عوامل پیش بینی شدت علائم زناشویی در اختلال هراس با موقعیت هراس

Twenty-six to forty percent of individuals suffering from panic disorder with agoraphobia (PDA) do not benefit significantly from cognitive-behavior therapy. Marital problems are among risk factors that may explain this limited impact. Some studies suggest that PDA treatment outcome is related to the couple’s ability to communicate and solve problems during and after treatment. It may be also useful to further clarify the interplay of marital interpersonal variables with PDA severity before any intervention. This study aims at specifying the links between PDA symptom severity on the one hand and, on the other hand, marital adjustment, attachment style and personal problem-solving skills in both spouses. Results obtained from a group of 67 PDA patients (44 women and 23 men) and their partners showed that some PDA symptoms or comorbid depressive symptoms were more severe when both spouses independently scored low on problem-solving skills or marital adjustment, and when attachment style of PDA patients was insecure. Marital adjustment and difficulties in problem-solving, more specifically, avoidance of problem-solving activities in PDA patients, were the best predictors of PDA symptom severity. In light of these findings, a more complete program of problem-solving and acceptance strategies could be developed as part of a cognitive-behavior treatment of PDA. Other theoretical and clinical implications are discussed.

Cognitive-behavior therapy is, as of now, the most documented and efficient psychological treatment for panic disorder with agoraphobia (PDA) (Clum, Clum, & Surls, 1993; Gould, Otto, & Pollack, 1995; White & Barlow, 2002). Seeking to improve the treatment of PDA, researchers have tried to understand the role of interpersonal difficulties and marital problems in the development and maintenance of this disorder. Until now, however, studies regarding the role of marital variables in the etiology and treatment of PDA are mixed (Bouchard, Bolduc, Boisvert, & Gauthier, 1995; Carter, Turovsky, & Barlow, 1994; Marcaurelle, Bélanger, & Marchand, 2003; Marchand, Comeau, & Trudel, 1994). Some studies examined whether marital relationship of PDA patients was more problematic than for people without this disorder. According to data from the Epidemiological Catchment Area (ECA) study, 12% of people suffering from panic disorder with or without agoraphobia did not get along well with their spouse, this number being six times more than for people without this disorder (Weissman, 1991). Although the ECA study was done on a large sample (18,000 participants), the assessment of the marital relationship was done through a single question only, namely, whether the participants felt they got along well or not with their partners. Thus these findings should be interpreted with reserves. A number of experimental studies concluded that, compared to normal individuals, people suffering from PDA were less adjusted or satisfied in their marriage (Fauerbach, 1992 and McCarthy & Shean, 1996), experienced more dysfunctional couple communication (Buglass, Clarke, Henderson, Kreitman, & Presley 1977; Chambless et al., 2002) or perceived less support from their spouse (Buglass et al., 1977). But still others have found no significant difference in marital adjustment or communication of PDA patients as compared to general population (Fisher & Wilson, 1985 and Powers, 1984). To sum up, apart from the CAE epidemiological study, four studies supported the hypothesis of more marital problems in PDA patients than in normal population, whereas two others did not confirm it. In these six trails, the type of measurement (self-report or interaction coding) and the participation of the non-agoraphobic spouse in the assessment does not seem to be associated with either conclusion. Participants were selected according to proper structured interview (SCID, etc.) or validated questionnaires, and matched for comparison in a well-controlled manner. However, none of these trials included a significant number of men with PDA. On a total of 151 agoraphobic participants in these six studies, only 11 (7%) were men, while in reality about 33% PDA patients are males according to recent epidemiological studies (White & Barlow, 2002). Thus, at this point, the prevailing finding that PDA patients tend to have more marital problems apply essentially to agoraphobic women. While the above studies compared marital variables of PDA patients with those of normal population, others examined the links between various marital variables and PDA symptom severity prior to treatment. According to Monteiro, Marks, and Ramm (1985), PDA patients with weaker marital adjustment had more severe phobias. However, Cobb, Mathews, Childs-Clarke, and Blowers (1984) as well as Peter and Hand (1988) found no relationship between marital adjustment of both spouses and PDA symptoms. Using a single perceptual assessment of marital relationship, Bland and Hallman (1981) found that the wider the gap perceived by the non-agoraphobic partner between the ideal self and the real self of the PDA partner, the more intense were PDA symptoms. However, two other studies (Chambless, 1985 and Chambless & Gracely, 1988) found no significant correlation with the same questionnaire. In terms of variables assessed through behavioral coding, the more PDA patients criticized their spouses, the more they showed agoraphobic anxiety (Peter & Hand, 1988) or