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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
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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
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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.
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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.,
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(Kessler et al., 1994) and the older Epide 2005). In fact, a substantial proportion of ado
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