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chapter 1 panic disorder and agoraphobia michelle g craske david h barlow thetreatment protocol described in this chapter represents one of the success stories in the development of empirically supported ...

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                                                              CHAPTER 1
                                   Panic Disorder and Agoraphobia
                                                                MICHELLE G. CRASKE
                                                                  DAVID H. BARLOW
                                     Thetreatment protocol described in this chapter represents one of the success stories in
                                     the development of empirically supported psychological treatments. Results from numer-
                                     ous studies indicate that this approach provides substantial advantages over placebo
                                     medication or alternative psychosocial approaches containing “common” factors, such as
                                     positive expectancies and helpful therapeutic alliances. In addition, this treatment forms
                                     an important part of every clinical practice guideline in either public health or other
                                     sources from countries around the world, describing effective treatments for panic disor-
                                     der and agoraphobia. Results from numerous studies evaluating this treatment protocol,
                                     both individually and in combination with leading pharmacological approaches, suggest
                                     that this approach is equally effective as the best pharmacological approaches in the short
                                     term and more durable over the long term. But this treatment protocol has not stood still.
                                     For example, we have learned a great deal in the past 5 years about neurobiological
                                     mechanisms of action in fear reduction, and the best psychological methods for effecting
                                     these changes.In this chapter we present the latest version of this protocol, incorporating
                                     thesechangesandadditionsasillustratedinacomprehensiveaccountofthetreatmentof
                                     “Julie.”—D. H. B.
                            Advances continue in the development of bio-          of treatment outcome data, this chapter covers
                            psychosocial models and cognitive-behavioral          recent theoretical and empirical developments
                            treatments for panic disorder and agoraphobia.        in reference to etiological factors, the role
                            The conceptualization of panic disorder as an         of comorbid diagnoses in treatment, ways of
                            acquired fear of certain bodily sensations, and       optimizing learning during exposure therapy,
                            agoraphobia as a behavioral response to the           and the effect of medication on cognitive-
                            anticipation of such bodily sensations or their       behavioral treatments. The chapter concludes
                            crescendo into a full-blown panic attack, con-        with a detailed, session-by-session outline of
                                                                             -                                                     -
                            tinues to be supported by experimental, clini         cognitive-behavioral treatment for panic disor
                            cal, and longitudinal research. Furthermore,          der with agoraphobia (PDA). This protocol has
                                                                                                                                   -
                            the efficacy of cognitive-behavioral treatments       been developed in our clinics; the full proto
                            that target fear of bodily sensations and associ-     col is detailed in available treatment manuals
                            ated agoraphobic situations is well established.      (Barlow & Craske, 2006; Craske & Barlow,
                            In addition to presenting an up-to-date review        2006).
                                                                               1
                          2                   CLINICAL HANDBOOK OF PSYCHOLOGICAL DISORDERS
                          NATURE OF PANIC                                      nomic activation reflects anticipatory anxiety
                          ANDAGORAPHOBIA                                       rather than true panic (Barlow et al., 1994), es-
                          Panic Attacks                                        pecially because more severe panics are more
                                                                               consistently associated with accelerated heart
                          “Panic attacks” are discrete episodes of intense     rate (Margraf et al., 1987). Another example of
                          dread or fear, accompanied by physical and           discordance occurs when perceptions of threat
                          cognitive symptoms, as listed in the DSM-IV-         or danger are refuted despite the report of in-
                          TRpanic attack checklist (American Psychiat-         tense fear. This has been termed “noncog-
                          ric Association, 2000). Panic attacks are dis-       nitive” panic (Rachman, Lopatka, & Levitt,
                          crete by virtue of their sudden or abrupt onset      1988). Finally, the urgency to escape is some-
                          and brief duration, as opposed to gradual-           times weakened by situational demands for
                          ly building anxious arousal. Panic attacks in        continued approach and endurance, such
                          panic disorder often have an unexpected qual-        as performance expectations or job demands,
                          ity, meaning that from the patient’s perspective,    thus creating discordance between behavioral
                          they appear to happen without an obvious trig-       responsesontheonehand,andverbalorphysi-
                          ger or at unexpected times. Indeed, the diagno-      ological responses on the other.
