ترس و اجتناب در اختلال هراس با موقعیت هراسی: ارتباط بالینی تغییر در جنبه های مختلف اختلال
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|32840||2007||11 صفحه PDF||سفارش دهید||محاسبه نشده|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Journal of Behavior Therapy and Experimental Psychiatry, Volume 38, Issue 1, March 2007, Pages 29–39
Different aspects of change were examined in 62 patients who fulfilled the DSM-IV criteria for a primary diagnosis of panic disorder with agoraphobia of moderate to severe magnitude, and who were treated with 16 sessions of behavioral therapy. The treatment resulted in substantial effects on panic attacks and agoraphobic avoidance. Panic-free status only differentiated the patients regarding mood at pre- and post-treatment. Changes in panic and avoidance were related to each other, but change in avoidance was more related to change in negative affect. Change in quality of life (QOL) was also more associated with change in avoidance at post-treatment. At follow-up change in QOL was more related to change in panic than change in avoidance.
Panic disorder with agoraphobia (PDA) is a pervasive disorder that has far reaching implications for the individual. It is also one of the most well-researched disorders regarding the efficacy of psychological treatment. It is an area where significant contributions to the field of established efficacious treatments have come from the cognitive-behavioral tradition. But it is also an area of competing assertions regarding necessary and sufficient treatment components. This clinical disorder was initially conceptualized as a phobia, as implied by the name agoraphobia. Accordingly, the earlier treatment formulations were centered on in vivo exposure to external conditioned anxiety-evoking stimuli. These behavioral treatments have gained strong empirical support (Shapiro, Pollard, & Carmin, 1993). Since the revision of DSM-III, where panic attacks were given primacy in the clinical picture and the agoraphobic avoidance was considered secondary, the treatment focus has shifted to the task of eliminating these attacks (Barlow, 2002). The causal role of panic attacks for agoraphobic avoidance has been an area of continuous controversy. However, there seems to be a general consensus that in clinical samples the agoraphobic avoidance develops following panic attacks or panic-like sensations. It is generally recognized that it is uncommon in clinical samples to find agoraphobic avoidance not preceded by panic attacks or limited symptom attacks (Craske, DeCola, Sachs, & Pontillo, 2003). While the etiological relationship between panic attacks and agoraphobic avoidance may not bear any necessary implication for treatment, the relative importance of these phenomena in maintaining the disorder could be regarded as more crucial. However, the presence of recurring panic attacks, per se, does not seem to be closely linked to agoraphobia, and neither severity nor frequency of panic attacks has been found predictive of agoraphobic severity (Cox, Endler & Swinson, 1995). The level of avoidance of agoraphobic situations is more accurately predicted by the anticipatory anxiety surrounding panic attacks (Craske, Rapee, & Barlow, 1988). It seems as if the expectation of panic attacks and of their consequences appears to be more critical in predicting agoraphobia than the quality or quantity of the panic attacks. In a longitudinal study, it was found that panic expectancy was predominantly influenced by a trait-like expectancy component, but uninfluenced by the previous day's experienced anxiety (Rodebaugh, Curran, & Chambless, 2002). Cox et al. (1995) found that the more severe group, not only was more avoidant of agoraphobic situations, but the patients also reported more general anxiety related to novel or ambiguous situations. Apart from that, they also scored higher on measures of depressed mood and state anxiety, which suggests that agoraphobic severity is associated with more clinical distress. While the diagnostically distinguishing features of PDA focus exclusively on panic attacks and phobic avoidance, agoraphobic patients have been noted to show generally more severe impairment and a markedly higher co-morbidity rate for depression than do other phobias (Wittchen & Essau, 1991). Generally a high co-morbidity with other anxiety disorders and mood disorders is reported within this population (Brown, Anthony, & Barlow, 1995). They are consistently found to suffer from a plethora of clinical problems (Chambless, 1985) and the remission rates are lower and relapse rates are higher for PDA than panic disorder (Keller et al., 1994). The well-established cognitive-behavioral treatments for panic disorder have frequently focused on subjects with minimal or no agoraphobia, thereby limiting their scope to the patients within a less serious spectrum of the disorder (Barlow, 2002). This not only raises serious questions about the generalization of these treatments over the full spectrum of panic disorder, but it also means that research has been focusing on the part of the patient spectrum, subsumed under the category panic disorder, which shows a lesser degree of general impairment. The generalization of treatment methods focusing on ameliorating panic attacks, over the full spectrum of panic disorder, rests on the hypothesis that controlling panic attacks may mediate reductions in agoraphobia. A study by van den Hout, Arntz and Hoekstra (1994) found that cognitive therapy for panic attacks and exposure had differential effects on panic attacks versus avoidance. Cognitive therapy had effects on panic but not on avoidance, and exposure had effects on avoidance but not on panic. But apart from the fact that the two approaches had differential effects, exposure was also beneficial regarding state/trait anxiety and depression. However, later studies have shown that in vivo exposure has a clinically substantial effect on panic attacks, even in the absence of cognitive interventions specifically targeting these attacks (Bouchard et al., 1995; Öst, Thulin, & Ramnerö, 2004; Williams & Falbo, 1996). It has also been suggested that the interventions employed by van den Hout et al. for panic control were not given reasonable time to affect avoidance, and thereby not constituting a fair trial (Craske et al., 2003). Craske and co-workers set out to try panic control treatment (in the absence of explicit situational exposure work) in a group of PDA patients, thus testing the hypothesis that control of panic attacks may mediate reductions in agoraphobia, and therefore panic control treatment alone may be sufficient in ameliorating agoraphobia. Their results confirmed this hypothesis and they found that reduction in panic attacks, but not a variety of other panic-related measures, predicted change in agoraphobia. Now this study has limitations in that panic was rated retrospectively or in relation to interoceptive exposure approach tasks, and agoraphobia was either rated by a clinician, or from a behavioral approach test (BAT), solely regarding a small enclosed space. These limitations set boundaries for the external validity of these results. While the relationship of change in panic and change in avoidance is of both theoretical and clinical interest, the pervasiveness of PDA as a clinical disorder is not fully accounted for in this relationship. Findings indicate that psychological treatment for one anxiety disorder is accompanied by a reduction in other concurrent anxiety disorders or mood disorders (Borkovec, Abel, & Newman, 1995; Brown et al., 1995). Successful treatment for agoraphobia is associated with altered depression (Chambless, 1985). Exposure-based treatments for PDA have been shown to have an impact on a range of measures such as social adjustment, mood, trait anxiety and quality of life (QOL) (Öst et al., 2004). This broadening of the scope not only gives a fuller picture of the treatment impact on the total clinical picture, but it also opens the door for investigating the possibility that the change that occurs during therapy, in these different aspects, might not progress as a uniform process. Our interest was to investigate the relationship between panic-free status and other aspects of the outcome in the treatment of PDA. The relationship to agoraphobic avoidance is an obvious target but we also wanted to investigate the relationship with two further areas of special interest: (i) the more diffuse area of generalized negative affect, since this posits a central role in modern theorizing about panic disorder (Barlow, 2002), (ii) the perceived QOL, since this is not the aspect foremost dealt with in in vivo exposure for PDA, but a variable that could be considered crucial for the credibility of the results of therapy.