Overcoming Agoraphobia and Extreme Anxiety Disorders

Overcoming Agoraphobia & Extreme Anxiety Disorders

After reading Overcoming Agoraphobia & Extreme Anxiety Disorders, youll be given a better understanding of all things related to the condition, so that you dont have to be afraid anymore. If youve been suffering for any amount of time, dont allow yourself to feel hopeless and alone. This problem is more common than you might think and the first step to overcoming any anxiety issue is by learning all you can about it. Find out what causes panic disorders and discover how you can create a different life for yourself starting today. Here are just a few things youll learn by reading this complete anxiety guide: What anxiety is and why it happensHow anxiety can lead to panic disordersWhat agoraphobia is and how to know if youre at riskHow to recognize symptoms of agoraphobia and how to manage itAn overview of the different types of anxiety disordersWhat you can do to improve this condition once and for allHow to fight the root of anxiety and panic disorders stressWhether or not adrenal fatigue is the cause of your problemsHelpful therapy options that have been proven to be effectiveAlternative remedies for stress, depression and panic disorders

Overcoming Agoraphobia & Extreme Anxiety Disorders Summary

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Agoraphobia Definition

DSM-III agoraphobia is defined as a fear and avoidance of being in places or situations from which escape might be difficult or in which help might not be available in the event of sudden incapacitation (APA, 1980). As a result of such fears, the agoraphobic person avoids travel outside the home or requires the accompaniment of a companion when away from home. Moderate cases may cause some constriction in lifestyle, while severe cases of agoraphobia may result in the person being completely housebound or unable to leave home unaccompanied. As outlined in the panic disorder section above, DSM-III-R revised the diagnosis of agoraphobia to a condition accompanying panic disorder (panic disorder with agoraphobia). Although the diagnosis of agoraphobia without history of panic disorder was retained, this category emphasized the avoidance behavior as a TABLE 8. Prevalence Rates per 100 of Agoraphobia Using DSM-III aPanic with agoraphobia.

Relationship Between Agoraphobia and Panic

In DSM-III, agoraphobia was considered a separate phobic disorder which may or may not be accompanied by panic attacks. Largely due to the influence of Klein's argument that agoraphobia is a conditioned avoidance response to the aversive stimulus of spontaneous panic attacks, the diagnostic view of agoraphobia changed considerably in DSM-III-R, in which panic disorder is viewed as primary, with or without the secondary development of agoraphobia. An important factor in this change was the observation by Klein and others that, in clinic settings, agoraphobia rarely occurs without preceding spontaneous panic attacks or limited symptom attacks. Considerable controversy continues regarding the nature of the relationship between agoraphobic avoidance and panic attacks. Marks (1987) and other European investigators have questioned the temporal precedence and causal role of panic attacks in the development of agoraphobia. Contributing to the controversy are the large differences between...

Primary Anxiety Disorders

Present either with or without agoraphobia (i.e., anxiety about, or avoidance of, places or situations from which escape may be difficult). Studies of adult patients have shown that individuals with panic attacks are high utilizers of medical care (Barsky et al. 1999). This is particularly true for patients who experience chest pain and who repeatedly present at emergency rooms or are referred for diagnostic workups. However, when symptoms of agoraphobia are also present, patients may have particular difficulty participating in treatment within the medical setting and adhering to follow-up appointments.

Features Context And Approach To Therapy

Another feature of this case is that breakdown occurred in middle life, and involved the reactivation of childhood trauma. The most usual course of psychosis involves breakdown at the early life transitions of leaving home, or, in the case of women, entering committed relationship or having children. Helena had passed all these life stages, albeit restricted by agoraphobia and depression. She had brought up two children, gone through three marriages (the third was remarriage of her first husband), before threats to her latest marriage resulted in psychotic breakdown. A feature of her troubles was severe hopelessness, leading to impulses to suicide, which have made the transition from hospital to the community hard to achieve.

Nonpharmacologic Therapy

Patients with PD should be counseled to avoid stimulant agents (e.g., decongestants, diet pills, and caffeine) that may precipitate a panic attack. CBT consists of psy-choeducation, continuous panic monitoring, breathing retraining, cognitive restructuring, and exposure to fear cues.50 CBT may involve these features to varying degree. Panic-focused psychodynamic psychotherapy (PFPP) focuses on underlying meaning of panic symptoms (e.g., they have a specific emotional significance) and on current social and emotional functioning.50 PFPP may be used alone or with other modalities. Exposure therapy is useful for patients with phobic avoidance. CBT is considered a first-line treatment of PD, with efficacy similar to that of pharmacotherapy. In a large placebo-controlled trial comparing CBT with imipramine or combination (CBT + imi-pramine), CBT was as effective as the antidepressant after 12 weeks. Patients receiving CBT were less likely to relapse during the 6 months after treatment...

