrists and psychoanalysts.

Henri Legrand du Saulle, célèbre aliéniste français du XIX siècle, rédige en 1878 l"Étude clinique sur la peur des espaces (l'agoraphobie des Allemands) - névrose émotive". Ce texte constitue une vaste récapitulation critique de tous les travaux psychiatriques existants sur l'agoraphobie à cette époque, ainsi qu'une excellente compilation d'études cliniques. Elle nous révèle surtout les fondements de cette psychopathologie qui seront par la suite développés par la psychiatrie et la psychanalyse.

Henri Legrand du Saulle, un célebre psiquiatra francés del siglo XIX, escribió en 1878 "Estudio clínico del miedo a los espacios (la agorafobia de los alemanes) - neurosis emotiva". Una amplia recapitulación crítica de los trabajos psiquiátricos del siglo XIX sobre la agorafobia y una excelente compilación de descripciones clínicas. Ese texto lanza los fundamentos de esa psicopatologia específica, los cuales fueron desarrollados ulteriormente por la psiquiatria y por el psicoanálisis.

Conocimientos acerca del trastorno de ansiedad generalizada y el trastorno de pánico con y sin agorafobia entre médicos residentes de medicina en entrenamiento durante el año 2009 / Knowledge of generalized anxiety disorder and panic disorder with and without agoraphobia among medical residents training during 2009

Objetivos: Estimar el grado de conocimiento que los médicos residentes de dos hospitales públicos tienen acerca del diagnóstico y tratamiento del trastorno de ansiedad generalizada (TAG) y el trastorno de pánico (TP). Material y Métodos: Se diseñó y validó, mediante revisión por jueces y un estudio piloto con médicos generales, un instrumento para evaluar conocimientos acerca del diagnóstico y manejo del TAG y el TP, el cual se aplicó a 70 médicos residentes de medicina de los Hospitales Cayetano Heredia y Arzobispo Loayza en enero del 2009. Resultados: El 22,9% de los participantes diagnosticó correctamente el TAG; 70%, el TP; y 20%, la agorafobia. Los psicofármacos mencionados como tratamiento de primera línea fueron las benzodiazepinas (78,5% para el TAG y 71,4% para el TP), seguidos de los antidepresivos, siendo los más comunes, fluoxetina (21,4% para el TAG y 20% para el TP) y sertralina (20% para el TAG y 17,1% para el TP). El 51,9% y el 52,4% de los participantes indicarían sólo benzodiazepinas para el TAG y el TP, respectivamente. El 80% y 88,6% de médicos residentes transferirían al Servicio de Psiquiatría los pacientes con TAG y TP, respectivamente. Conclusiones: Los médicos residentes diagnostican mejor el TP que el TAG o la agorafobia. Asimismo, en general consideran que estos trastornos requieren tratamiento farmacológico y tratarían a pacientes con estos cuadros si acudieran a su consulta; sin embargo, no indicarían un adecuado tratamiento. Por lo tanto, se debe mejorar la enseñanza sobre estos trastornos en el pregrado y la residencia.

Objective: To estimate the knowledge about diagnosis and management of generalized anxiety disorder (GAD) and panic disorder (PD) among medical residents from two public hospitals. Material and Methods: An instrument to evaluate knowledge about diagnosis and management of GAD and PD was designed and validated by means of expertsÆ review and pilot study with general practitioners. This instrument was administered to medical residents from Cayetano Heredia and Arzobispo Loayza Hospitals (Lima, Perú) during January 2009. Results: Twenty- three percent of participants correctly diagnosed GAD; 70%, PD; and 20%, agoraphobia. Psychotropic drugs considered as first line treatment were benzodiazepines (78.5% for GAD and 71.4% for PD) followed by antidepressant drugs, the commonest being fluoxetine (21.4% for GAD and 20% for PD) and sertraline (20% for GAD and 17.1% for PD); 51.9% and 52.4% of participants would prescribe benzodiazepines as monotherapy for GAD and PD, respectively. Eighty percent and 88.6% of medical residents would refer to a psychiatry service the patients with GAD and PD, respectively. Conclusions: Medical residents diagnose better PD than GAD or agoraphobia. In addition, generally they consider that these disorders require pharmacological treatment and would manage patients with these illnesses if they sought help in their office; however, there are deficiencies in the treatment that they would prescribe. Therefore, it is necessary to improve the education about these disorders in medical students and residents.

