آموزش تثبیت توجه: آموزش افراد برای تشکیل نقشه های شناختی بمنظور کمک به کنترل علایم اختلال هراس با موقعیت هراسی

Nine individuals diagnosed with panic with agoraphobia received three elements of Attentional Fixation Training (AFT): Directed attention to the external environment, directed topographical synthesis, and directed orientation in space-time to control characteristics of panic. They then walked a standard 2.5 km route and practiced these elements upon entering one of the five panic-inducing situations: (a) walking alone near a busy street with the examiner following at 20 m, (b) walking alone near a busy street with the examiner out of client's visual field, (c) shopping with the examiner present, (d) traveling on a bus alone, and (e) shopping alone. Heart rate was monitored in each of these five situations. Except for the case of using public transport, heart rate activity decreased to a considerable extent during AFT practice suggesting AFT elements provided a good way to control symptoms of panic in vivo. Results were discussed within the confines of a model suggesting that an attentional deficit, which produces a spatial disorientation disorder that maintains both panic and agoraphobia, can efficiently be overcome by means of all three AFT tools.

Panic disorder with Agoraphobia is characterized by recurrent panic attacks accompanied by concern about future attacks, worry about what might happen as a consequence of the attack, and/or changes in behavior associated with the attacks (DSM IV, APA). The panic attacks are often triggered when the person is alone and in places perceived as new and/or dangerous (place neophobia). In the face of the new or apparently dangerous, individuals experiencing such attacks often seek and find a talisman, a trusted companion, or another form of safety signal (Clark, 1986; Rachman, 1987). In the midst of an attack, the individual appears all too aware of and unable to control psychophysiological responses such as sweating, increased heart rate, chest pain, and paresthesias. Those experiencing panic attacks almost uniformly report heart palpitations, pounding heart, or accelerated heart rate. In response to such self-report, many have studied in relations among panic attacks and heart rate (e.g., Margraft & Ehlers, 1988; Hodden & Barlow, 1986). Often the form of panic studied in the laboratory is induced by “artificial” means (e.g., Gorman, Dillon & Fyer, 1985; Margraft & Ehlers, 1988). For some, this raises questions about the external validity of laboratory-based findings. Intuitively, the form and intensity of a panic attack should at least partially depend on the ways in which cognitive structures interact with situational variables (Taylor et al., 1986). Attempts to examine the external validity of laboratory-based findings make use of mobile monitoring equipment to monitor physiological reactions under naturalistic conditions (Margraft, 1990; Freedman, 1989; Freedman, Ianni, Ettedgui & Puthezhath, 1985). Panic attacks occurring in the field do not take place under standardized situations, however. The situational variability inherent in designs gathering data under naturalistic conditions has prompted some to argue that in vivo data gathered from such equipment should be treated, at best, as psychophysiological case studies (Mavissakalian & Michelson, 1982; Taylor, Telech & Havik, 1983). Moreover, attempts to control such sources of error in naturalistic studies are difficult. A study of heart rate under “real-life” (in vivo) conditions such as shopping or travelling may be thwarted by strategies the person uses to escape or minimize the probability of a panic attack. For example, panic attacks engender an intense desire to escape the unfamiliar/dangerous place, produce a sense of disorganized behavior and cognition and engenders intense avoidance of the places associated with panic attacks (e.g., unfamiliar place or places in which panic attacks have occurred). Each of these factors make it difficult to convince individuals to enter a panic-engendering situation, let alone record the physiology of panic under standardized but naturalistic conditions. Thus, at one extreme, data from naturalistic designs present no small interpretative difficulties; at another data from highly controlled designs may not well represent the phenomenon of interest. The present study attempts to use a design incorporating strengths from both naturalistic and highly controlled studies. The manipulation in the present study was anchored in a model outlined by Jacobs and Nadel (1985). Jacobs and Nadel (1985) proposed a model of specific phobia couched within the now well-accepted notion of neural-based multiple learning systems (see e.g., Nadel, 1994; Schacter & Tulving, 1994). These authors pointed to two kinds of learning systems: A locale system concerned with spatial maps and spatio-temporal context centered in the hippocampus, and nonhippocampal taxon systems, the most important of which is concerned with emotional (fear) memory centered in the amygdala (see e.g., LeDoux, 1993; Metcalfe & Jacobs, 1996 and Metcalfe & Jacobs, 1998). Briefly, these authors argued that one route to a clinically significant problem involves six steps: (1) classical fear conditioning occurs before the anatomical and physiological maturation of the hipppocampal system (e.g., Squire, Cohen & Nadel, 1984); (2) the hippocampal formation matures anatomically and physiologically; (3) severe physiological stress occurs some time after this maturation; (4) the hippocampal formation becomes “disabled” as a result of this stress, (5) simultaneous exposure to stimuli sharing features with those stimuli to which infantile conditioning had occurred and (6) reinstatement of the primitive emotional memories held latent in neural circuits centering on amygdala occurs (e.g., Campbell & Jaynes, 1966; Riccio & Haroutunian, 1979). If all the six of these elements come together in proper temporal order, then an anxiety disorder will appear (see Tataryn, Nadel & Jacobs, 1989; Jacobs, Nadel & Hayden, 1992 for extensions of this model). Kállai (1989) independently extended the model to suggest that the characteristics of panic disorder, most particularly the excessive stress generated during a panic attack and agoraphobic avoidance, may produce conditions that ensure a continuation of repeated panic attacks and avoidance. Specifically, Kállai (1989) proposed that in the midst of a panic attack or agoraphobic avoidance the person (a) attends to the “inner” feelings of anxiety and fear and thereby (b) fails to form a cognitive map of the environment in which the event occurs and thereby (c) fails to encode a spatial context or temporal coherence to the experience (e.g., the experience is not encoded as in the “here and now”, Nadel & Jacobs, 1996). As a result, the person does not contextualize the experience, or become familiar with places and things triggering panic or agoraphobic avoidance, instead, he or she simply