Interpretation paradigms and panic

Having extolled the virtues of information-processing paradigms to examine basic cognitive processes associated with emotion, we shall nevertheless begin with a brief look at some self-report data. As we have seen in our discussion of theoretical approaches to panic, the idea that individuals suffering from panic disorder cata-strophically misinterpret bodily sensations is a central claim within the literature (Clark, 1986). To examine such biases in interpretation, McNally and Foa (1987), inspired by the work of Butler and Mathews (1983, see below), gave people with agoraphobia with panic attacks, recovered agoraphobic people, and healthy controls a series of ambiguous scenarios involving either internal or external stimuli (e.g., You feel discomfort in your chest area. Why ). Participants were required to write down the first explanation that came to mind for each scenario and then to rank order three candidate explanations of the scenarios provided by the experimenter. In each...

Current treatments for emotional disorders in youth and adulthood

Within the adult literature, new examples of the beneficial effect of treatment for a principal anxiety disorder on co-occurring emotional disorders have recently appeared. For example, the presence of additional diagnoses in a sample of 126 patients treated for Panic Disorder with Agoraphobia (PDA) at the Center for Anxiety and Related Disorders was recently examined (Barlow, Allen, & Choate, 2004). At pretreatment, 26 had an additional diagnosis of GAD, but the rate of comorbid GAD declined significantly at post-treatment to 9 , and remained at this level at a two-year follow-up. Whether these findings represent the generalization of elements of treatment to independent facets of both disorders, or a way of effectively addressing core features of emotional disorders, is not significant to our purpose here. In both cases, the efficiency of a unified treatment protocol is suggested. Moreover, the fact that a wide range of emotional disorders

Defining The Syndrome Of Panic Disorder

The syndrome now called panic disorder was first described in the medical literature in 1895, by Sigmund Freud (1895a), under the term anxiety neurosis. His description differed from the currently accepted one in Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR) (APA, 2000), in that he included features of the illness other than panic attacks, including general irritability, anxious expectation, rudimentary anxiety attacks (which bear a similarity to our current conceptualization of limited symptom attacks), vertigo, phobias and agoraphobia, nausea and other gastrointestinal symptoms, and paresthesias. peak within 10 min, discrete periods) and emotional quality (intense fear or discomfort). At least four of the following typical panic symptoms must be present pounding heart or accelerated heart rate, sweating, trembling or shaking, sensations of shortness of breath or smothering, feeling of choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy,...

Cognitive Behavioral Model

The central feature of the cognitive-behavioral model of panic disorder is the patient's catastrophic misinterpretation of events and or somatic sensations leading to feelings of imminent danger associated with panic attacks (Craske, 1988). Patients develop a fear of the somatic sensations associated with panic attacks, considered part of the body's fight-or-flight alarm response. Catastrophic misinterpretations of these sensations include fears of dying (e.g., having a heart attack or suffocating) and fears of losing control or going crazy. Somatic sensations associated with panic attacks come to serve as cues of danger and potential panic via classical conditioning. Thus, increasing anxiety leads to increased fear of somatic sensations, which leads to increasing anxiety in a vicious cycle. Patients become vigilant to the presence of these sensations, increasing the likelihood that experienced somatic sensations will trigger the escalating cycle and panic attacks. These panic...

Psychodynamic Model of Panic Disorder

Busch et al. (1991) and Shear et al. (1993) developed a psychodynamic formulation for panic disorder based on psychological, clinical, and temperamental observations and studies about panic patients. Beginning with the studies of temperament of Kagan et al. (1990) and Biederman et al. (1990), the authors postulated that panic patients are constitutionally predisposed to fearfulness of unfamiliar situations early in life. This is based in part on Rosenbaum et al.'s (1988) finding that children of patients with panic disorder, who are likely to develop panic, are found to have a high rate of behavioral inhibition. Behaviorally inhibited children manifested long latencies to interact when exposed to novelty, retreated from the unfamiliar, and ceased play and vocalizations while clinging to their mothers (Biederman et al., 1990, p. 21). In addition, children with behavioral inhibition demonstrated higher rates of childhood anxiety disorders (Biederman et al., 1990). Rosenbaum et al....