Association Study between 5-HT1A Receptor Gene C(-1019)G Polymorphism and Panic Disorder in a Korean Population

OBJECTIVE: Serotonergic dysfunction is quite evident in panic disorder. We investigated whether the C(-1019)G polymorphism of 5-HT1A receptor gene may play a role in the pathogenesis of panic disorder in a Korean population. METHODS: The 5-HT1A receptor genotype for the single nucleotide polymorphism (SNP) C(-1019)G was analyzed in 94 patients and 111 healthy controls. The severity of the patients' symptoms was examined using the Spielberger State-Trait Anxiety Inventory (STAI), Panic Disorder Severity Scale (PDSS), Anxiety sensitivity index (ASI), Acute Panic Inventory (API) and Hamilton's Rating Scale for Anxiety (HAM-A). RESULTS: The distribution of the genotypes of the C/G polymorphism did not differ significantly from those predicted by Hardy-Weinberg equilibrium in patients as well as the controls. No association between the C(-1019)G polymorphism and panic disorder was detected in either the allele frequency or genotype distribution. There was no significant association with genotype distribution in the panic disorder with agoraphobia. However, there was a significant difference of symptom severity between C/C, C/G, and G/G genotype or between C and G allele in panic disorder patients without agoraphobia. PDSS scores were significantly higher in subjects with the G/G genotype or with G allele in patients without agoraphobia, not in total patients or patients with agoraphobia. CONCLUSION: Although there were no significant differences in the genotype and allele distributions, we found a significant association between panic symptom severity and the serotonin 1A receptor gene. This result suggests that the serotonin 1A receptor and serotonin may play a role in the pathogenesis of panic disorder.

Difference in Psychiatric Comorbidity of Panic Disorder According to Age of Onset

OBJECTIVES: It is reported that panic disorder is frequently comorbid with other psychiatric illnesses. The aim of this study was to investigate differences of psychiatric comorbidity according to age of onset of panic disorder. METHODS: Three hundred-two patients participated in the study. All the patients were evaluated by clinical instruments for the assessment the presence of other comorbid psychiatric disorders and various clinical features; Korean version of Mini International Neuropsychiatric Interview, Self-report questionnaires(Beck Anxiety Inventory, Beck Depression Inventory, Anxiety Sensitivity Index and State-Trait Anxiety Inventory) and clinical rating scale (Hamilton Anxiety Scale, Hamilton Depression Scale and Global Assessment of Functional score). Chi-square test was used to determine the difference between early onset and late onset panic disorder. RESULTS: Forty percent of panic patients were found to have at least one comorbid psychiatric diagnosis. There were no differences among the groups divided by number of comorbidity in sex, agoraphobia comorbidity, duration of panic disorder, except onset age of panic disorder. Early onset group had more comorbidy with social phobia, agoraphobia, PTSD. We also found that Early onset panic disorder patients were more likely to experience derealization, nausea, parethesia than late onset panic disorder patients. CONCLUSION: The results of our study are in keeping with previous data from other parts of the world. Our finding suggest that earier onset of panic disorder related to more psychiatric comorbidity.