                          sis of panic disorder is given in the case of re-       A subset of individuals with panic disorder
                          current “unexpected” panic attacks, followed         experience nocturnal panic attacks. “Noctur-
                          byatleast 1 month of persistent concern about        nal panic” refers to waking from sleep in a
                          their recurrence and their consequences, or by       state of panic with symptoms that are very sim-
                          a significant change in behavior consequent to       ilar to panic attacks during wakeful states
                          the attacks (American Psychiatric Association,       (Craske & Barlow, 1989; Uhde, 1994). Noc-
                          1994).                                               turnal panic does not refer to waking from
                             As with all basic emotions (Izard, 1992),         sleep and panicking after a lapse of waking
                          panic attacks are associated with strong action      time, or nighttime arousals induced by night-
                          tendencies; Most often, these are urges to es-       mares or environmental stimuli (e.g., unex-
                          cape, and less often, urges to fight. These fight    pected noises). Instead, nocturnal panic is an
                          and flight tendencies usually involve elevated       abrupt waking from sleep in a state of panic,
                          autonomic nervous system arousal needed to           withoutanobvioustrigger.Nocturnalpanicat-
                          support such fight–flight reactivity. Further-       tacks reportedly most often occur between 1
                          more, perceptions of imminent threat or dan-         and 3 hours after sleep onset, and only occa-
                          ger, such as death, loss of control, or social       sionally more than once per night (Craske &
                          ridicule, often accompany such fight–flight re-      Barlow, 1989). Surveys of select clinical groups
                          activity. However, the features of urgency to es-    suggest that nocturnal panic is relatively com-
                          cape, autonomic arousal, and perception of           mon among individuals with panic disorder:
                          threat are not present in every self-reported oc-    44–71% report having experienced nocturnal
                          currence of panic. For example, despite evi-         panic at least once, and 30–45% report re-
                          dence for elevated heart rate or other indices of    peated nocturnal panics (Craske & Barlow,
                          sympathetic nervous system activation during         1989; Krystal, Woods, Hill, & Charney, 1991;
                          panic attacks on average (e.g., Wilkinson et         Mellman&Uhde,1989;Roy-Byrne,Mellman,
                          al., 1998), Margraf, Taylor, Ehlers, Roth, and       &Uhde, 1988; Uhde, 1994). Individuals who
                          Agras (1987) found that 40% of self-reported         suffer frequent nocturnal panic often become
                          panic attacks were not associated with acceler-      fearful of sleep and attempt to delay sleep on-
                          ated heart rate. Moreover, in general, patients      set. Avoidance of sleep may result in chronic
                          with panic disorder are more likely than non-        sleep deprivation, which in turn precipitates
                          anxious controls to report arrhythmic heart          more nocturnal panics (Uhde, 1994).
                          rate in the absence of actual arrhythmias               “Nonclinical” panic attacks occur occasion-
                          (Barsky, Clearly, Sarnie, & Ruskin, 1994).           ally in approximately 3–5% of people in the
                          Heightened anxiety about signs of autonomic          general population who do not otherwise meet
                          arousal may lead patients to perceive cardiac        criteria for panic disorder (Norton, Cox, &
                          events when none exist (Barlow, Brown, &             Malan, 1992). Also, panic attacks occur across
                          Craske, 1994; Craske & Tsao, 1999). We be-           a variety of anxiety and mood disorders
                          lieve that self-reported panic in the absence of     (Barlow et al., 1985), and are not limited to
                          heart rate acceleration or other indices of auto-    panic disorder. As stated earlier, the defining
                                                                Panic Disorder and Agoraphobia                                  3
                            feature of panic disorder is not the presence of     THERAPIST: What worries you most about oth-
                            panic attacks per se, but involves addition-           ers noticing your physical symptoms?
                            al anxiety about the recurrence of panic or          PATIENT: That they will think that I am weird
                            its consequences, or a significant behavioral          or strange.
                            change because of the panic attacks. It is the       THERAPIST: Would you be anxious in the meet-
                            additional anxiety about panic combined with           ings if the panic attacks were fully prevent-
                            catastrophic cognitions in the face of panic that      able?
                            differentiate between the person with panic dis-
                            order and the occasional nonclinical panicker        PATIENT: I would still be worried about doing
                            (e.g., Telch, Lucas, & Nelson, 1989) or the per-       or saying the wrong thing. It is not just the
                            son with other anxiety disorders who also hap-         panic attacks that worry me.
                            pens to panic. The following scenario exempli-       THERAPIST: Are you worried about panic at-
                            fies the latter point.                                 tacks in any other situations?
                            PATIENT: Sometimes I lay awake at night think-       PATIENT: Formal social events and sometimes
                              ing about a million different things. I think        when I meet someone for the first time.
