Different rates of improvement of different symptoms in combined pharmacological and behavioral treatment of agoraphobia

Psychoticism in patients with panic disorder with or without comorbid agoraphobia

OBJECTIVE

A few case-reports have previously described transient psychotic-like symptoms in non-psychotic patients with panic disorder (PD). We aimed to systematically explore whether PD patients without any current or past psychosis can be differentiated according to the severity of 'psychoticism' as a dimension, comprising clinical features such as psychotic-like experiences, increased social alienation, hostility and suspiciousness.

METHODS

Sample included 35 (female = 26) medication-free, non-psychotic patients consecutively referred from our Department's Outpatient Clinic for acute symptoms of DSM-5 PD with (PDA; N = 29) or without concurrent agoraphobia. Psychometric measures included the Symptom Checklist-90-Revised (SCL-90-R), Agoraphobic Cognitions Questionnaire (ACQ), Body Sensations Questionnaire (BSQ), and panic attacks during last 21 days PA-21d.

RESULTS

Multiple regression analysis (forward stepwise) revealed that, among all SCL-90-R subscales, the psychoticism-subscale was most significantly associated with panic-related beliefs included in the ACQ, while significant associations emerged between the paranoid ideation-subscale and the ACQ and BSQ measures. Moreover, significant correlations emerged between the SCL-90-R psychoticism-subscale and all three measures of PD symptoms (ACQ, BSQ, PA-21d) and between the SCL-90-R paranoid ideation-subscale and both the ACQ and BSQ.

CONCLUSIONS

This significant association between levels of psychoticism and severity of panic symptoms may reflect a more severe subtype of PD.

Specific phobias in older adults: characteristics and differential diagnosis

BACKGROUND

Differential diagnosis implies identifying shared and divergent characteristics between clinical states. Clinical work with older adults demands not only the knowledge of nosological features associated with differential diagnosis, but also recognition of idiosyncratic factors associated with this population. Several factors can interfere with an accurate diagnosis of specific phobia in older cohorts. The goal of this paper is to review criteria for specific phobia and its differential diagnosis with panic disorder, agoraphobia, post-traumatic stress disorder and obsessive compulsive disorder, while stressing the specific factors associated with aging.

METHODS

A literature search regarding specific phobia in older adults was carried out using PubMed. Relevant articles were selected and scanned for further pertinent references. In addition, relevant references related to differential diagnosis and assessment were used.

RESULTS

Etiologic factors, specificity of feared stimulus or situation, fear predictability and the nature of phobic situations are key points to be assessed when implementing a differential diagnosis of specific phobia.

CONCLUSIONS

First, age-related sensory impairments are common and interfere both with information processing and communication. Second, medical illnesses create symptoms that might cause, interfere with, or mimic anxiety. Third, cohort effects might result in underreporting, through the inability to communicate or recognize anxiety symptoms, misattributing them to physical conditions. Finally, diagnostic criteria and screening instruments were usually developed using younger samples and are therefore not adapted to the functional and behavioral characteristics of older samples.

Combined psychotherapy plus antidepressants for panic disorder with or without agoraphobia

BACKGROUND

Panic disorder can be treated with pharmacotherapy, psychotherapy or in combination, but the relative merits of combined therapy have not been well established.

OBJECTIVES

To review evidence concerning short- and long-term advantages and disadvantages of combined psychotherapy plus antidepressant treatment for panic disorder with or without agoraphobia, in comparison with either therapy alone.

SEARCH STRATEGY

The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTR-Studies and CCDANCTR-References) were searched on 11/10/2005, together with a complementary search of the Cochrane Central Register of Controlled Trials and MEDLINE, using the keywords antidepressant and panic. A reference search, SciSearch and personal contact with experts were carried out.

SELECTION CRITERIA

Two independent review authors identified randomised controlled trials comparing the combined therapy against either of the monotherapies among adult patients with panic disorder with or without agoraphobia.

DATA COLLECTION AND ANALYSIS

Two independent review authors extracted data using predefined data formats, including study quality indicators. The primary outcome was relative risk (RR) of "response" i.e. substantial overall improvement from baseline as defined by the original investigators. Secondary outcomes included standardised weighted mean differences in global severity, panic attack frequency, phobic avoidance, general anxiety, depression and social functioning and relative risks of overall dropouts and dropouts due to side effects.

MAIN RESULTS

We identified 23 randomised comparisons (representing 21 trials, 1709 patients), 21 of which involved behaviour or cognitive-behaviour therapies. In the acute phase treatment, the combined therapy was superior to antidepressant pharmacotherapy (RR 1.24, 95% confidence interval (CI) 1.02 to 1.52) or psychotherapy (RR 1.17, 95% CI 1.05 to 1.31). The combined therapy produced more dropouts due to side effects than psychotherapy (number needed to harm (NNH) around 26). After the acute phase treatment, as long as the drug was continued, the superiority of the combination over either monotherapy appeared to persist. After termination of the acute phase and continuation treatment, the combined therapy was more effective than pharmacotherapy alone (RR 1.61, 95% CI 1.23 to 2.11) and was as effective as psychotherapy (RR 0.96, 95% CI 0.79 to 1.16).

AUTHORS' CONCLUSIONS

Either combined therapy or psychotherapy alone may be chosen as first line treatment for panic disorder with or without agoraphobia, depending on patient preference.

