Panic and Phobias: Empirical Evidence of Theoretical Models and Longterm Effects of Behavioral Treatments

135 Pages·1986·4.88 MB·English

by  Iver Hand

Panic and Phobias
Empirical Evidence of Theoretical Models and Longterm Effects
of Behavioral Treatments
Edited by I. Hand and H.-U. Wittchen
With contributions by
J. Angenendt, D. M. Clark, A. Ehlers, W. Fiegenbaum,
M. Fischer, B. Garssen, E. Griez, I. Hand, M. A. van den Hout,
R. King, R. Maddock, J. Margraf, W. T. Roth, P. M. Salkovskis,
G. Semler, C. Wilke, H.-U. Wittchen
With 22 Figures
Springer-Verlag
Berlin Heidelberg New York Tokyo
Iver Hand, M.D.
Professor of Psychiatry
Behavior Therapy Outpatient Unit
Psychiatric University Clinic Hamburg
Federal Republic of Germany
Hans-Ulrich Wittchen, Ph.D., Dipl.-Psych.
Professor of Clinical Psychology
University of Mannheim
and Unit for Evaluation Research
at the Max-Planck-Institut fur Psychiatrie Munchen
Federal Republic of Germany
ISBN-13: 978-3-642-71167-1 e-ISBN-13 :978-3-642-71165-7
DOl: 10.1007/978-3-642-71165-7
library of Congress Cataloging-in-Publication Data
Panic and phobias. Includes bibliographies and index.
I. Panic attacks. 2. Phobias. 3. Behavior therapy. 1. Hand, Iver. II. Wittchen, Hans-Ulrich.
[DNLM: 1. Anxiety Disorders. 2. Fear. WM 172 P192] RC535.P35 1986 616.85'223 86-3924
ISBN-13: 978-3-642-71167-1
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Foreword
Isaac Marks, Institute of Psychiatry, London
Human emotion seems to have changed Westphal's perceptive label. Many factor
since DSM-III burst on the world in 1980. analytic studies in Europe and the USA
The mere fear or anxiety that people used showed that fears of public places are sali
to feel has been transformed into dramatic ent in this problem, and that such agora
panic attacks, and it has become vital to phobic panic and avoidance was also fre
know whether 3 of these occurred over the quently accompanied by other nonphobic
last 3 weeks. A rash of papers has appeared (nonsituational) features like tonic tension
proving that 'panic disorder' is a disease and phasic panics independent of any
with a specific genetic background, child special cue, depression and depersonal
hood antecedents, biological markers, and ization. Unlike agoraphobia, panic is a
pharmacological treatment. With alacrity rather nonspecific term. Spontaneous panic
'panic disorder' has been clutched to the is almost as frequent in anxious depression
psychiatric bosom as proof of our medical as in panic disorder, while phobic panic is a
identity. hallmark of nearly all severe phobias, be
Alas, we have been here before. Did not they specific, social or agoraphobias.
Benedikt in 1870 call similar symptoms This book is a refreshing addition to the
'platzschwindel', believing that the com swelling literature on anxiety disorders,
mon symptom of dizziness pointed to a much of it bringing perspective from little
central disturbance in balance? Did not known but seminal research (names and
many later think that the usual symptom of numbers in parentheses henceforth denote
palpitations pointed to cardiovascular dis chapter numbers and authors). The many
turbance at the core, leading to names like somatic features of anxiety leads to an
neurocirculatory asthenia, soldier's heart, overlap of panic and somatization dis
and effort syndrome. Roth suggested that orders (8, King et al.). Epidemiological
the symptoms of depersonalization denoted work in Munich (3, Wittchen) has found
temporal lobe disturbance, and called the prevalences in the general population of
syndrome phobic-anxiety-depersonaliza agora- and specific phobias and obsessive
tion. Recently quite a few have seen hy compulsive disorder which are remarkably
perventilation or the fear of fear as the key. close to those found in the ECA survey in
The current panic school is the latest in a the USA. Those 2 surveys, together with
long line. Successive generations pin their that of Angst in Zurich, show that such anx
faith on different symptoms of a protean iety disorders are far more common than
disorder as the root of the problem. All used to be thought. The female predomi
grasp at different parts of the elephant. nance remains marked among agoraphob
Whatever we call it, a beast of some kind ics in community as well as clinic samples.