Cognitive Behavioral Treatment Studies

Very few studies have assessed the efficacy of CBT in addition to antipanic medication. Marks et al. (1993) evaluated the comparative efficacy of alprazolam and CBT, both alone, and in combination in patients with panic and agoraphobia, and found that alprazolam dampened patients' response to CBT. In the recent multicenter treatment trial that extended over 7 years, CBT alone was compared with placebo, imipramine alone, the combination of both CBT and imipramine, and CBT plus placebo for panic disorder (Barlow et al., 2000). In this study, all active treatments produced responses superior to placebo, but the combined treatment cell was not significantly superior to either CBT or imipramine alone after the active treatment phase. However, the combination of CBT and imipramine conferred more substantial advantage than either treatment alone by the end of the 6-month maintenance phase of the study. The major limitation of this important multicenter study is that the patients studied had...

Psychodynamic Psychotherapy for Panic Disorder

An open trial of PFPP has been completed (Milrod et al., 2001, 2000). In this study, PFPP followed a 24-session, psychodynamic psychotherapy program, delivered twice weekly in 45 to 50 min sessions, over 12 weeks. Twenty-one patients with primary DSM-IV panic disorder entered the treatment trial. Four patients dropped out. Sixteen of 21 patients experienced remission of panic and agoraphobia. Treatment completers with major depression (N 8) also experienced remission of their depression. Symptomatic and quality of life improvements were substantial and consistent across all measured areas. Symptomatic gains were maintained over 6 months. While the sample size in this study was too small to draw firm conclusions, as a result of this pilot research,

Panic Disorder Definition

More important, DSM-III-R changed the diagnostic hierarchy so that panic disorder could be diagnosed as a primary disorder with or without agoraphobia and dropped the category of agoraphobia with panic attacks. This change placed the emphasis on identifying panic disorder as a discrete entity and reflected the clinical experience that panic attacks tended to occur prior to the development of agoraphobia, which was increasingly viewed as a phobic avoidance response to the frightening experience of spontaneous panic attacks, near panic experiences or limited symptom attacks.

Treatment Of Anxiety In Clinical Practice Symptoms of Anxiety

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association (1994) includes eight major types of anxiety disorders, most of which have been summarized in previous chapters, including PTSD (Chapter 11), panic attacks (Chapter 12), obsessive-compulsive disorders (Chapter 13), and various acute stress reactions (Chapter 4). Here we will be primarily concerned with generalized anxiety disorders, but the coverage is also relevant for specific phobias, including social phobias and agoraphobia. The most common clinical symptom of all these disorders is excessive worry and sustained feelings of mental anguish. Among the common symptoms of generalized anxiety there are a variety of psychological disturbances, such as uncontrollable apprehensive expectations, jumpiness, and a tendency for excessive vigilance and fidgeting. The accompanying autonomic symptoms commonly include gastrointestinal irritability, diarrhea, and frequent urination, as well...

Interaction of Depression and Anxiety

Disorders are more likely to lead to subsequent depression that is, panic disorder, agoraphobia, OCD, PTSD and GAD more frequently lead to depression compared to either social phobia or simple phobia. In addition, patients with both illnesses often have increased severity of symptoms, increased frequency of episodes (either mood or anxiety episodes), poorer response to treatment, higher suicide rates, a more chronic course, and overall poorer prognosis. Treatment is complicated by the fewer studies on coexisting depression and anxiety, providing clinicians with a smaller evidence-base for treatment decisions. Patients with comorbid major depressive disorders are half as likely subsequently to recover from panic disorder with agoraphobia or GAD, and comorbid major depression almost doubles the likelihood of recurrence of panic disorder with agoraphobia (Bruce et al., 2005). In addition, children and adolescents with anxiety disorders are at eight times the risk of additional depression...

Diagnosis of Anxiety Disorders

Patients with panic disorder experience recurrent, unexpected panic attacks, followed by at least 1 month of persistent worry that they will suffer another panic attack. Panic disorder patients may begin to avoid places where a prior attack occurred or where help may not be available such avoidance can lead to the development of agoraphobia and typically worsens their psychosocial functioning (Box 47-5).

Phenomenology and nosology of the secondary anxiety disorders

The DSM-IV-TR (APA, 2000) divides the anxiety disorders into a series of sub-disorders including panic attacks, agoraphobia, panic disorder with and without agoraphobia, the specific phobias, social phobia, obsessive-compulsive disorder (OCD), posttraumatic stress disorder, generalised anxiety disorder (GAD), anxiety disorder due to a general medical condition, substance-induced anxiety disorder, and anxiety disorders not otherwise specified. Readers are encouraged to consult DSM-IV-TR for the full details of the diagnostic criteria for each of the anxiety conditions.