                              about what is going to happen to my daugh-           In this case, even though the patient experi-
                              ter if I get sick. Who will look after her, or     ences panic attacks, the real concern is about
                              what would happen if my husband died and           being judged negatively by others consequent
                              we didn’t have enough money to give my             to panic attacks, and the panic attacks do not
                              daughter a good education? Then I think            occur in situations other than social ones.
                              about where we would live and how we               Hence, this presentation is most aptly de-
                              would cope. Sometimes I can work myself            scribed as social phobia.
                              up so much that my heart starts to race, my
                              handsgetsweaty,andIfeeldizzyandscared.
                              SoIhavetostopmyselffromthinkingabout               Agoraphobia
                              all those things. I usually get out of bed and
                              turn on the TV—anything to get my mind             “Agoraphobia” refers to avoidance or endur-
                              off the worries.                                   ance with dread of situations from which es-
                            THERAPIST: Do you worry about the feelings of        cape might be difficult or help unavailable in
                              a racing heart, sweating, and dizziness hap-       the event of a panic attack, or in the event of
                              pening again?                                      developing symptoms that could be incapaci-
                            PATIENT: No. They’re unpleasant, but they are        tating and embarrassing, such as loss of bowel
                              the least of my concerns. I am more worried        control or vomiting. Typical agoraphobic sit-
                              about my daughter and our future.                  uations include shopping malls, waiting in
                                                                                 line, movie theaters, traveling by car or bus,
                                                                                 crowded restaurants, and being alone. “Mild”
                              This scenario illustrates the experience of        agoraphobia is exemplified by the person who
                            panic that is not the central focus of the per-      hesitates about driving long distances alone but
                            son’s anxiety. More likely, this woman has gen-      manages to drive to and from work, prefers to
                            eralized anxiety disorder, and her uncontrolla-      sit on the aisle at movie theaters but still goes to
                            ble worry leads her to panic on occasion. The        movies, and avoids crowded places. “Moder-
                            next example is of someone with social phobia,       ate” agoraphobia is exemplified by the person
                            who becomes very concerned about panicking           whose driving is limited to a 10-mile radius
                            in social situations, because the possibility of a   from home and only if accompanied, who
                            panicattackincreasesherconcernsaboutbeing            shops at off-peak times and avoids large super-
                            judged negatively by others.                         markets, and who avoids flying or traveling by
                                                                                 train. “Severe” agoraphobia refers to very lim-
                            P                                                    ited mobility, sometimes even to the point of
                             ATIENT: I am terrified of having a panic attack
                              in meetings at work. I dread the thought of        becoming housebound.
                                                                                                                                -
                              others noticing how anxious I am. They               Not all persons who panic develop agora
                              must be able to see my hands shaking, the          phobia, and the extent of agoraphobia that
                              sweat on my forehead, and worst of all, my         emerges is highly variable (Craske & Barlow,
                              face turning red.                                  1988). Various factors have been investigated
                          4                   CLINICAL HANDBOOK OF PSYCHOLOGICAL DISORDERS
                          as potential predictors of agoraphobia. Al-         miologic Catchment Area (ECA; Myers et al.,
                          though agoraphobia tends to increase as his-        1984) study.
                          tory of panic lengthens, a significant pro-            Individuals with agoraphobia who seek
                          portion of individuals panic for many years         treatment almost always report that a history
                          without developing agoraphobic limitations.         of panic preceded their development of avoid-
                          Nor is agoraphobia related to age of onset or       ance (Goisman et al., 1994; Wittchen, Reed, &
                          frequency of panic (Cox, Endler, & Swinson,         Kessler, 1998). In contrast, epidemiological
                          1995; Craske & Barlow, 1988; Kikuchi et al.,        data indicate that a subset of the population
                          2005; Rapee & Murrell, 1988). Some studies          experiences agoraphobia without a history of
                          report more intense physical symptoms during        panic disorder: 0.8% in the last 12 months
                          panic attacks when there is more agoraphobia        (Kessler, Chiu, et al., 2005) and 1.4% lifetime
                          (e.g., de Jong & Bouman, 1995; Goisman et           prevalence (Kessler, Berglund, et al., 2005).