experiences the extreme reaction controlled by the critical taxon systems and triggered by a neophobic response (see above). Based on this idea, Kállai (1989) designed Attention Fixation Training, an intervention that, under laboratory conditions, effectively alleviated symptoms of Panic Disorder with Agoraphobia. Kállai trained clients to use three specific skills to produce relief from symptoms of panic and agoraphobia. First, by teaching the client to monitor the external environment, the client also ceases to monitor triggering stimuli emanating from the cognitive and physiological milieu. Second, by teaching the client to form a cognitive map of the extant environment, the client becomes familiar with and may habituate to environmental complexes that trigger panic attacks or agoraphobic avoidance. Third, by teaching the client to anchor an experience in the here and now, the client provides both spatial context and temporal coherence to the experience. In so doing, he or she integrates current experience with past and anticipated future experiences. Kállai (1989) reported that extensive training in each of these areas produced dramatic changes in physiological and avoidance behavior level when practiced by clients diagnosed with panic disorder with agoraphobia. Although the results of the initial study were promising, they were obtained under highly controlled conditions. The purpose of the present study is to examine client responses to this intervention under semi-naturalistic conditions while monitoring activity in each of four separate constellations: Affective (emotion), Cognitive (thought), Behavioral (action), and Physiological (Jacobs et al., 1992). A well-accepted method for collecting clinical data under semi-naturalistic conditions involves recording activity while the participant engages in a “free walk”. Mavissakalian and Michelson (1982), for example, compared heart rate measures for individuals diagnosed as agoraphobic and individuals carrying no diagnosis during a structured 1.5 mile `street walk'. Those in the Agoraphobia group showed significantly higher heart rates than those in the Control group during the walk. This difference was not due to situational cues enhancing heart rate but was rather due to higher resting heart rates in the Agoraphobia group. A “standard walk” methodology has emerged from this semi-naturalistic design. In this method, each participant covers a standardized route while providing affective, behavioral, cognitive, and physiological data. The method facilitates an examination of both a naturalistic analysis of and the assessment of programmatic interventions targeting panic disorder with agoraphobia. Although studies using the standard walk have consistently detected higher resting heart rates in individuals diagnosed with panic disorder with agoraphobia (PDA) than in controls (e.g., Hodden & Barlow, 1986; Roth & Telech, 1986), when this factor is controlled, those suffering PDA react to the conditions presented during standardized walk with significant increases in heart rate and blood pressure. The response is both subjective and a physiologically measurable (Woods & Charney, 1987). In addition, acceleration in heart rate and blood pressure triggered during a standardized walk has been detected. Jennings (1986) argued that such changes indicate both the initiation and termination of intense monitoring (attention). Similarly, Lacey (1967) and Graham and Clifton (1966) reported that a decrease in heart rate is associated with facilitation in the reception of stimuli. Hare and Blevings (1975) reported that pictures triggering a strong subjective fear also triggered heart rate acceleration in phobic patients, but triggered heart rate deceleration in a control group. At a related level, heart-rate deceleration appears to accompany the Orienting Response and stimulus exploration whereas heart-rate acceleration accompanies defensive reactions and stimulus avoidance (e.g., Hugdahl, 1981.). Consistent with these data, Andreassi (1995) has argued that heart-rate deceleration is associated with an `opened attentional stance’ whereas heart-rate acceleration is associated with a `closed attentional stance'. We shall therefore use heart-rate deceleration as an indicator of monitoring of individual external stimuli, triggers, and the stimulus complex. As outlined above, Attentional Fixation Training involves training modules designed to increase monitoring of specific environmental stimuli and relations among those stimuli. One useful measure of the success of such training can be found in heart rate records taken during a standardized walk. An untrained client should show heart-rate acceleration to any and all triggering stimuli (or stimulus arrays) encountered during a standardized walk (Öst, 1990) and, because an untrained client monitors internal stimuli extensively (e.g., Clark, 1986), little or no heart-rate deceleration to any set of environmental stimuli. Conversely, because successful Attentional Fixation Training turns monitoring focus from internal to external stimuli, we expect a well-trained client to show heart-rate deceleration to a wide variety of environmental stimuli (or stimulus arrays) encountered during a standardized walk. In addition, because successful Attentional Fixation Training should produce an integration of spatial and temporal aspects of current experience, and the formation of a cognitive map, we expect little or no heart-rate acceleration to any set of environmental stimuli encountered during a standardized walk.

The therapeutic effect of Attention Fixation Training on the attention allocation from egocentric reference to allocentric space in panic disorder with agoraphobic subjects has not yet been sufficiently supported for the practice. At present the effect of the AFT may only constitute a part of the therapeutic repertoire. Longitudinal empirical studies are needed to decide the load of this maneuver. Our therapeutic experience suggests that AFT, as a part of the therapeutic method, is accepted by the patients and after a short training session led by the therapist, they are able to apply the method on their own without the therapist's control in several potentially threatening situations. A previous study of panic disorder with agoraphobia, generalized anxiety and normal control subjects, (Bata, 1996) found that generalized anxiety and normal control subjects do not have specific heart-rate response to the five panicogenic situations detailed in the Procedure. Further, in these groups no significant HR deceleration was experienced during the AFT. Based on our experimental data, we can suggest that the positive effect of the attention allocation from egocentric reference to allocentric space — a specific characteristic feature of panic disorder with agoraphobia — should be considered not only in therapeutic practice but in the research into the behavioral and cognitive elements of panic disorder with agoraphobia as well.