Table Of ContentPanic and Phobias 2
Treatments and Variables
Affecting Course and Outcome
Edited by
Iver Hand and Hans-UlrichWittchen
Foreword by G.L.Klerman
Epilogue by LM.Marks
Springer-Verlag
Berlin Heidelberg New York
London Paris Tokyo
Iver Hand, Prof. Dr. med
Psychiatrische UniversiHitsklinik
Verhaltenstherapie - Ambulanz
MartinistraBe 52
0-2000 Hamburg 20
Hans-Ulrich Wittchen, Prof. Dr. phil., Oipl.-Psych.
Universitat Mannheim
Klinische Psychologie and
Max Planck Institut fUr Psychiatrie
Unit for Evaluation Research
Kraepelinstra6e 10
0-8000 Munchen 40
ISBN-13 :978-3-642-73545-5 e-ISBN-13:978-3-642-73543-1
DOl: 10.1007/978-3-642-73543-1
This work is subject to copyright. All rights are reserved, whether the whole or
part of the material is concerned, specifically the rights of translation, reprint
ing, reuse of illustrations, recitation, broadcasting, reproduction on microfilms
or in other ways, and storage in data banks. Duplication of this publication or
parts thereofis only permitted under the provisions of the German Copyright
Law of September 9,1965, in its version of June 24, 1985, and a copyright fee
must always be paid. Violations fall under the posecution act of the German
Copyright Law.
© Springer-Verlag Berlin Heidelberg 1988
Softcover reprint of the hardcover 1s t edition 1988
The use of general descriptive names, trade names, trade marks, etc. in this
publication, even if the former are not especially identified, is not to be taken
as a sign that such names, as understood by the Trade Marks and Merchandise
Marks Act, may accordingly be used freely by anyone.
Product Liability; The publisher can give no guarantee for information about
drug dosage and aplication thereof contained in this book. In every individual
case the respective user must check its accuracy by consulting other
pharmaceutical literature.
2125/3140/543210
Preface
Behavioral and biological research in behavioral techniques were developed
recent years have produced partially con already in the early 1970s (Hand et al.
tradictory treatment results and recom 1974) and have proved extremely success
mendations for phobias with and without ful in long-term follow-ups (Hand et al.
panic attacks, for panic disorder, and for 1986). The occurrence of panic attacks
anxiety disorders in a broader sense. independent of phobic trigger situations
The new classification of anxiety disor is almost never mentioned as an obstacle
ders in both DSM-III (1980) and its to the effective behavioral therapy of
revision DSM-IIIR (1987), which gives phobias.
panic attacks a key role with regard to Until very recently, professional interac
etiology, differential diagnoses, and treat tion and mutual evaluation regarding
ment has not only stimulated research in these contradictory views and results have
this field but has also provoked growing been almost non-existent. Together with
controversy among clinicians and resear European and American colleagues, we
chers. Biologically oriented authors have addressed these questions in a previous
interpreted anxiety disorders with panic volume, examining in more detail the
attacks as "endogenous" disorders linked epidemiological, psychopathological, and
to depression, claiming pharmacological experimental evidence for each of these
treatments to be the essential interven positions (Hand and Wittchen 1986).
tions. The concept of panic attacks has This new volume has a more interven
recently been expanded even further by tion-oriented perspective. The time ap
its new operationalization in DSM-IIIR. pears to have come for an attempt to
In the future, it will be applied to almost resolve some of the treatment controver
all kinds of anxiety disorders, as long as sies: pharmacological research now inves
they involve at least one attack-like event tigates the effects of both long-term
followed by a persistent anticipatory fear medication and of its discontinuation,
of further such attacks: while behavioral research has begun to
On the other hand, over the past two focus on patients who have either failed
decades a vast number of carefully con or dropped out of exposure treatments.
trolled, clinical studies have accumulated Thus, both the behavioral-cognitive and
evidence that phobias, including agora the biological researchers and clinicans
phobia with and without panic attacks, are now ready to face inconsistencies in
9an in the majority of cases be successful their theoretical models and failures in
ly treated with behavioral methods, such their treatment methods. There is now
as exposure in vivo (most recent review evidence of a growing willingness to en
by Marks 1987). For acute panic states in gage in joint efforts not only to improve
the context of phobic responses, effective treatments; but also to advance know-
VI Preface
ledge of why a considerable proportion of We hope that the very fact that the many
anxiety patients still refuse, drop out or authors in this book partly use the same
fail from and relapse after either of these data to draw conclusions that differ in part
treatment approaches. from one another will also stimulate the
The authors of this book met at an inter reader to join the discussion for the
national Symposium at the Ringberg welfare of the patients.