Tratamento cognitivo-comportamental para o transtorno de pânico e agorafobia: uma história de 35 anos / Cognitive-behavioral therapy for panic disorders and agoraphobia: 35 years of history

Este artigo descreve a evolução do conhecimento sobre um tratamento cognitivo-comportamental do transtorno de pânico e da agorafobia. É baseado em contribuições de vários pesquisadores e descrito como um tratamento integrativo na medida em que associa tratamento farmacológico e vários tipos de intervenções cognitivas e comportamentais. Utiliza técnicas de reestruturação cognitiva, habituação interoceptiva, técnicas respiratórias, de exposição situacional e reestruturação existencial. O tratamento foi originalmente desenvolvido para atendimentos individuais, mas depois foi também utilizado para atendimentos em grupo. Foi concebido para ser um atendimento que pudesse ser desenvolvido por terapeutas que trabalhassem em locais onde não existisse uma terapia cognitivo-comportamental qualificada, em um modelo de tratamento passo-a-passo. Os resultados têm sido muito satisfatórios, com exceção de algumas intervenções, como o treinamento em assertividade e o relaxamento muscular. Ajustes foram realizados para atender esses achados.

This paper describes the evolution of knowledge of cognitive-behavioral treatment of panic disorder and agoraphobia. It is based on contributions by diverse researchers, and it is described as an integrative treatment inasmuch as it combines pharmacological treatment and various types of cognitive and behavioral therapies. It uses cognitive restructuring techniques, interoceptive habituation, techniques for breathing, situational exposure and existential restructuring. The treatment was originally developed for an individual approach, but it was also later used with group treatments. It was conceived as a treatment to be used by therapists working in places where it would not be possible find qualified cognitive-behavioral treatment, in a step-by-step treatment model. Results have been most satisfactory with the exception of some interventions such as assertiveness training and muscular relaxation. Adaptations were made to cater to these findings.

O tabagismo e o transtorno do pânico: gravidade e comorbidades / Smoking and panic disorder: severity and comorbidities

INTRODUÇÃO: Estudos indicam que há uma associação entre tabagismo e transtorno do pânico, e alguns autores sugerem que o tabagismo aumenta o risco de ataques de pânico e transtorno do pânico. Este estudo analisa a hipótese de que pacientes fumantes com esse transtorno apresentam um quadro clínico mais grave. MÉTODO: Sessenta e quatro pacientes em tratamento no Laboratório do Pânico e Respiração (Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro), com transtorno do pânico, segundo critérios do Manual de Diagnóstico e Estatística das Perturbações Mentais (DSM, 4ª edição), foram divididos em grupos de tabagistas e não-tabagistas. Os grupos foram avaliados quanto a características sociodemográficas, comorbidades e gravidade do quadro clínico. RESULTADOS: Não houve diferença significativa em relação à gravidade do transtorno do pânico; no entanto, tabagistas tiveram prevalência de depressão significativamente maior (p = 0,014) do que não-tabagistas. CONCLUSÃO: Este estudo não evidenciou que o transtorno do pânico em tabagistas é mais grave, porém indicou que esses pacientes têm mais comorbidade com depressão.

INTRODUCTION: Several studies indicate that panic disorder and tobacco smoking are associated, and some authors hypothesize that smoking increases the risk of panic attacks and panic disorder. The objective of this study is to investigate whether smokers have a more severe form of panic disorder than non-smokers. METHOD: Sixty-four patients already in treatment at the Laboratory of Panic and Respiration (Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro) with panic disorder as established by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, were divided into groups of smokers and non-smokers. Both groups were compared regarding sociodemographic data, comorbidities and clinical status severity. RESULTS: There was no statistically significant difference between the two groups regarding severity; however, prevalence of depression was significantly higher in the smoker group than in non-smokers (p = 0.014). CONCLUSION: This study did not indicate that smokers have a more severe form of panic disorder, but smoking and comorbid depression were associated.

