The role of personality in anxiety disorders.

It is widely believed that personality disorders and/or traits (PDT) have significant impact on the phenomenology, severity and consequently the treatment of anxiety disorders (AD). Specific PDT's are thought to be characteristic of certain types of AD's. However, little experimental data support these assumptions. The interpretation of the few comorbidity and outcome studies investigating the role of PDT's in anxiety is problematic from both theoretical and methodological points of view. The authors review what is known about the co-occurrence of PDT's and some of the AD's. Particular attention is paid to studies that demonstrate the alteration of PDT's as a result of successful treatment of an AD and to those assessing the difficulties encountered in the treatment of AD's in the presence of certain PDT's. Specific recommendations for much needed research are given.

Early separation anxiety and adult agoraphobia.

The authors compared 137 adult patients who had agoraphobia with 81 patients who had either simple or social phobia for a history of childhood and adolescent separation anxiety. Female agoraphobics reported significantly more childhood separation anxiety than female combined simple and social phobics; males showed no significant difference between diagnostic groups. The reported prevalence of separation anxiety in adolescence was relatively low, but agoraphobics of both sexes reported significantly more separation anxiety than combined simple and social phobics. There were no significant differences between groups for parental losses or severe family disruption during childhood. The results suggest that childhood separation anxiety is a risk factor in females but not in males for the later development of agoraphobia.

Treatment of panic disorder with imipramine alone.

Ten patients with panic disorder were treated solely with imipramine in an open pilot trial. All patients reported cessation of panic attacks and considerable overall improvement. Four patients who took medication 5 months or longer reported marked overall improvement.

Differential treatment of phobias: use of imipramine for panic attacks.

The core disorder in agoraphobia and mixed phobia typically is the "spontaneous" panic attack, which may be due to various psychologic and physiologic triggering mechanisms. The panics tend to lead to anticipatory anxiety and, consequently, avoidance behavior. Tricyclics and MAO inhibitors suppress the spontaneous panics. Once this is accomplished, psychotherapeutic intervention helps patients overcome their phobias. Supportive psychotherapy, imaginal desensitization and in vivo exposure appear to be equally effective. Phobics who do not experience spontaneous panics are unaffected by these drugs but improve with psychotherapeutic techniques.

Treatment of phobias. I. Comparison of imipramine hydrochloride and placebo.

In a controlled-outcome study of phobias, 218 adult phobic patients (147 women and 71 men) received a course of 26 weekly treatment sessions that consisted of behavior therapy (BT) and imipramine hydrochloride, BT and placebo, or supportive psychotherapy and imipramine. The BT consisted of systematic desentization using fantasy and assertiveness training. Patients were classified as agoraphobic, mixed phobic, or simple phobic. Although the conditions of most patients in each group showed moderate to marked improvement, the effects of imipramine were significantly superior to those of placebo in patients with spontaneous panic attacks, ie, patients with agoraphobia or mixed phobia. In patients with simple phobia, who do not experience spontaneous panic, there was not a significant difference between imipramine and placebo. This study clearly distinguished those phobic patients who experienced spontaneous panic from those who did not in terms of pharmacologic benefits.

Treatment of phobias. II. Behavior therapy and supportive psychotherapy: are there any specific ingredients?

Systematic hierarchical desensitization (behavior therapy [BT]) was compared with supportive psychotherapy (ST) during a 26-week treatment trial of patients with agoraphobia, mixed phobia, or simple phobia. We found essentially no difference in effectiveness, not because patients treated with BT had done badly, but because patients receiving ST had done well. A detailed methodologic review concludes that this finding is entirely compatible with the major critical reviews of the psychotherapy literature. Is the active ingredient in psychotherapy simply the generation of hopeful expectancies? This is necessary but not sufficient. For phobics, the psychotherapy session serves primarily as an instigator. The specific corrective activity occurs outside of the formal session in the form of maintained exposure in vivo. Supposed differences between therapies may be entirely due to the rapidly with which the instigational function becomes effective.

Mitral valve prolapse syndrome in agoraphobic patients.

Twenty-five agoraphobic women were compared with 23 controls for the presence of mitral valve prolapse syndrome (MVP). All subjects underwent cardiac examination, electrocardiography, phonocardiography, and echocardiography. Eleven of the agoraphobic patients had MVP; 5 had echo findings alone, 3 had both auscultory and echo findings, and 3 had auscultory findings alone. Two controls had evidence of MVP, both with echo findings alone. Echo chamber size and wall motion were similar in both groups. One patient had inferior T wave changes on ECG while all controls had normal tracings. The authors conclude that a significant number of agoraphobic patients have MVP and discuss the thoretical and clinical implications of this association.

Treatment of agoraphobia with group exposure in vivo and imipramine.

Seventy-six white agoraphobic women, 21 to 45 years old, were treated with combined group exposure in vivo and imipramine or placebo in a randomized double-blind study. A majority of the patients in both the placebo and imipramine groups showed moderate to marked improvement. However, imipramine therapy was significantly superior to placebo therapy on three of the four reported measures of improvement: primary phobia, spontaneous panic, and global improvement. There was a negative correlation between depression and outcome; ie, the more depressed patients fared worse on several outcome measures than those who were less depressed. A comparison of these patients with agoraphobic women previously treated with imipramine and imaginal desensitization showed a superiority of exposure in vivo midway in treatment, but no significant difference between the two groups at the completion of therapy.

Behavior therapy, supportive psychotherapy, imipramine, and phobias.

In a controlled outcome study of phobias, 111 adult patients (69% women, 31% men) received a course of 26 weekly treatment sessions consisting of (1) behavior therapy and imipramine hydrochloride (2) behavior therapy and placebo, or (3) supportive psychotherapy and imipramine. Patients were classified as agoraphobic, mixed phobic, or simple phobic. The great majority of patients in all groups showed moderate to marked global improvement (70% to 86%, depending on rater). In agoraphobics and mixed phobics (both groups experiencing spontaneous panic attacks), imipramine was significantly superior to placebo. There was no difference between behavior therapy and supportive therapy, both resulting in high improvement rates (76% to 100%, depending on rater). In simple phobic patients, there was a high rate of improvement with all treatment regimens (72% to 93%, depending on rater), with no significant difference between imipramine and placebo or between behavior therapy and supportive therapy. Of 88 moderately to markedly improved patients followed up for one year after completing treatment, 83% maintained their gains and 17% relapsed. No patients showed symptom substitution. Eighteen percent of the patients receiving imipramine hydrochloride showed marked stimulant side effects on from 5 to 75 mg/day.