Castle in Bavaria (sponsored by the Max
Planck Society) to engage in intensive
References
discussions of behavioral, cognitive, and
biological treatments of anxiety disorders.
Hand I, Lamontagne Y, Marks 1M (1974) Group
This joint venture definitely broadened
exposure (flooding) in vivo for agoraphobics. Br
views and modified initial cautious in
J Psychiatry 124:588-602
teractions into an open-minded and pro Hand I, Wittchen HU (eds) (1986) Panic and
ductive exchange of knowledge and opi phobias. Empirical evidence of theoretical
nions. models and longterm effects of behavorial
treatments. Springer, Berlin Heidelberg New
Panic and Phobias II is the outcome of
York
this exciting conference and evaluates in
Hand I, Angenendt J, Fischer M, Wilke C (1986)
detail not only those behavioral, cogni Exposure in vivo with panic management for
tive, and pharmacological treatments that agoraphobia: treatment rationale and longterm
are currently best elaborated, but also the outcome. In: Hand I, Wittchen HU (eds) Panic
and phobias. Empirical evidence of theoretical
most promising new research in this field.
models and longterm effects of behavioral
This book does not however provide final
treatments. Springer, Berlin Heidelberg New
answers to the question "What is the best York
treatment?," but it does give the most Marks 1M (1987) Fears, phobias and rituals. Panic,
anxiety, and their disorders. Oxford University
current and comprehensive description of
Press, New York
results in the three major areas of
research relevant to the treatment of IVER HAND
anxiety disorders. HANS-ULRICH WITTCHEN
Foreword
Sources of Current Controversies in
Treatment of Panic and Phobia
G. L. KLERMAN1
In reviewing advances in a scientific field, During the 1960s and 1970s, the contin
the conventional wisdom holds that prog uum model was challenged by a number
ress occurs in a linear fashion through of sources. This challenge resulted in
incremental new knowledge. This view of revision of the USA classification as
the history of science as a rational and promulgated by the American Psychiatric
progressive process has been challenged Association in its third edition of the
by many observers, notably Thomas Diagnostic and Statistical Manual (DSM
Kuhn, the philosopher and historian of III). Subsequently, controversies have
science at Princeton University, who erupted concerning the nature of anxiety
views progress in a scientific field not so disorders, their etiology and pathogenesis,
much as the rational accumulation of new and the most suitable and effective
knowledge arrived at by dispassionate methods for their treatment. Currently,
scientists; rather, he believes that the this controversy involves the conflicting
history of a field is punctuated by periods views held by adherents of a biological
of ferment and revolution during which paradigm and a behavioral paradigm.
competing theories and groups of scien In the midst of this controversy, the 1987
tists adhering to these theories (which Ringberg Conference brought together
Kuhn calls "paradigms") contend with many of the leading investigators in this
each other until, subsequently, one para field to share ideas and, hopefully, to
digm emerges triumphant. reconcile differences and formulate a
The field of anxiety is a current example consensus as to the treatment of panic
of this process. For many decades, there and phobias. While the goal of formulat
w~s a consensus that anxiety in normal ing a consensus was only partially rea
and clinical states was aligned on a contin lized, the papers in this volume capture
uum of severity. This view, which I have the ferment in the field and offer the
called the "continuum model," was ac reader insight into efforts to resolve the
cepted by otherwise competing theories - controversies relating to treatment.
behavioral, psychodynamic, biological -
and was embodied in most classifications
of mental disorders and in textbooks of The Continuum Model and Its
psychiatry and psychology. Discontents
It is of note that this continuum view was
1 Professor of Psychiatry and Associate Chairman held by the advocates of three different
for Research, Department of Psychiatry, Cornell
theoretical paradigms - biological, psy
University Medical College, c/o Payne Whitney
Clinic, 525 East 68th Street, New York, NY 10021, choanalytic, and behavioral - which
USA emerged between World War I and World
VIII Foreword
War II and which offered both competing demonstration of the efficacy of selected
explanations for the origin of anxiety and psychopharmacological agents for anxiety
extensively different treatment recom states.