does seem to be there. More parts than Specific phobias are the most common
most were touched by the term coined by phobia in the community but not in the
Benedikt's contemporary, Westphal, in clinic, perhaps because they are less likely
1871 - agoraphobia. 'Agoraphobia' is par to cause disability and thus urgency in
ticularly apposite as some fears of various seeking treatment.
public places are prominent in most cases, A lucid critique of a purely biological
and there is good reason to continue with formulation of panic disorder comes from
VI Foreword
Ehlers, Margraf and colleagues (4, 6). They Two long-term followup studies from
note that a) the familial risks for panic and Germany (9 - Fiegenbaum, II - Hand et
generalized anxiety have not yet been al.) add to the already impressive UK and
shown to be independent and that there are Dutch literature showing the durability of
no adoption studies to indicate whether gains in agoraphobics for 3 or more years
these risks are genetic ones, and b) the after exposure therapy, improvement often
strongest association of childhood separa increasing even further during followup.
tion anxiety is with adult depression rather Mood seems to improve along with agora
than panics. Moreover, c) the response to phobia and social adjustment. These en
lactate infusions or CO inhalation by cases couraging results suggest that exposure
2
of panic disorder is not a specific biological therapy for agoraphobia should be more
marker, the higher levels of anxiety and widely used by mental health care pro
arousal that are attained during such chal viders than is often the case.
lenge largely being a function of their high Sufferers from panic disorder with agora
er baseline level compared with that in phobia can now be helped much more than
controls. Similar observations were made a couple of decades ago, though we have
by Maranon in 1924 about the response of gone less far on the path to understanding
volunteers to an injection of epinephrin. etiology. Knowledge would advance faster
And the response to the cold pressor test if a partisan biological or psychological
and even just wearing a gas mask while ex approach gave way to an integrated per
pecting an inhalation is rather like that to spective taking both sets of factors into ac
lactate and CO count, while sufferers would get a better
2 •
Hyperventilation can produce some deal from therapists who acknowledged
features of natural anxiety and respiration that drugs alone are not the complete solu
training may reduce some of these (7 - tion but have a role as an addition to ex
Garssen, 10 - Salkovskis & Clark). This posure in some cases. The interaction be
raises several questions. What proportions tween biology and psychotherapy is gradu
of agoraphobics a) hyperventilate in re ally emerging in work showing the biologi
sponse to fear, b) become frightened as a cal consequences of habituation in animals
reaction to hyperventilation, c) do both in a and behavioral psychotherapy has demon
vicious circle, d) do neither? Historically, strable biological consequences which
when the agoraphobia began, in how many overlap with those of drugs (Marks 1986).
cases was hyperventilation a primary initi
ating element, a secondary complicating Marks IM (1986) Fears, Phobias and Rituals.
factor, or absent? Oxford Univ. Press, NY.
Contents
1. Introduction . . . . . . . . . .
Iver Hand and Hans-Ulrich Wittchen
I. Diagnostic Reliability and Epidemiology of DSM-ill Anxiety Disorders
2. Diagnostic Reliability of Anxiety Disorders . . . . . . 7
Hans-Ulrich Wittchen and Gert Semler
1. Introduction................ 7
2. Definition and Classification of Anxiety Disorders. 7
3. Aims.. 9
4. Methods........... 9
5. Results............ 11
5.1. Diagnostic Test-Retest Reliability. 11
5.2. Test-Retest Reliability of Symptom Questions 11
5.3. Comparison of Two Diagnostic Methods (DSM-III checklist versus CIDI) . 14
6. Discussion 15
7. References............... 17
3. Epidemiology of Panic Attacks and Panic Disorders. 18
Hans-Ulrich Wittchen
1. Introduction: Contribution of Epidemiological Data to the Classification
of Anxiety Disorders . . . . . . . . . . . . . 18
2. Aims.................... 19
3. Methods.................. 20
3.1. Description of the Munich Follow-up Study (MFS) 20
3.2. Design and Instruments. . . . . . . . . . . . 20
3.3. Data from the NIMH Epidemiological Catchment Area (ECA) Program 21
3.4. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . 22
4. Results . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.1. Prevalence Rates and Biosocial Characteristics ofDSM-III Anxiety
Disorders. . . . . . . . . . . . . . . . . . . . . . . . . 22
4.2. Frequencies of Symptoms and Syndromes Related to Panic Disorders 22
4.3. Age of Onset of Anxiety Disorders 25
5. Discussion 26
6. References.......... 27
n.