                          al., 1994; Noyes, Clancy, Garvey, & Anderson,       The discrepancy between clinical and epidemi-
                          1987; Telch, Brouillard, Telch, Agras, & Tay-       ological data has been attributed to misdiag-
                          lor, 1989). Others fail to find such differences    nosis of generalized anxiety, specific and social
                          (e.g., Cox et al., 1995; Craske, Miller, Ro-        phobias, and reasonable cautiousness about
                          tunda, & Barlow, 1990). On the one hand,            certain situations (e.g., walking alone in un-
                          fears of dying, going crazy, or losing control do   safe neighborhoods) as agoraphobia in epide-
                          not relate to level of agoraphobia (Cox et al.,     miological samples (Horwath, Lish, Johnson,
                          1995; Craske, Rapee, & Barlow, 1988). On            Hornig, & Weissman, 1993), and to the fact
                          the other hand, concerns about social conse-        that individuals who panic are more likely to
                          quences of panicking may be stronger when           seek help (Boyd, 1986).
                          there is more agoraphobia (Amering et al.,             Rarely does the diagnosis of PD/PDA occur
                          1997; de Jong & Bouman, 1995; Rapee &               in isolation. Commonly co-occurring Axis I
                          Murrell, 1988; Telch, Brouilard, et al., 1989).     conditions include specific phobias, social pho-
                          In addition, in a recent investigation, Kikuchi     bia, dysthymia, generalized anxiety disorder,
                          and colleagues (2005) found that individuals        major depressive disorder, and substance abuse
                          who developed agoraphobia within 6 months           (e.g., Brown, Campbell, Lehman, Grishman, &
                          of the onset of panic disorder had a higher         Mancill, 2001; Goisman, Goldenberg, Vasile,
                          prevalence of generalized anxiety disorder but      & Keller, 1995; Kessler, Chiu, et al., 2005).
                          not major depression. However, whether the          Also, 25–60% of persons with panic disorder
                          social evaluation concerns or comorbidity are       also meet criteria for a personality disorder,
                          precursors or are secondary to agoraphobia re-      mostlyavoidantanddependentpersonalitydis-
                          mains to be determined. Occupational status         orders (e.g., Chambless & Renneberg, 1988).
                          also predicts agoraphobia, accounting for 18%       However, the nature of the relationship be-
                          of the variance in one study (de Jong &             tween PD/PDA and personality disorders re-
                          Bouman, 1995). Perhaps the strongest predic-        mains unclear. For example, comorbidity rates
                          tor of agoraphobia is sex; the ratio of males to    are highly dependent on the method used to es-
                          females shifts dramatically in the direction of     tablish Axis II diagnosis, as well as the co-
                          female predominance as level of agoraphobia         occurrence of depressed mood (Alneas &
                          worsens (e.g., Thyer, Himle, Curtis, Cameron,       Torgersen, 1990; Chambless & Renneberg,
                          &Nesse, 1985).                                      1988). Moreover, the fact that abnormal per-
                                                                              sonality traits improve and some “personality
                                                                              disorders” even remit after successful treat-
                          PRESENTING FEATURES                                 ment of PD/PDA (Black, Monahan, Wesner,
                                                                              Gabel, & Bowers, 1996; Mavissakalian &
                          From the latest epidemiological study, the Na-      Hamman, 1987; Noyes, Reich, Suelzer, &
                          tional Comorbidity Survey Replication (NCS-         Christiansen, 1991) raises questions about the
                          R; Kessler, Berglund, Demler, Jin, & Walters,       validity of Axis II diagnoses. The issue of
                          2005; Kessler, Chiu, Demler, & Walters, 2005)       comorbidity with personality disorders and its
                          prevalence estimates for panic disorder with or     effect on treatment for PD/PDA is described in
                          without agoraphobia (PD/PDA) are 2.7% (12           more detail in a later section.
                          month) and 4.7% (lifetime). These rates are            The modal age of onset is late teenage years
                          higher than those reported in the original NCS      and early adulthood (Kessler, Berglund, et al.,
                                                                         -                                                    -
                          (Kessler et al., 1994) and the older Epide          2005). In fact, a substantial proportion of ado
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...Chapter panic disorder and agoraphobia michelle g craske david h barlow thetreatment protocol described in this represents one of the success stories development empirically supported psychological treatments results from numer ous studies indicate that approach provides substantial advantages over placebo medication or alternative psychosocial approaches containing common factors such as positive expectancies helpful therapeutic alliances addition treatment forms an important part every clinical practice guideline either public health other sources countries around world describing effective for disor der numerous evaluating both individually combination with leading pharmacological suggest is equally best short term more durable long but has not stood still example we have learned a great deal past years about neurobiological mechanisms action fear reduction methods effecting these changes present latest version incorporating thesechangesandadditionsasillustratedinacomprehensiveaccou...

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