mendations. All three paradigms accepted Psychotherapeutic theory and practice,
the continuum model. particularly in North America, had been
This continuum model was also the basis strongly influenced by psychoanalytic and
for the official diagnostic classification psychodynamic ideas and methods during
systems - the leD 8 and 9 - developed by and after World War II. After World
the World Health Organization (WHO), War II, behaviorally derived techniques
as well as the first and second editions of such as relaxation, desensitization, expo
the Diagnostic and Statistical Manual of sure in imagery, exposure in vivo, and
the American Psychiatric Association flooding emerged. These treatments were
(DSM-I and DSM-II). supported by the growing advances in
The continuum theory came under in learning theory, particularly those follow
creasing criticism during the 1960s and ing the ideas of B.F. Skinner. Many new
1970s. The discontent with the continuum techniques were developed and applied
model derived from two lines of investiga with increasing success to neurotic condi
tion, psychopathological and therapeutic. tions such as anxiety states, phobias
Psychopathological investigations, particu (including agoraphobia), obsessions and
larly in the United Kingdom, led to an compulsions, and sexual dysfunctions. In
increasingly differentiated view of anxiety many clinical centers, particularly in the
states. Roth and his associates at N ew United Kingdom and Australia and New
castle applied multivariate statistical tech Zealand, behavioral techniques became
niques, particularly discriminant function the standard forms of psychotherapy of
and factor analysis, to interview data and neuroses.
rating scales involving large numbers of In parallel, diverse psychopharmacologi
neurotic patients. These techniques gen cal agents were applied to the treatment
erated evidence for the separation of of anxiety states. The most widely pre
anxiety states from depressive states and, scribed group of anti-anxiety agents, the
within the depressive states, for the sep benzodiazepines, were mainly useful for
aration of endogenous depression from situational generalized anxiety. The con
neurotic depression. Marks and Gelder ventional wisdom among experienced
proposed a three-way classification of psychopharmacologists was that the ben
phobias distinguishing among simple zodiazepines have limited efficacy in
phobias, social phobias, and agoraphobia. agoraphobia and other phobic conditions,
The agoraphobic syndrome came under obsessions, compulsions, and dissociative
increasing clinical attention and the clini states. In this context, a number of reports
cal utility of the syndrome was partially about atypical depression appeared in
validated by factor analytic studies which which anxiety and phobic symptoms were
identified a cluster of common situations prominent, being responsive to monoa
precipitating agoraphobia, notably those mine oxidase (MAO) inhibitors.
involving public transportation, shops and The contributions of Donald Klein were
markets, cinemas and theater, and other of major importance. Klein documented
public gatherings. the efficacy of imipramine against agora
Therapeutic investigations proceeded in phobia and elaborated upon his observa
two directions: first, the emergence of tions about the important role played by
behavioral therapeutic techniques which panic attacks in the psychopathogenesis
challenged psychoanalysis and psychody of agoraphobia. Thus, by the latter part of
namic psychotherapy and, secondly, the the 1970s, the continuum view had no
Foreword IX
longer proven viable, and alternative or unconscious level or to problems of
views emphasized multiple clinical anxi learning and conditioning. Their treat
ety states and both psychotherapeutic and ment was expected to take place in outpa
pharmacological treatments in the treat tient settings, with hospitalization
ment of anxiety conditions. required only on infrequent occasions
and for brief durations. When treatment
was available, it would be psychotherapy,
The Impact of DSM-III behavioral, psychodynamic, individual, or
group.
The promulgation in 1980 by the Ameri Instead of a single overriding category of
can Psychiatric Association of the DSM neurotic conditions, DSM-III proposed a
III served as a watershed in the develop series of new categories: "affective disor
ment of theory, research, and procedure ders," "anxiety disorders," "eating disor
about anxiety and anxiety disorders in ders," "psychosexual disorders," etc. The
general and panic and phobias in particu grouping together of different disorders
lar. The DSM-III broke with established into these categories did not represent
tradition in a number of important ways; any presumption as to a common etiolo
applied to anxiety disorders, two impor gy; rather, the categories were based on
tant features of the DSM-III are notewor vigor presenting symptoms, in the case of
thy. anxiety disorders, presentations due to
First, the DSM-III discontinued the time tension, anxiety, and fears.
honored category of neurotic conditions. Most controversial in the reclassification
For eight decades, almost all diagnostic of anxiety disorders was the separation of
and classification systems of mental disor panic disorder from generalized anxiety.
ders distinguished between organic and The separation of anxiety neurosis into
functional states, and within the func panic disorder and generalized anxiety
tional or nonorganic states, the major had been incorporated in the Research
diagnostic separation was between psy Diagnostic Criteria (RDC) developed for
choses and neuroses. The psychotic-neu use in the NIMH Collaborative Program
rotic distinction had implications for de on the Psychobiology of Depression and
scription, etiology, locus of treatment, and increasingly applied in clinical studies in
type of treatment. The psychoses were the 1970s and also in the community
considered to be caused by constitutional epidemiological surveys. Furthermore,
or biological factors, manifested clinically the pathogenic linkage between panic
by delusion, hallucinations, dementia, or anxiety and agoraphobia was highlighted,
other serious impairments of higher men and two forms of agoraphobia were in
tal functions discontinuous with normal cluded within the category of anxiety
experience and justifying hospitalization, disorders - panic disorder with agorapho
often involuntary hospitalization with bia and agoraphobia without panic disor
civil commitment. Where treatments der. However, the DSM-III narrative
were available, they were almost always clearly indicated that the expectation was
somatic treatments, such as electrocon that agoraphobia without panic attacks
vulsive therapy, or, in earlier decades, was to be considered as a nonexistent or,
insulin coma treatment, or such drastic at best, rare condition.
