نقش تروما و تفکیک در نتیجه روان درمانی شناختی-رفتاری و نگهداری برای اختلال پانیک با موقعیت هراسی

The relationship between traumatic experiences and dissociation with pretreatment psychopathology and rates of recovery, relapse and maintenance for patients receiving cognitive-behavioral treatments for panic disorder with agoraphobia (PDA) were investigated. One-hundred and forty-seven subjects who met DSM-III criteria for agoraphobia with panic attacks and who completed participation in one of two previously conducted treatment outcome studies were mailed packets containing measures to assess history of trauma, victimization and dissociation. Eighty-nine of these were returned and completed sufficiently to be included in the present study. It was hypothesized that a variety of trauma-related variables (e.g. history of traumatic experience, type of trauma, age at which the trauma first occurred, perceived responsibility, social supports available, self-perceived severity, level of violence, and whether or not the traumatic event was followed by self-injurious or suicidal thoughts and/or behaviors) and dissociative symptomatology would be predictive of (1) greater psychopathology at pretreatment, (2) poorer treatment response and (3) higher relapse rates and poorer maintenance over a 1 year longitudinal follow-up. These hypotheses were supported by the findings and the theoretical, empirical and clinical implications are discussed.

The purpose of this investigation is to examine the relationships between traumatic experiences and dissociation with pretreatment psychopathology and rates of recovery, relapse and maintenance for patients receiving cognitive-behavioral treatments for panic disorder with agoraphobia (PDA). The cost to those persons suffering from PDA are varied and often quite serious. This disorder has been associated with chronic debilitating anxiety, a self-perception of poor physical or emotional health, increased alcohol abuse, excessive utilization of health care and emergency health care services, unemployment, financial difficulties, stress on important interpersonal relationships, a general sense of demoralization and suicide attempts (Weissman et al., 1978; Chambless, 1982; Weissman et al., 1989; Markowitz et al., 1989; Johnson et al., 1990). Johnson et al. (1990) found that the rates of suicide attempts were significantly increased in subjects with panic disorder if it was comorbid with another disorder (23.6%). However, this rate dropped to 7% if the panic disorder was uncomplicated (not comorbid) and to 1% for subjects who did not receive a psychiatric diagnosis. Given this information, there is additional cause for concern because persons with anxiety disorders tend to underutilize mental health services (Shapiro et al., 1984). Unfortunately, the lives of those who experience symptoms of PDA are oftentimes further complicated by the difficulties associated with comorbid disorders. For example, major depressive disorder occurs in individuals with panic disorder at a frequency of 50–65% and in two-thirds of these cases the panic disorder preceded the depression (DSM-IV). Other disorders comorbidly associated with panic disorder include substance abuse, social phobia, obsessive–compulsive disorder, specific phobias and generalized anxiety disorder (Barlow, 1988; Stein et al., 1989; Cox et al., 1990; Robins and Regier, 1991; DSM-IV). Barlow (1985) used the anxiety disorders interview schedule (ADIS) to assess comorbidity and found that approximately half of the subjects with agoraphobia received no other DSM-III anxiety disorder diagnosis, but the remaining subjects received one (20%), two (27%) or three or more (10%) secondary diagnoses. Additionally, approximately 50% of patients with PDA also exhibit Axis II comorbidity (Mavissakalian and Hamann, 1986; Friedman et al., 1987; Reich, 1988). Results from an epidemiologic catchment area (ECA) survey sponsored by NIMH found that 2.8 to 5.7% of the randomly sampled populations met criteria for agoraphobia, with an additional 1% experiencing panic disorder (Myers et al., 1984). However, a more recent ECA study, Robins and Regier (1991), found that only 1.5% of their subjects met DSM-III criteria for panic disorder at some time in their life, with about a third of these persons also meeting criteria for agoraphobia. In the more recent study, rates for panic disorder were cross-sectionally higher in persons ages 35–44 and lowest in older persons ages 65 or older. Peak age of onset was typically in the mid-twenties and no significant differences were found among African-Americans, Mexican-Americans and Caucasians. In a previous study, Robins et al. (1984) found that college graduates across three ECA sites exhibited lower agoraphobia prevalence rates than noncollege graduates (2.9 and 6.1%, respectively). Whether these findings can be attributed to