Tontura associada a distúrbio do pânico e agorafobia: relato de caso e revisão da literatura / Dizziness associated with panic disorder and agoraphobia: case report and literature review

Tontura é uma das queixas mais freqüentes no consultório médico tanto primário quanto especializado. Muitos dos pacientes que se apresentam com tontura sem causa orgânica aparente, portanto considerados como portadores de tontura idiopática, podem ter um distúrbio psiquiátrico. Além disso, mesmo a tontura de causa orgânica pode desencadear ou exacerbar alterações psiquiátricas "latentes". Um dos distúrbios mais comumente associados à tontura é o Distúrbio do Pânico, com ou sem Agorafobia. O objetivo deste estudo é relatar o caso de uma paciente com essa associação e realizar uma revisão da literatura relacionada ao assunto.

Dizziness is one of the most frequent complaints in both primary and specialized medical care facilities. Many dizzy patients, without a known organic cause, considered as having idiopathic dizziness, may have a psychiatric disorder. Besides, even organic dizziness may cause or exacerbate latent psychiatric alterations. One of the most common disorders associated with dizziness is Panic Disorder with or without Agoraphobia. The aim of this paper is to report a patients case and make a literature review on the subject.

A Comparison of the Clinical Features between Panic Disorder with and without Agoraphobia

OBJECTIVES: This study was performed to investigate the differences of the clinical feature between panic disorder with agoraphobic patients and panic disorder without agoraphobic patients. METHODS: Two hundred nine patients meeting the criteria of DSM-IV panic disorder were recruited. One group was panic disorder with agoraphobia(n=78, 42 male(53.8%), mean age 37.6+/-9.9 years), another was panic disorder without agoraphobia(n=131, 81 male(61.8%), mean age 40.5+/-10.3 years). The numbers and frequency of panic symptoms were compared between two groups with t-test, and the logistic regression analysis were used for predicting panic disorder with agoraphobia. RESULTS: The number of panic symptoms during panic attack was significantly higher in the group of panic disorder with agoraphobia than the group of panic disorder without agoraphobia(p<0.05). 'Sweating', 'nausea or abdominal distress', 'fear of losing control of going crazy', 'chills or hot flushes' were more frequent in the group of panic disorder with agoraphobia(p<0.05). Among panic symptoms on logistic regression analysis, 'sweating', 'nausea or abdominal distress', 'fear of losing control or going crazy' turned out to correlate significantly with risk of development of agoraphobia in panic disorder. CONCLUSION: These results suggest that the frequency of some symptoms during panic attack may be a predictor of agoraphobia in patients with panic disorder.

Agorafobia (con o sin pánico) y conductas de afrontamiento desadaptativas. Estudio empírico. Segunda parte