interventions as lobotomy and other For the most part, this controversy over
forms of psychosurgery. the DSM-III approach has led to stimulat
In contrast, the neuroses were believed to ing investigations in epidemiology, family
be due to environmental causes, includ and genetic disorders, and clinic psycho
ing psychological conflict at the conscious pathology.
X Foreword
The most extensive and intense con ence and the editors of this volume, had
troversies have been in the area of treat expected that the available evidence
ment. The focus of controversy is now in would allow a consensus to emerge. The
the relative merits of behavioral and opposing points of view are represented
cognitive psychotherapeutic techniques in this volume, and the alternative inter
versus psychopharmacological methods. pretations of available data are presented
Interpreting the content of these con in articulate and reasoned fashion. The
troversies is made difficult by the con first part of their expectation was well
founding of scientific and professional realized: The individual papers capture
issues. The advocates of behavioral and the current diversity of the field. Howev
cognitive techniques tend to be Ph.D. er, in the area of therapeutics, the main
psychologists, while the advocates of focus of this volume, it is evident that
psychopharmacological agents are the further research is necessary before the
M.D. psychiatrists. Moreover, issues of issues will be resolved. Carefully designed
the efficacy of specific treatments are studies are needed in the following areas:
related to general theories of causation,
1. Evaluation of pharmacological treatments as
with the psychopharmacologists empha
compared with placebo controls
sizing a genetically determined abnormal
2. Carefully designed controlled studies of beha
ity of CNS chemistry as the predisposition vioral treatment as compared with creditable
and minimizing environmental and cogni psychological controls
tive factors. In contrast, the behavior 3. Comparative studies of drugs as related to
psychological treatments
therapists emphasize the role of learning
4. Studies of combined drug and psychological
and situational and environmental cues treatment
and minimize the possible role of endoge 5. Long-term studies to assess relapse, recur
nous physiological abnormalities. rence, and psychosocial functioning
6. Studies to improve design and methodology
These therapeutic differences are often
extended to issues of diagnosis, nosology,
Seen in the context of both the historical
and classification. For the most part, the
background and the ongoing scientific
advocates of behavior therapy have been
disputes, this volume provides the reader
hesitant to accept the nosologic separa
with an excellent assortment of current
tion of panic anxiety from generalized
investigations in Western Europe and
anxiety and tend to emphasize the contin
North America. High-quality research is
uity of normal and clinical anxiety,
under way based on investigations from a
regarding panic as the more intense form
variety of theoretical backgrounds and
of anxiety. In contrast, the biological
disciplines. One looks forward to future
theorists emphasize the discontinuity
reports similar to this. The quality of
between panic anxiety and normal states
investigations continues to improve, the
and the uniqueness of the sUbjective
issues become more sharply defined, and
experience and biology of the panic
the results are more precisely interpreted.
attack.
Until results of such studies are available,
this volume provides the state of the art in
anxiety research.
Future Directions
As stated in their introduction, Wittchen
and Hand, the organizers of the confer-
Contents
Preface
v
I. HAND and H.-U. WITTCHEN
Foreword:
Sources of Current Controversies in Treatment of Panic and Phobia
G. L. KLERMAN . . . . VII
List of Contributors .. . XV
Acknowledgments . . . . .. XIX
Part I: Psychological or Biological Treatments of Panic and Phobias:
Current State of the Controversy
1. Natural Course and Spontaneous Remissions of Untreated Anxiety
Disorders: Results of the Munich Follow-up Study (MFS)
H.-U. WITT CHEN ....................... . 3
2. Biology and Pharmacological Treatment of Panic Disorder
T. W. UHDE and M. B. STEIN ................ . . . . .. 18
l .. The Mutually Potentiating Effects of Imipramine and Exposure in
Agoraphobia
M. MAVISSAKALIAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 36
Part II: Pharmacological, Cognitive, and Behavioral Treatment of Panic
and Phobias: Current State of Research
4. Effects of Discontinuation of Antipanic Medication
A. J. FYER ....................... . ..... 47
5. Comparison of Alprazolam and Cognitive Behavior Therapy in the
Treatment of Panic Disorder: A Preliminary Report
J. S. KLOSKO, D. H. BARLOW, R. B. TASSINARI, and J. A. CERNY. . . . . . .. 54