agoraphobic avoidance (Chambless et al., 2002). Negative verbal behavior on the part of the non-agoraphobic partner was related to a shorter duration of in vivo exposure ( Craske, Burton, & Barlow, 1989) or more avoidance (Chambless et al.) for the PDA patient, thus compromising a major therapeutic factor. On the other hand, negative non-verbal behavior from the non-agoraphobic partner was associated with greater duration of in vivo exposition yet more anxiety during exposure ( Craske et al., 1989); this also seems to compromise the healing process, since anxiety during exposure has been linked to lesser improvement in PDA treatment ( Michelson, Mavissakalian, Marchione, Dancu, & Greenwald, 1986). Similarly, the more the partner exerted pressure toward confronting phobic situations, the greater was the agoraphobic’s anxiety (Craske et al.). Finally, agoraphobic women were more avoidant when they showed more negative verbal behaviors and less self-disclosure (Chambless et al.). Thus, most studies using self-report marital adjustment or satisfaction found no connection between these variables and PDA severity, while those using couple interaction coding all found significant correlations with the same. Therefore, it seems relevant to explore marital variables other than adjustment or satisfaction when studying the links between marital relationship and PDA severity. In addition, among the nine studies mentioned above, eight included between 0 and 4 men in their sample, while one study had 33 men. On a total of 366 participants in these trials, there were only 52 men (14%). This shows again a need for samples that are more representative of clinical population in terms of gender. Some studies suggest that the couple’s ability to communicate and solve problems during and after treatment is related to PDA treatment outcome (Craske et al., 1989; Daiuto, Baucom, Epstein, & Dutton, 1998; Marcaurelle et al., 2003). It may be useful to further clarify this issue by evaluating the links between PDA symptom severity and the ability to solve problems prior to any treatment. Is PDA severity related to lesser problem-solving ability in one or both spouses? Studies have shown that anxiety is connected to problem-solving ability. Kant, D’Zurilla, and Maydeu-Olivares (1997) found for instance that problem-solving skills had a mediating function between stressful life events and anxiety as well as depression in middle-aged and elderly participants. This suggests that problem-solving skills may be a causal factor in anxiety and depressive disorders, because when problem-solving ability is good, anxiety or depressive symptoms may not even occur. Conversely, Nezu (1986) found that problem-solving ability plays a moderating role between stressful life events and anxiety. This implies that adequate problem-solving skills will reduce anxiety in the face of stressful life events, whereas a lesser problem-solving ability will increase it. In this context, problem-solving ability would not be considered a cause of anxiety, but would only influence its intensity. Whether a moderating or a mediating factor toward anxiety, problem-solving ability seems relevant to anxiety disorders and therefore to PDA. In addition, marital adjustment has been linked to problem-solving ability (Bélanger, Sabourin, Dulude, & Wright, 1993). Therefore, it seems relevant to study these variables together in their relationship to PDA severity. Attachment styles have been found to be significant factors in close interpersonal relationships (Simpson & Rholes, 1998). They are also associated with anxiety: according to Leveridge (1998), Nelligan (1995) and Searle (1998), individuals with an insecure style of attachment seem more prone to anxiety and depression than those with a secure style. Conversely, Chongruksa (1995) found that secure individuals had more mature coping strategies. As shown in a meta-analysis and secondary analysis by de Ruiter and van Ijzendoorn (1992), panic disorder (with or without agoraphobia) is associated with an insecure attachment style. On the other hand, Simpson, Rholes, and Nelligan (1992) found that, among normal couples, a secure attachment style was associated with more physical contact and supportive comments, as well as greater efforts to seek and give emotional support, when one of the partners was exposed to an experimentally induced anxiety-provoking situation. Thus, attachment style may have a significant bearing on PDA severity and on the management of PDA within the couple. A better knowledge of marital adjustment, problem-solving ability and attachment style in both spouses could render therapeutic interventions more specific to the factors responsible for maintenance of PDA. The purpose of this study was to further understand, for both men and women, prior to therapeutic intervention, the links between PDA symptom severity and interpersonal variables in the couple—including problem solving and attachment style as well as the more classical measure of marital adjustment. We hypothesized that PDA symptoms would be more severe in PDA patients when partners independently report (1) less marital adjustment; (2) less problem-solving skills; and (3) an insecure attachment style. Furthermore, since problem-solving skills have been clearly shown to play a mediating or moderating role toward anxiety, we predicted that (4) problem-solving skills of both partners would be better predictors of PDA severity than marital adjustment and attachment style.