Theoretical Models and Empirical Evidence
4. Panic Attacks: Theoretical Models and Empirical Evidence. 31
Jurgen Margraf, Anke Ehlers, and Walton T. Roth
VIII Contents
1. Introduction......... 31
2. Biological Models of Panic Attacks 32
2.1. Klein's and Sheehan's Models 32
2.2. Empirical Evidence 33
2.2.1. Specificity of Drug Treatments 33
2.2.2. Panic Induction . . . . . . 33
2.2.3. Family and Twin Studies . . 33
2.2.4. Spontaneity of Panic Attacks. 34
2.2.5. Separation Anxiety and School Phobia 34
3. Psychophysiological Models of Panic Attacks. 35
3.1. Principles of Psychophysiological Models 35
3.2. Empirical Evidence . . . . . . 36
3.2.1. Positive Feedback Loops in Panic. 36
3.2.2. Role of Cognitions . . . . . . 37
3.2.3. Role of Hyperventilation . . . 37
3.2.4. Role of Cardiovascular Events . 38
3.2.5. Role of Vestibular Dysfunction. 39
4. Discussion and Conclusions 39
5. References......... 40
5. Experimental Panic: Biobehavioral Notes on Empirical Findings 44
Marcel A. van den Hout and Eric Griez
1. Introduction..... 44
2. Phobias ......... . 45
2.1. Some Behavioral Models .. . 45
2.2. Biological Aspects of Behavioral Models of Phobias 45
3. Panic ................... . 46
3.1. Biological Models . . . . . . . . . . . . . . 46
3.2. Behavioral Aspects of Pharmacological Panic Models 48
4. Concluding Remarks 50
5. References.................. 50
6. Experimental Induction of Panic Attacks 53
Anke Ehlers, Jurgen Margraf, and Walton T. Roth
1. Introduction............. 53
2. Sodium Lactate and Carbon Dioxide as Panic Challenges -
Historical Development. . . . . . . . . . 54
2.1. Lactate Infusion and Panic Attacks . . . . . 54
2.2. Carbon Dioxide Inhalation and Panic Attacks 54
3. Results of Panic Induction Studies . . 55
3.1. Effects of Lactate and CO 55
2 , • • • • •
3.1.1. Self-Reported Anxiety and Symptoms. 55
3.1.2. Physiological Effects . . . . . . . . 55
3.1.3. Biochemical Effects .... . . . . 56
3.2. Incidence of Lactate and CO -Induced Panic Attacks 56
2
3.3. Similarity of Laboratory-Induced and Naturally Occurring Panic 57
4. Panic Induction: Limitations and Open Questions. . 58
4.1. Methodological Considerations ... . . . . . . 58
4.2. Sensitivity and Specificity of Panic Challenges . . . 58
4.3. Relevance of Baseline Levels of Anxiety and Arousal 59
5. Two Studies on Panic Induction 59
6. Discussion and Conclusions 62
7. References......... 64
Contents IX
7. Agoraphobia and the Hyperventilation Syndrome - the Role ofInterpretations
of Complaints . . . 67
Bert Garssen
1. Introduction 67
2. Methods. 68
3. Results.. 69
4. Discussion 70
5. References 71
8. Panic Disorder - Overlap with Symptoms of Somatization Disorder . 72
Roy King, Jurgen Margraf, Anke Ehlers, and Richard Maddock
1. Introduction 72
2. Methods.................... 73
2.1. Subjects . . . . . . . . . . . . . . . . . . . . 73
2.2. The Self-Report Inventory for Somatic Symptoms (SISS) 73
2.3. Procedure............ 73
3. Results.................. 74
3.1. Psychometric Properties of the SISS. . . . . . 74
3.2. Differences between Panic and Control Groups . 74
3.3. Relationship between Phobic Avoidance and Major Depression. 74
3.4. Relationships with Other Measures 74
4. Discussion 75
5. References.......... 77
ill. Treatments and Longterm Outcome of Phobias with Panic Attacks