Temperament and Personality

The major impediment to evaluation of the causal role of life events in anxiety (or depression), is the retrospective nature of most research addressing this issue. For example, Lteif and Mavissakalian (1996) found that patients with panic or agoraphobia exhibited an increased tendency to report life events in general this suggests that studies that limit assessment of life events to those preceding onset of a disorder may be misleading because they fail to provide comparison for the time period of onset. Moreover, stressful life events may interact with other risk factors such as family history of depression in precipitating episodes of panic (Manfro et al., 1996).

General Approach to Treatment

Treatment options include medication, psychotherapy (e.g., CBT preferred), or a combination of both. In some cases, pharmacotherapy will follow psychotherapy treatments when full response is not realized. Patients with panic symptoms without agoraphobia may respond to pharmacotherapy alone. Agoraphobic symptoms generally

Overlap Between Mood And Anxiety Disorders

Biederman J, Rosenbaum JF, Bolduc EA, Faraone SV, Hirshfeld DR (1991) A high risk study of young children of parents with panic disorders and agoraphobia with and without comorbid major depression. Psychiatry Research 37 333-348. Last C, Barlow D, O'Brien G (1984) Precipitants of agoraphobia Role of stressful life events. Psychological Reports 54 567-570. Lteif GN, Mavissakalian MR (1996) Life events and panic disorder agoraphobia A comparison at two time periods. Comprehensive Psychiatry 37 241 -244. Magee WJ, Eaton WW, Wittchen H-U, McGonagle KA, Kessler RC (1996) Agoraphobia, simple phobia and social phobia in the National Comorbidity Survey. Archives of General Psychiatry 53 159-168. Rosenbaum JF, Biederman J, Gersten M (1988) Behavioral inhibition in children of parents with panic disorder and agoraphobia A controlled study. Archives of General Psychiatry 45 463-470.

Self Awareness Self Concept and Visual Perspective

Wells and Papageorgiou (1999) suggest greater third-person perspective use during social situations should extend to all individuals with abnormal self-focused processing. Indeed, they found both individuals with social phobia and agoraphobia rated their social memories as more third-person compared to blood injury phobics and controls. Agoraphobics also rated their neutral memories as more third-person than all other groups. Day, Holmes, and Hackmann (2004) found that agoraphobics experienced more images that alternated between first-person and third-person perspectives compared to controls. The authors suggest this was due to a change in focus between the self (i.e., third-person perspective) and the situation (i.e., first-person perspective). Spider-anxious individuals who rate high in social evaluative concerns use third-person perspectives more than those who rate low when asked to imagine spider-related imagery (Pratt, Cooper, & Hackmann, 2004). Individuals with body dysmorphic...

Definitions and Assessment of the Anxiety Disorders

In this chapter, we consider the anxiety disorders as defined by the DSM-IV criteria including panic, phobias, and general anxiety. The major subtypes of anxiety include panic disorder (with or without agoraphobia), specific phobia, social phobia, and generalized anxiety disorder (GAD). Although obsessive -compulsive disorder and post-traumatic stress disorder are also included as anxiety disorders in the DSM-IV, they will not be included here due to differences in their prevalence rates and correlates. There are two additional subtypes of anxiety that are specific to youth separation anxiety disorder and overanxious disorder. The DSM-IV did not include the category of overanxious disorder because of the purportedly substantial degree of overlap with GAD. However, as described below, there is emerging evidence that overanxious disorder does indeed provide coverage of anxiety disorder in youth who do not meet criteria for GAD.

Disordered Fear And Anxiety

So, if individuals experience frequent, recurrent, unexpected panic attacks combined with concern about such attacks and worry about the implications of such attacks, then they are considered to be suffering from a panic disorder. Phobias, in contrast to panic attacks where the nosological focus is on the symptoms of fear or anxiety, are defined with respect to the avoided situations. So, social phobic people exhibit excessive and inappropriate fear of situations involving putative scrutiny by others or situations in which there is a perceived risk of embarrassment or humiliation. Specific phobias involve fear that is focused on specific, discrete stimuli such as small animals, heights, blood, receiving an injection, etc. The individual with the specific phobia recognises that the fear is excessive or unreasonable and avoids the fear-provoking stimulus. There is a considerable degree of lifetime co-morbidity between the anxiety disorders such that sufferers are likely to experience...

Psychopharmacological Treatments

Benzodiazepines remain an important class of medications for treatment of panic disorder, despite their replacement as first-line agents by antidepressants. In clinical practice, these medications can provide rapid relief of panic attacks, allowing symptom reduction while other treatments, such as antidepressants or psychotherapy, are being introduced. An important limitation to the use of benzodiazepines is their lack of impact on depression or other commonly coexisting psychiatric conditions, such as agoraphobia, specific phobias, or obsessive-compulsive disorder. Side effects include sedation, fatigue, and memory impairment. Although these medications carry a potential risk of abuse, the risk is felt to be overestimated in patients with anxiety disorders (Uhlenhuth, et al., 1989). Avoidance of these medications out of fear of abuse may be more problematic than the risk of abuse. If benzodiazepines are employed over an extended period of time, patients are at risk for recurrence of...