resumen está disponible en el texto completo

Abstract: This paper is focused in the coping strategies used by patients with an agoraphobic disorder (AD) when they are forced to confront phobic situations. Traditionally, the coping strategies considered were those used by agoraphobia patients to reduce anxiety and psychological distress: the avoidance behavior (to avoid the phobic stimuli) and the escape behavior (when the phobic stimulus is present). Additionally, behaviors used to try to avoid negative physiological responses similar to those occurring in an anxiety crisis (interoceptive avoidance) are also included. A fourth group of behaviors has received less attention: coping strategies that partially allow agoraphobia patients to confront and resist the presence of phobic stimuli. These are stimuli that they need to or are forced to confront. These partial coping strategies (often rituals behaviors) are behaviors to which patients assign a value in decreasing the anxiety to tolerable levels until they are able to confront and resist the phobic scenes (even partially). These behaviors play a non-adaptative role because they difficult the development of adaptative self-control strategies, interfere with daily living conditions, and support the disorder providing an initial and immediate relief of psychological distress. We prefer to name all these strategies non-adaptative coping behaviors. Despite the relevance of these partial coping strategies in the development and consolidation of agoraphobia, their empiric study has been infrequent (especially when compared to the study of both avoidance and escape behaviors). In that sense, with the present study we try to provide data about the following issues: 1) to know how frequently AP' use non-adaptative coping behaviors compared with a group of patients with other disorders. 2) The differential use of behavioral patterns by agoraphobic patients (AP): avoidance behaviors, interoceptive avoidance, escape behaviors, and, especially, the partial coping strategies. 3) The role of partial coping strategies in the evaluation of therapeutic outcome, according to the clinician opinion. The empirical study was designed in two stages: First, the elaboration of a scale to measure coping strategies of phobic stimuli. For that purpose, we took into account literature on the topic, observational data and clinical histories of patients with agoraphobia. The result was a scale (CAD scale) composed by 87 overt behavior items, and 52 covert behavior items. All of these items allowed for the formation of four behavioural patterns, grouping items according to their functions in coping with phobic stimuli: 1) avoidance behavioral pattern; 2) interoceptive avoidance pattern; 3) escape behavioral pattern; and 4) partial coping behavioral pattern. Second stage: The application of the CAD scale to a clinical simple. A group of psychologists and psychiatrists (from a local mental health service unit) were requested to administrate the scale to their patients, with their informed consent. The final sample (n = 235) was as follows: 40 with agoraphobic disorder (30 women and 10 men); 30 with panic disorder (18 women and 12 men); 30 mixed with anxious-depressive disorder (25 women and 5 men); 40 with depressive disorders (32 women and 8 men); 25 with psychotic disorders (10 women and 15 men). A matched group without any clinical disorders was added later (N = 70, 49 women and 21 men). After analysing the results related to the use of non-adaptative coping behaviors, these may be summarized as follows: In gene ral, the group which used less the CAD strategies was the non-clinical group. The patients with agoraphobia were the ones who used the CAD strategies in a more significant level, compared with both the non-clinical group and the groups with other disorders. This includes the use of partial coping behaviors. Results were similar both to CAD overt strategies and covert strategies. Comparing the differential use of CAD strategies by patients with agoraphobia, results show a more significant use of avoidance behaviors (especially in overt behavior form), followed by escape behaviors. Interoceptive avoidance was the third CAD more frequently used. Partial coping behaviors were less used in contrast with other CAD strategies. According to therapist judgments with respect to the relationship between the use of coping strategies and the therapeutic progress evaluation, the AP sample was divided into two groups: positive progress and non-positive progress (negative, unstable or no progress). The positive progress group shows a significant lower use of avoidance behaviors, interoceptive avoidance, and escape behaviors, but only in the overt behavior form. There were no significant effects for partial coping behavior. In other words, a positive evolution in PA was joined by a decrease in avoidance overt behaviors, interoceptive overt avoidance, and escape overt behaviors, but there were no changes in the use of both cognitive coping strategies and partial coping behaviors. Our findings confirm that CAD strategies are more used by AP. Partial coping behaviours are included among these. It was a well-known fact (and previous data supported it), that agoraphobia patients tended to use more both avoidance and escape strategies as procedures which relieved them from anxiety and psychological distress. But, also, there were few data about the role of strategies allowing AP to confront and resist the phobic scenes: the partial coping behaviors. Our data provide information about this kind of coping. Results support that it is more frequently used by agoraphobia patients. This is true when comparing it with patients with other disorders, and, obviously, in contrast with the normal population. But the use of partial coping behaviors is not commonly compared with "more traditional" behaviors such as avoidance or escape behaviors. It may be said that people with agoraphobia choose to avoid or to escape from phobic situations as the best way for them to reduce anxiety. But there is a group of phobic situations an agoraphobic patient must confront on some occasions (attending a medical service, buying something, etc.). These few occasions represent an opportunity to use partial coping strategies. The limited use of these strategies may be due to the fact that other strategies reduce anxiety in a more effective way. In that sense, they may be considered as behaviors having a low frequency of occurrence and a high intensity. We especially appreciate findings about the role of partial coping strategies in the therapeutic progress when a clinician emits judgments about the improvement of agoraphobia patients. These judgments are linked to a decrease of several non- adaptative overt strategies, but there is no change in cognitive coping strategies and neither in partial coping behaviors. These may be interpretated as imprecise therapist judgments, but also as the role played by this kind of strategies in the latent maintenance of agoraphobic responses. Finally, this paper discusses these results according to the counter-therapeutic role of partial coping strategies, and the need to consider them as a target objective in treatment process.