9. Longterm Efficacy of Exposure in-Vivo for Cardiac Phobia. 81
Wolfgang Fiegenbaum
1. Introduction.............. 81
2. Description of our Exposure Therapy Package 81
2.1. Diagnostic Phase. . . . 82
2.2. Cognitive Preparation 82
2.3. Intense Exposure in-Vivo 82
2.4. Self-Control...... 83
3. Goals and Design of our Study . 83
4. Methods...... 84
4.1. Patients and Therapists . 84
4.2. Assessment...... 84
4.2.1. Questionnaire Measures. 85
4.2.2. Behavioral Test . . . . 85
4.2.3. Other Symptom-Relevant Variables. 85
5. Results............. 85
5.1. Results for the Entire Patient Group 85
5.1.1. Questionnaire Measures. . . . . . 85
5.1.2. Behavioral Test .. . . . . . . . 86
5.1.3. Other Symptom-Relevant Variables. 87
5.2. Comparison of Groups A and B 88
6. Discussion........... 89
7. References........... 89
10. Cognitive and Physiological Processes in the Maintainance and Treatment
of Panic Attacks . . . . . . . . . . 90
Paul M. Salkovskis and David M. Clark
1. Introduction........................ 90
X Contents
2. Effectiveness of Treatment Based on the Cognitive Model of Panic 92
3. Interpretation of Treatment Studies . . . . . . . . . . 96
4. Effects of Stress and Panic on Respiration in Panic Patients 97
5. Discussion . 100
6. Conclusions 101
7. References . 102
11. Exposure In-Vivo with Panic Management for Agoraphobia:
Treatment Rationale and Longterm Outcome . . . . . . . 104
Iver Hand, Jorg Angenendt, Martina Fischer, and Cornelia Wilke
1. Introduction.................. 104
2. Experimental Design . . . . . . . . . . . . . . 105
2.1. Treatments: Exposure In-Vivo and Panic Management 105
2.2. Patients.. 108
2.3. Assessments . . . . . . . . . . 109
3. Results............ III
3.1. Outcome for Total Patient Sample . 111
3.1.1. Symptom Scales: Prospective Follow-Up 111
3.1.2. Interview Data: Retrospective Follow-Up. 112
3.l.3. Comparison of Outcome with Three Different Modes of Exposure 115
3.2. Outcome of Mild Agoraphobia . . . . . . . . . . . . 116
3.3. Outcome of Severe Agoraphobia . . . . . . . . . . . 116
3.3.1. Comparison of Outcome with Group Exposure and Home
Based Treatment . . . . . . . . . . . . . . . . . . 116
3.3.2. Comparison of Gainers and Losers . . . . . . . . . . 117
3.3.3. Level of Multisymptomatic Disturbance and Outcome in Agoraphobia 119
3.3.4. Changes During Follow-Up 120
4. Summary and Discussion 121
5. References. 125
Subject Index . . . . 129
Acknowledgements
This book gives a comprehensive overview highly reliable cooperation of all the con
of three symposia on diagnosis; etiology tributors is gratefully acknowledged as well
and treatment of anxiety disorders, that as the help and the support of our col
were held at the 15th annual Meeting of the leagues and secretaries in the final prep
European Association of Behavior Ther aration of the manuscript.
apy, in August 1985 in Munich. We wish to
thank Johannes C. Brengelmann, Director We are especially grateful to Springer
at the Max Planck Institute for Psychiatry, Publishing House for the most efficient
chiefo rganizer of this meeting, for his con management of all problems and difficul
stant encouragement in the planning and ties resulting from the rapid publishing
the organization of these symposia. The process.