Course of Illness

A third of patients experiencing spontaneous symptom remission. The risk for relapse and recurrence of symptoms is also high for anxiety disorders. In a 12-year follow-up study of anxiety disorder patients, recurrence rates ranged from 58 of PD and GAD patients to 39 of SAD patients.8 Remission, if achieved with treatment, is most likely to occur within the first 2 years of an index episode.9 Similarly, the highest rates of relapse are seen within the same timeframe thus, many patients need ongoing maintenance treatment. Rates of remission and relapse do not appear to vary by gender 9 however, one study reported that women with PD without agoraphobia were three times more likely than men to experience a relapse of symptoms. Patients with anxiety disorders spend a significant portion of time being ill during a particular episode, ranging from 41 to 80 of the time.8 Expectedly, anxiety disorders are associated with impaired psychosocial functioning and a compromised quality of life.10...

Phobias

Phobias are usually defined as irrational fears of objects or situations. Simple phobias involve fear of, for example, snakes or spiders combined with an ability to see that there is no reason to be afraid. Agoraphobia is somewhat different and is characterised by fear of leaving the home or safe environment. Agoraphobia is highly co-morbid with panic problems and we have touched upon it briefly in the section on panic. Finally, social phobia involves anxiety about social situations and a fear of embarrassment. We argued at the beginning of this chapter that phobic problems, particularly specific phobias, are extremely common and that in our view it is a mistake to assume that, just because indivduals meet the majority of criteria for a clinical diagnosis of phobia, it means that they are pathological, abnormal, or disordered in any way. This issue of distinguishing normal fears from phobias is a factor in epidemiological studies which, nevertheless, reveal an average of about 6 per...

Anxiety Disorders

In a cross-national study of 10 independently conducted community surveys in 10 different countries (United States, Canada, Puerto Rico, France, West Germany, Italy, Lebanon, Taiwan, Korea, New Zealand), lifetime prevalence rates for DIS DSM-III panic disorder were found to range from 1.4 per 100 to 2.9 per 100 in Florence Italy with a much lower prevalence rate in Taiwan of 0.4 per 100 (Weissman et al., 1997). These findings underscore the relative consistence of panic disorder in its prevalence and distribution across diverse cultures. Women were found to have higher prevalence rates than males in all countries, and age of onset was found to be early to middle 20s (Weissman et al, 1997.) Consistent with previous epidemiologic studies, across all countries included in the study, panic disorder was found to be strongly associated with increased risk of major depression and agoraphobia.

Future Developments

A number of major epidemiologic studies have cross-sectionally examined the prevalence and nature of mood and anxiety disorders. Certain consistent findings have emerged, but the answers to major questions remain elusive. Although women have been found to consistently have higher rates of major depression and panic disorder, for example, no satisfactory scientific explanation has been found for this difference. Similarly, several studies have shown secular trends for increasing rates of depression, but no good understanding of this trend has yet been achieved. Substantial questions remain regarding the comorbidity between psychiatric disorders, such as the nature of the interaction between panic disorder and agoraphobia. The National Comorbidity Survey has addressed some of these comorbidity issues. Future epidemiologic studies will need to address questions regarding the nature, etiology, changing character, and interactions of mood and anxiety disorders. Considerable progress needs...

Emotional Disorders

Distortions or exaggerations of fear reactions are frequently experienced by child abuse survivors. Agoraphobia, a fear of open spaces, is common. Others are fear of driving and claustrophobia, a fear of entrapment in small spaces that may require an adult survivor to have a door or window open at all times.

Formulation

The following formulation was shared with the multidisciplinary team, who were struggling with Helena's continuing impulses to commit suicide and the problems of working towards discharge. They found it particularly difficult to cope with her constant talk of her voices and the urge to commit suicide, and the team was split into those who advocated for her, and those who had essentially lost patience. The meeting, which took place five sessions into the weekly therapy, served to increase tolerance and understanding, and so to reunite the team effort. In summary, I identified Helena's core beliefs as self-unacceptability and shame, reinforced by the rape experience. These led to assumptions about her worth being dependent on caring for others, and her survival dependent on others seeing her as worth taking care of. Because of these assumptions, role and relationships had been partially protective against the core beliefs for most of her life, but with the loss of both, the psychotic...