Agorafobia (con o sin pánico) y conductas de afrontamiento desadaptativas. Primera parte

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Abstract: The present paper examines the role of a type of coping strategy used by patients with agoraphobic disorders (AD) when they confront phobic stimuli. This strategy consists in a group of overt behaviors and thoughts (ritual behaviors, frequently) which allow agoraphobic patients (AP) to resist the presence of phobic scenes. Those behaviors function like a partial coping in the sense that they allow initially to confront the phobic stimuli, but later they transform themselves in non-adaptative coping behaviors that limit the therapeutic efficiency. The agoraphobic disorder (AD), with or without panic attack (CIE-10, F 40), is considered the more complex phobia and which produces the highest level of disability. Besides, this phobia, contrary to social or specific phobias, has a pervasive tendency (panphobia), reaching each time more situations and stimuli. The essential clinical aspects include anxiety, sensitivity, emotional responses of fear-anxiety-panic and shame, anticipatory responses, catastrophic thoughts, and avoidance and escape behaviors toward phobic scenes. There is an important volume of research about those clinical aspects. But there are only a few studies about the coping strategies used by AP when they need to resist a phobic situation. Traditionally, coping strategies considered were those used by AP to reduce anxiety and psychological distress: the avoidance behavior (to avoid the phobic stimuli) and the escape behavior (when the phobic stimulus is present). Additionally, it also includes behaviors targeted to avoid the negative physiological responses similar to those occurring in an anxiety crisis (interoceptive avoidance). Nevertheless, some experts have reported that AP used some other coping strategies that allowed them to accomplish partial and temporary confrontations toward phobic elements (elements that they needed to confront). In that sense, some authors have proposed other strategies beyond avoidance and escape behaviors, including those partial coping behaviors in the repertories used by agoraphobic patients. So, there are several classifications that take into account these behaviors, but under different terms: Distractions (thoughts or conducts that relieve anxiety in the presence of phobic stimuli). Calming strategies (behaviors that they use when they need to confront a phobic scenario). Searchingfor company (looking for the company of a relative, friend or pet). Safety behaviors or safety signs (behaviors adopted to limit the level of distress as a consequence of feeling "caught" in a phobic situation). Counter-phobic objects (objects or persons to which patients assign the ability to diminish the distress in the case of crisis). Different experts have denominated these strategies "defensive mechanisms", "useless coping strategies", "partial coping strategies" or "non-adaptative coping behaviors". This kind of behaviors and thoughts can be useful in the short-term, but in the long term they favor the continuity of anxiety and the avoidance cycle. These partial coping strategies allow patients with agoraphobia to confront and to resist the presence of the phobic stimuli, but this is done with a high cost, since the confrontations are only partial (they confront the phobic scenarios in certain contexts and with certain characteristics) and temporary, generalizing the use of these strategies to future confrontations. These strategies provide a certain apparent validity: the person is capable to resist the phobic element (that is not possible with both avoidance and escape strategies). Nevertheless, the information provided by these behaviors acts as a reinforcing mechanism and acquires by itself a value of discriminative stimulus about the circumstances in which are possible for confronting the phobic scenes. The role of these behaviors and thoughts in the development of agoraphobia in a chronic disorder is also evident. In this sense, they play a non-adaptative role. These strategies turn to be the unique ways to confront (some part of) phobic stimuli. Then, they generate a high degree of interference with both adaptive behaviors and thoughts that must be dominant in the therapeutic process. Finally, the partial coping strategies pass from being a resource that allows them to resist the phobic stimuli, to a therapeutic aim that clinicians must reduce and eliminate. Taking into account the state of the question, we propose in this paper a new classification of non-adaptative coping strategies used by agoraphobic patients, for including the partial coping strategies. The parameters for constructing a new taxonomy are three: (i) the coping strategies must be grouped according to its function role (i.e., to avoid anxiety and negative physiological responses, to reduce anxiety if it appears, to confront the stimuli with the lower level of distress). So, we prefer the term behavioral patterns, like a group of behaviors and thoughts which rule similar functions. (ii) The classification has to attend to the nature of behaviors, differentiating between overt (manifest) and covert (cognitive) behaviors. This distinction is elemental from an applied point of view. (iii) The third element is to identify the non-adaptative character of the confrontation behaviors, because they incapacitate and interfere in the normal development of the daily life. Additionally, a terminology question: there is several concepts that are being used in an indistinct manner, such as behavioral patterns, strategies or, even, styles. According to what the agoraphobic patients do (in an overt or covert way), we prefer the term behavior, in the sense that this term emphasizes what the people do (and not what they believe o what they would like to do). According to those three parameters, we propose four behavioral patterns. These behavioral patterns have two versions: overt and covert behavior. The components of each pattern share similar functions and they cover all of those strategies that can be used for persons with agoraphobia for coping with the different phobic scenes. The four behavioral patterns are as follow: Avoidance behaviors. This pattern includes all of those behaviors and thoughts that the agoraphobic patients do to avoid the phobic stimuli. Its function consists in to prevent the anxiety and psychological distress by means of avoidance of phobic elements. Interoceptive avoidance. This pattern refers to all behaviors and thoughts that try to avoid the interoceptive signs (negative physiological responses) similar to those that occur during an agoraphobic crisis. Its function consists to prevent physiological negative states by means of avoidance of those behaviors that can generate those states and can be interpreted like the beginning of a crisis. Escape behaviors. This group of behaviors refers to all behaviors and thoughts that are used to remove the patients from a phobic scene. So, its function consists in to reduce and to eliminate the anxiety states by means to run away from the phobic stimuli. Partial coping behaviors. Finally, this fourth behavioral pattern includes all of those strategies that allow AP to resist the presence of phobic elements. This resistance is doing according to some contexts and according to certain characteristics of those elements. The strategies consist on behaviors and thoughts, such as safety signs, distractions, or rituals that reduce the anxiety to tolerable levels. Its function consists to provide several resources that allow to a person with agoraphobia to cope with a phobic situation. Usually, the anxiety does not disappear, but the psychological distress does not reach disability levels. Frequently, the patients carry out these strategies because they are forced or need it. This approach is discussed according to the utility to take into account these four behavioral patterns, and not only the avoidance and escape behaviors. An special consideration have the partial coping strategies in the extent in which these behavior may suppose a false therapeutic progress, at the time that they turn into a resistant element that interferes with the therapeutic resources.