higher levels of education or higher socioeconomic standing is unclear. In the Agoraphobia Program at the University of Pittsburgh, the average duration of illness for 100 patients with PDA seen in treatment was approximately 11 years (Michelson, 1987). However, there are few studies examining the long-term course of PDA. Findings to date suggest that in most cases it is a chronic disorder that intermittently increases and declines in severity and those who experience PDA tend to have a more severe and complicated course (Wolfe and Maser, 1994). To date, the majority of literature connecting trauma to panic disorder and agoraphobia has focused on correlational research and the possible etiological role of trauma in the development of PDA. There are no published studies examining the role of trauma as a predictor of pretreatment psychopathology and treatment outcome and maintenance for PDA. The primary aim of the present investigation was to examine the role of trauma and dissociation in pretreatment status, treatment outcome and longitudinal maintenance. This study investigates the relation of prior traumatic experiences and a variety of trauma-related constructs with greater pretreatment psychopathology and poorer treatment outcome in PDA patients receiving cognitive-behavioral treatment protocols across two NIMH-supported studies. In addition, given that prior research has found higher levels of dissociation associated with prior trauma, its potential role in treatment outcome for PDA is also examined. In the following sections, the role of stress and, more specifically, the role of traumatic stress as an antecedent to the onset of PDA will be discussed. Then, several etiological models of PDA and traumatic stress will be presented to give background and context for possible mechanisms suggesting that trauma could play a role in treatment outcomes for persons with PDA. Additionally, the overlapping symptoms and cognitive schemes for individuals with PDA and individuals who have experienced traumatic stressors will be addressed in light of possible interactions between the two and complications that might arise in treatment for persons dealing with both conditions. Then, dissociation, which is commonly believed in the field of traumatology to be associated with traumatic experiencing, will be discussed, followed by the presentation of several theoretical models of dissociation. As was the case for presenting various models of traumatic stress, the discussion of dissociation models will provide background and context for the role dissociation may play in treatments for PDA. Finally, the hypotheses of the present investigation will be presented. 1.1. The role of stress It is generally recognized that the occurrence of stressful life events typically precedes the first panic attack in patients who later develop panic disorder and agoraphobia by three to twelve months (Michelson, 1987). Barlow, in a review of studies looking at this topic, found that approximately 80% of patients with panic disorder experienced at least one major negative life event preceding their first panic (Barlow, 1988). As Barlow points out, Roth (1959) found that 96% of their sample of 135 agoraphobics reported some type of stress preceding the onset of the disorder. Some of these stressors were categorized as follows: bereavement or a suddenly developing serious illness in a close relative or friend (37%), illness or acute danger to the patient (31%) and severance of family ties or acute domestic stress (15%). Tearnan et al. (1984) concluded that stress may play a major role in the development of panic. The stress-diathesis model is well-known and posits that an existing proclivity towards a certain disorder may be realized if a given individual is subjected to stress, which presumably weakens the ability of the individual to defend against the onset of the disorder. Next, the role of trauma as an extreme form of stress will be considered. 1.2. Trauma In the field of traumatology, what constitutes a `traumatic' event or stressor has been a matter of considerable debate. Peterson et al. (1991) have outlined the essential characteristics of traumatic events: (1) serious life threat, (2) serious threat to one's physical integrity, (3) serious threat or possible harm to one's children, spouse, close relatives, friends, (4) sudden destruction of one's home or community, (5) seeing a serious injury or killing, (6) physical violence and (7) learning about serious harm or threat to a relative or family member. These characteristics are consistent with those delineated in the DSM-IV criteria of an `extreme traumatic stressor' for posttraumatic stress disorder (PTSD) (APA, 1994) and they will serve as the defining characteristics of a `traumatic event' for the purposes of the present study. The DSM-IV also requires that the person's response to the