Contribution of behavior therapy and biofeedback to laxative therapy in the treatment of pediatric encopresis

A model incorporating physiological, behavioral, and psychological parameters are presented to explain the maintenance and consequences of pediatric encopresis. It was hypothesized that the more comprehensive a treatment in addressing these parameters, the more efficacious it would be and the more children it would benefit. Eighty-seven children between the ages of 6 and 15 with the primary complaint of encopresis were randomly assigned to one of three treatments: (a) Intensive Medical Care (IMC), receiving enemas for disimpaction and laxatives to promote frequent bowel movements; (b) Enhanced Toilet Training (ETT), using reinforcement and scheduling to promote response to defecation urges and instruction and modeling to promote appropriate straining, along with laxatives and enemas; or (c) Biofeedback (BF), directed at relaxing the external anal sphincter during attempted defecation, along with toilet training, laxatives, and enemas. Three months following initiation of treatment, ETT and BF produced similar reductions in soiling/child (76% and 65%) that were superior (p's < .04) to IMC (21%). ETT significantly benefited more children than the other two treatments, employing fewer laxatives and fewer treatment sessions at a lower cost. Consistent with the presented model, reduction in soiling was associated with an increase in bowel movements in the toilet, reduction in parental prompting to use the toilet, and defecation pain. These results demonstrate that ETT should be used routinely with laxative therapy in the treatment of chronic encopresis.

Multiple chemical sensitivities--syndrome and solution

After describing two patients seen by the author, we define multiple chemical sensitivities and discuss the scope of the problem and the epidemiology. Although the incidence of multiple chemical sensitivities is not known, the demographics are similar to that of agoraphobia. The classical conditioning model is proposed as a useful description of multiple chemical sensitivities. The desensitization approach to the diagnosis and treatment is proposed. Results with three patients were encouraging and the approach seems worthy of further evaluation and refinement.

Depression, mastery and number of group sessions attended predict outcome of patients with panic and agoraphobia in a behavioural/medication program

From a list of 214 patients suffering from panic and agoraphobia and who had been treated with cognitive behaviour therapy, 30 patients who had very good outcomes and 32 who had poor outcomes were selected. The groups were selected by the nurse therapist and psychiatrist on the basis of personal knowledge of the patients. The distinction into good and poor outcome groups was confirmed by the results of a follow-up questionnaire completed by the patient. Of several clinical and demographic variables which had been hypothesized to be predictors of outcome, only depression, as measured by the Beck Depression Inventory, mastery, as measured by the Pearlin Mastery Scale and the number of group therapy sessions attended predicted outcome. Levels of depression and mastery might be clinically modifiable variables which affect the outcome of treatment for patients with panic and agoraphobia.

Effects of concurrent diazepam treatment on the outcome of exposure therapy in agoraphobia

In a study designed to evaluate the impact of benzodiazepine use on the outcome of behaviour therapy, 91, severe, chronic agoraphobics (46 BDZ users and 45 non-users) were randomly allocated on a double-blind basis to in vivo exposure with low-dose diazepam (ED) or placebo (EP). Drug doses were adjusted on the basis of weekly psychiatric assessments over weeks 1-4. Patients had 8 x 2 hr exposure sessions (weeks 5-12) and were then withdrawn from medication (weeks 13-16). Re-assessments were completed at weeks 4, 12 and 16, and follow-up assessments at approx 20, 46 and 72 weeks. In the analysis of the results, the clinical outcome was evaluated in relation to the therapeutic regime (ED vs EP) and prior BDZ use (users vs non-users). The results showed that the ED group had greater changes in anxiety than the EP group during the drug manipulation phases (anxiety increasing during BDZ withdrawal). There were no group differences in agoraphobic symptoms and no evidence that the outcome of the behavior therapy was significantly affected by concurrent BDZ treatment. There were significant improvements in agoraphobic symptoms over the treatment period, with no evidence for relapse of treatment gains on withdrawal from BDZ, nor for differential responses over the one year follow-up. Initial differences between users and non-users were less marked than expected, although there was a trend for more drop-outs among users across both ED and EP groups.

Behaviour therapy and benzodiazepines: allies or antagonists?

Behaviour therapy and benzodiazepines are directed towards common problems and are often used in combination. At present we know little about the beneficial or adverse interactions of these two treatments. This paper reviews the available literature and suggests that there are important theoretical and clinical issues to be resolved.

A 6-year follow-up of the effectiveness of respiratory retraining, in-situ isometric relaxation, and cognitive modification in the treatment of agoraphobia

A multiple baseline design across behaviors was used with 8 agoraphobics to evaluate respiratory retraining (RR), in-situ isometric relaxation (I IR), cognitive modification (CM), and a placebo treatment, imaginal rehearsal (IR). As hypothesized, RR significantly reduced psychophysiological accomplements of panic, I IR reduced anxiety, and CM reduced cognitive distress. The placebo treatment IR had a moderate but transitory effect. RR was the most effective component, and also reduced panic frequency, catastrophic cognitions. anticipatory anxiety, and behavioral avoidance. I IR also reduced panic frequency. The combined treatment components produced dramatic reductions in situational avoidance and anxiety, free-floating anxiety, panic frequency, and SCL-90R scores. All behavioral measures improved, as did work adjustment and marital satisfaction. These gains were maintained over the 6-year follow-up; however, 7 partial but temporary relapses occurred. The implications of these relapses for both theory and treatment are discussed, together with the role of exposure and anxiety management.