The Significance of Interoceptive Fear in Assessment of Panic Disorder Patients / 신경정신의학

OBJECTIVES: We investigated the significance of interoceptive fear in assessment of panic disorder (PD) patients. METHODS: 102 patients affected by PDs with (n=68) or without (n=34) agoraphobia according to DSM-IV criteria completed self-report questionnaires, such as Albany Panic and Phobia Questionnaire (APPQ), The Expanded Anxiety Sensitivity Index (ASI-R), Agoraphobic Cognitions Questionnaire (ACQ), Body Sensation Questionnaire (BSQ), Beck Anxiety Inventory (BAI), and Panic Disorder Severity Scale (PDSS). Pearson correlation analysis, stepwise regression analysis, paired t-test and independent t-test were used. RESULTS: All variables except BSQ were significantly correlated with panic severity. In stepwise regression analysis, interoceptive fear and catastrophic cognition were the most significant predicting variables for panic severity. After 3-months medication, all variables significantly diminished, but interoceptive fear and catastrophic cognition of panic patients were still significantly higher than normal control. CONCLUSION: Interoceptive fear is the fear of automatic sensations that are similar to those of a panic attack and is the most significant variable in predicting panic severity. After 3-months medication, interoceptive fear significantly decreased, but still was higher than the control group.