event must involve intense fear, helplessness or horror (or disorganized or agitated behavior in children). This requirement was altered from the DSM-III and DSM-III-R criteria which stated that the stressor must be psychologically distressing, markedly distressing to almost anyone and outside the range of usual human experience. A great deal of the research conducted in the field of traumatology has been directed to the study of PTSD. For the purposes of the present investigation, the specific criteria and diagnosis of this disorder are not of particular import. Rather, the generalizations which can be drawn from this research will be useful in this discussion of traumatic experiencing. And, later in this paper, models more typically utilized in the discussion of PTSD will be discussed as they relate to traumatic experiencing without an emphasis on the specific diagnosis of PTSD. March (1990) has stated that subjective perception of life threat, perceived potential for physical violence, the experience of extreme fear and attribution of personal helplessness are all factors that affect whether or not an event will induce PTSD. Because the individual's subjective experience of an event is so central to whether it will be experienced as traumatic or not, an inclusive list of traumatic events or stressors cannot possibly be generated. However, some exemplars of commonly discussed traumatic events in the traumatology literature are: military combat, violent assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, diagnosis of a life-threatening illness, sexual molestation (with or without violence), observing the serious injury or unnatural death of another person and witnessing a dead body or body parts (DSM-IV). Several factors contribute to the difficulty in calculating incidence and prevalence rates of traumatic events. The first has been pointed out by Barlow (1988) in a discussion of the incidence and prevalence rates of PTSD. Barlow states that a review of studies looking at PTSD rates among persons who have experienced traumatic events `exhibits striking inconsistencies'. Approximately equal numbers of studies show either exceptionally high rates of lifetime PTSD (24–70%) or exceptionally low rates (1–6%) (Kluznik et al., 1986; Helzer et al., 1987; Foy et al., 1987; Pynoos et al., 1987; McFarlane, 1989; Shore et al., 1989; Winfield et al., 1990; Breslau et al., 1991; APA, 1994). This inconsistency is apparently present across different types of traumatic events. However, Barlow hypothesizes that if factors such as proximity or level of exposure to the traumatic event were to be looked at, the rates of PTSD across many of these studies would very likely converge in accordance with the subjects' level of perceived threat. A second difficulty is that PTSD rates may not necessarily be an accurate estimate of the incidence and prevalence of specific traumatic events. Hence, the frequency, duration and severity of traumatic events may need to be examined individually. In a review of PTSD literature, Davidson and Fairbank (1993) point out that this disorder exhibits a high level of comorbidity. In two ECA studies conducted in St. Louis and North Carolina (Helzer et al., 1987 and Davidson et al., 1991, respectively) lifetime comorbidity rates were found to be 80 and 62% for those persons diagnosed with PTSD. These numbers dropped to 33 and 15% for respondents with no posttraumatic stress symptoms. The highest rates of comorbidity were associated with somatization disorder, panic disorder, obsessive compulsive disorder, social phobia, generalized anxiety disorder, substance abuse, depression and schizophrenia (Shore, 1986; Helzer et al., 1987; Davidson et al., 1991). 1.3. Relation of trauma with panic disorder and agoraphobia In a large community survey of adult women, Saunders et al. (1992) found that one-third of the women in their study had been victims of rape, molestation or sexual assault not involving physical contact before the age of 18 years. Of these, child rape victims were found to be at significantly greater risk of developing agoraphobia. Another study that has examined the long-term effects of childhood sexual abuse in women found that the risk for lifetime diagnosis of panic disorder was greater in a severely abused group than in women who experienced less severe abuse or no abuse (Walker et al., 1992). These authors also suggested that lifetime diagnosis of panic disorder was actually predictive of former severe childhood abuse. These findings have been supported by an investigation conducted by Murrey et al. (1993) in which the prevalence rate of a childhood history of sexual abuse in women diagnosed with an anxiety disorder was found to be 48.5%. Specifically, high rates of reported sexual abuse were found among women diagnosed with panic disorder (43%) and obsessive compulsive disorder (40%).