Early Treatment Studies
The first psychological treatment studies for agoraphobia centered on graduated invivo exposure alone to the feared situation (Hand, LaMontagne and Marks, 1974). That is, the agoraphobic patients were instructed to reenter the situations they had been avoiding.
Agoraphobia is a secondary complication of panic attacks. The agoraphobic patient utilizes escape and avoidance strategies to manage panic. They begin to live their life around panic, and restrictions in mobility can become severe. For example, in its most severe form, there is a fear of going out alone. Oftentimes, in Agoraphobia, there are less panic attacks than panic disorder and more restriction and fear of attacks. One of the major limitations with invivo exposure treatment is that the fear level can remain high while the patient remains in the feared situation. Then, the patient continues to wait to “get out” to obtain panic relief. In these cases, minimal improvement in reducing avoidance behavior occurs.
Early Diagnosis and Brief Intervention; A Prevention Model
I believe agoraphobic avoidance can be prevented with early diagnosis and brief intervention. For example, in 1992, Swinson and his associates studied “Brief Treatment of Emergency Room Patients with Panic Attacks.” Usually, Emergency Room Panic occurs at early onset and yields a ripe opportunity for prevention of the progression of panic disorder and secondary phobic complications. These researchers showed that emergency room panic patients, who were simply instructed to reenter the situation where they experienced their last attack and remain in the situation until the attack subsided, showed significant improvement. The control group, who were only given reassurance that they were fine physically, worsened in the area of agoraphobic avoidance.
Current Research and Status
Although invivo exposure is still considered important today, especially where there is significant avoidance behavior, current approaches target the panic attacks directly. A building body of scientific evidence supports Cognitive Behavioral Treatment (CBT) as a powerful treatment for panic disorder.
These treatments combine Cognitive therapy aimed at elimination of castastrophic thinking with interoceptive exposure (IE) to reduce the fear of the bodily sensations. In a now classic study, Dr David Barlow and his colleagues at the Center for Anxiety and Related Disorders (CARD) at Boston University, compared Cognitive Behavioral Treatment (CBT) with Xanax (alprazolam) in the treatment of panic disorder. The findings showed 87% of CBT patients were free of panic, post treatment, while 50% of the Xanax group were still encountering panic.
In my specialty panic practice in Boston (1983-2007), I routinely administered the Hopkins Symptom Checklist (HSCL-90-R) before panic disorder patients initiated panicLINK® Treatment and at selected points during and after the treatment was completed. The HSCL-90-R provided a consistent pretreatment profile of elevation on three of the nine clinical scales. The Classic triadic elevations occurred on Somatization (e.g., lump in the throat, nausea), Anxiety (e.g., the feeling that something bad is going to happen to you) and Phobic Anxiety (e.g., feeling fearful of going out alone).
In May 1995, I examined the pre- and post-panicLINK treatment HSCL-90-R profiles on a selected group of 16 very high medical utilizers. The mean number of treatment sessions was 6.5. Compared to the pretreatment profile, dramatic reductions occurred on all three elevated clinical scales following the completion of treatment. I have observed this same finding in thousands of panic patients in my clinical practice.
NIH Consensus Development Conference on Panic Disorder
In January 1993, Consumer Reports featured “Short-Term Psychotherapy; Relief Without Drugs.” The report stated that, “Late in 1991, cognitive-behavioral therapy was endorsed by an expert panel convened by the National Institutes of Health to evaluate treatments for panic disorder.”
The Consensus Statement (September 25-27, 1991 Volume 9, Number 2) indicated “Several different classes of treatment have been shown to be clinically effective, including cognitive and behavioral, pharmacologic, and a combination of the two.. Among the various psychotherapeutic approaches, combined treatments that include cognitive therapy in addition to other techniques appear to be most effective, especially in reducing panic attacks. Longer term follow up of theses interventions suggest a low relapse rate.”
Anthony and Swinson (2000) in their book entitled “Phobic Disorders and Panic in Adults: A Guide to Assessment and Treatment,” conclude:
“However, given the results of long-term studies, the first line treatment for Panic Disorder and Panic Disorder with Agoraphobia should be CBT. For patients, who require additional treatment, medication can be added. CBT fares better than medication long term because when you taper off the medication without CBT tools, higher relapse rates occur. Otto et al. (1992) has shown that CBT can actually help patients taper off medication and prevent the recurrence of panic attacks.”
Several studies by Clum and his associates (1993, 1995) have shown that self-help CBT manuals can be as effective as therapist-administered treatments for many panic disorder patients.