Some notes on a historical perspective of panic disorder

This article aims to describe important points in the history of panic disorder concept, as well as to highlight the importance of its diagnosis for clinical and research developments. Panic disorder has been described in several literary reports and folklore. One of the oldest examples lies in Greek mythology - the god Pan, responsable for the term panic. The first half of the 19th century witnessed the culmination of medical approach. During the second half of the 19th century came the psychological approach of anxiety. The 20th century associated panic disorder to hereditary, organic and psychological factors, dividing anxiety into simple and phobic anxious states. Therapeutic development was also observed in psychopharmacological and psychotherapeutic fields. Official classification began to include panic disorder as a category since the third edition of the American Classification Manual (1980). Some biological theories dealing with etiology were widely discussed during the last decades of the 20th century. They were based on laboratory studies of physiological, cognitive and biochemical tests, as the false suffocation alarm theory and the fear network. Such theories were important in creating new diagnostic paradigms to modern psychiatry. That suggests the need to consider a wide range of historical variables to understand how particular features for panic disorder diagnosis have been developed and how treatment has emerged.

A Validation Study of Korean Albany Panic and Phobia Questionnaire(APPQ) / 신경정신의학

OBJECTIVES: The Albany Panic and Phobia Questionnaire (APPQ) was developed to assess fear of activities that may elicit physical sensation in panic patients. There are three subscales (Agoraphobia, Social phobia, and Interoceptive fear) in the scale. The present study was conducted to determine the validity and reliability of APPQ in Korean population. METHODS: One hundred thirty five panic patients and 135 community samples and were enrolled in this study. All subjects completed a psychometric assessment package which included APPQ, ASI-R, ACQ, BSQ, BAI, BDI. RESULTS: 1) APPQ showed good internal consistency (Cronbach's alpha=.95) and high test-retest reliabilities (r=.77). 2) APPQ showed moderate correlations with ASI-R (r=.67), ACQ (r=.67), BSQ (r=.59) and BAI (r=.64). 3) An exploratory factor analysis revealed 3 factors (Agoraphobia, Social Phobia and Intorceptive fear). 4) Panic patients (with or without agoraphobia) had significantly higher sores of the APPQ interoceptive subscale than the community samples (F(2,27)=24.27, p<.001). CONCLUSION: We found that APPQ and its 3 subscales carry valuable internal consistency, test-retest reliability, and convergent and construct validity. These results suggest that APPQ is a reliable and valid instrument to assess patients with panic disorder.

Prolapso valvar mitral e transtorno do pânico / Mitral valve prolapse and panic disorder

Verificar a incidência de prolapso valvar mitral (PVM) em portadores de transtorno do pânico (TP) com e sem agorafobia. Sessenta e cinco pacientes (37 mulheres) com idades entre 19 e 67 (média 39,8) anos. O diagnóstico de PVM baseou-se na presença de estalido mesotelessistólico (EMS) e/ou de sopro mesotelessistólico, com em dados ecocardiográficos: deslocamento mesotelessistólico de uma ou de ambas as cúspides da mitral, 2 mm ou mais, posteriormente à linha de uniäo dos pontos C-D (modo "M") ou movimentaçäo sistólica de pelo menos uma das cúspides da mitral, além do plano do anel valvar, nas incidências apical e para-esternal, eixo transversal (modo bi-dimensional). Sinais clínicos e/ou ecocardiográficos de PVM foram encontrados em 29 (44,6%) pacientes, sendo 12 (42,6%) dos homens e 17 (45,9%) das mulheres. EMS foi auscultado em 19 (29,2%) e sinais ecocardiográficos de PVM foram identificados (39,6%), ambos em 14 (23,6%) pacientes. A incidência de PVM em portadores de TP é maior do que a da populaçäo em geral, de modo mais acentuado no sexo masculino