The Treatments for Panic Disorder with Agoraphobia - Essay Example

Running head: PANIC DISORDER WITH AGORAPHOBIA Recent Studies on the Treatments for Panic Disorder with Agoraphobia According to Medline Plus (2006), panic disorder with agoraphobia (PDA) is a mental disorder wherein the person’s anxiety attacks are linked to “fear of being in places where escape might be difficult or where help might be unavailable in case of a panic attack”. This life affecting illness is distressing, weakening and a big hindrance for a person to achieve his outmost capacity. The upside is that it is a treatable condition, unlike other mental disorders, wherein the treatments exists only to manage the recurring nature of the disease and not to reverse the condition. HelpGuide (2006) identifies the general treatments as “cognitive behavioral therapy, medication, or a combination of the two”. Little is known on the recent developments on the study of these existing treatments. This paper then will attempt to evaluate some recent studies or new investigations that researchers have come up with to gain knowledge on the nature of PDA and its treatments. National Institute of Mental Health says that there are approximately 2.4 million of American adults having panic disorder within the age group of 18 to 54 years. Which is “about 1.7 percent of people in this age group” and about one third of this population have agoraphobia (as cited in Helpguide, 2006). Symptoms of this disorder feature physical symptoms like shortness of breath, dizziness, palpitations, nausea or abdominal distress that are brought on by incidents that bring intense fear of being alone, dying and losing control in a public place. People with this particular panic disorder try to avoid or endure circumstances which they know they are not at eased with. Another indication is that they tend to become bound to their houses for long periods of time. Like other mental disorders, it is associated with many possible factors but the accurate cause of this disorder is yet to be known. One reason could be that physical symptoms of the anxiety attack of a panic disorder with agoraphobia coincide with symptoms of other medical conditions. Treatment of PDA usually comes with cognitive-behavior therapies like exposure therapy. It is a very effective way of treating the disorder because first and foremost it makes the patient understand and accept the nature of his situation. In a study done by Asbahr, De Araujo, De Barros-Neto, Ito, Marks, & Tess (2001), self exposure to interoceptive or internal phobia cues were studied in comparison to self exposure to external phobia cues. This study was conducted because exposure therapy to external phobic cues was known initially to be effective in treating people with PDA but there is no clear study on the efficiency of treating PDA by exposure to internal phobic cues. Comparisons of the effects of external, interoceptive and combined external and interoceptive self-exposure therapy on controlled subjects with PDA were studied. By random grouping, eighty out-patients diagnosed with PDA were grouped according to the exposure therapy they were to receive and to a control group (Asbahr et al., 2001). The subjects were assessed prior to the treatment. Each of them was given daily self-exposure homework aside from the seven sessions of their assigned self-exposure therapy in the duration of 10 weeks. Whereas the subjects in the control group were told that there is a possibility that their PDA symptoms would improve without treatment. The control group was to wait 10 weeks if they felt they still needed the treatment after that duration. They were however welcome to return if their symptoms worsened and they needed advice. After the duration of 10 weeks, the subjects were assessed not by their own therapists but by other professional assessors that were unaware of what specific therapies the subjects received. The subjects were also told not to divulge to the assessors what therapy they have undergone. Asbahr et al., (2001) were able to evaluate that in comparison to the control group, there was considerable improvement in the three self-exposure groups after the treatment and also after a 1-year follow up assessment. The researchers also found out that the three treatments were equally effective in treating the subjects because there was no significant difference in the outcome of the assessments. “Rates of improvement on main outcome measures averaged 60% at post-treatment and 77% at follow-up” (Ashbar et al., 2001). Similar to the real clinical settings, some subjects were also non-completers and were replaced during the duration of the research. Their reasons for not pushing through the treatments varied from inconvenience of attending, depression and lack of improvement which are also the same common reasons why patients cancel their treatments in the real setting. Since depression frequently occurs when one has panic disorder with or without agoraphobia, clinicians therefore recommend the use of various antidepressants to their patients. Two of these various antidepressants are Citalopram and Clomiparamine. “Citalopram is the most selective and one of the most potent SSRIs” (selective serotonin reuptake inhibitors) and “Clomiparamine is one of the most potent tricyclic antidepressants” (as cited in Koponen, Lehto, Leinonen, Lepola, Turtonen & Wade, 2000). Given their respective properties and abilities in curing PDA, these antidepressants were studied on their long-term effect on subjective phobic symptoms in patients with panic disorder by Koponen et al.,(2000). The 475 patients with panic disorder chosen for this study aged 18- 65 years old and had no depressive symptoms. They were then grouped randomly into a group that took “citalopram (10 to 15 mg per day; 20 to 30 mg per day; or 40 to 60 mg per day), clomipramine (60 to 90 mg per day)” and placebo as the control group (Koponen et al., 2000). Assessments were based on phobic symptoms defined by Phobia Scale and the Symptom Checklist’s (SCL- 90) phobia related factors. For eight weeks, the 475 patients were given their respective treatments and 279 patients chose to continue on to 10 more months, adding to 1 year of treatment. Based on the results of the subjective phobia of the patients after the first eight weeks of treatment, Koponen et al.,(2000) found out that citalopram and clomipramine were both effective in treating the patients in comparison to placebo with citalopram’s dosage of 20 to 30 mg per day the most effective dosage . However, in the continuation of the treatment, clomipramine did not produce a continuous effect on the patient and its effect was inconsistent in the long run. Citalopram, on the other hand, continued to lessen phobic symptoms until the end of the treatment period. Although all the treatment had considerable effects on the patients’ recuperation, Citalopram at 20 to 30 mg per day proved to be the most effective antidepressant for long-term treatments among the three medicines considered for the study. Another antidepressant called Imipramine used in treating PDA was studied for its long term effects. This time, the effects of discontinuing the intake of Imipramine on the patient’s possible relapse was studied by Mavissakalian and Perel (1999). For six months, 110 patients with PDA had an acute-phase open trial with imipramine with 2.25 mg/kg dosage per day. After that period, 56 subjects did not need continuation on the treatment because of their stable remission. Of these 56 subjects, 29 agreed to double-blind maintenance and the other 27 subjects discontinued the treatment but were assessed every 2 months for the whole year that followed. By using Mantex-Cox distribution statistic, with x2=10.47, P= 0.001, Mavissakalian and Perel (1999) were able to conclude that the maintenance treatment with 1 relapse and discontinuation subjects with 10 relapses had a significant difference in their survival curves. They were also able to conclude that a patient taking imipramine as maintenance had 92.5% lower risk of having a relapse than a patient with placebo. It was therefore proven with this study that it is more advisable to continue on the imipramine treatment after being diagnosed with remission, given the lesser risk of having a relapse while still on maintenance treatment compared to discontinuing the treatment. In an attempt to evaluate a psychodynamic psychotherapy for people with PDA, Aronson et al., (2001) conducted a brief open trial of manual psychodynamic psychotherapy for PDA patients. 21 patients aged 18- 50 years, diagnosed with panic disorder with or without agoraphobia were recruited to receive the psychodynamic psychotherapy. They took 24 sessions of Panic-Focused Psychodynamic Psychotherapy (PFPP) in 12 to 14 weeks with 2 sessions of therapy per week. Of the 21 patients subjected to the study, 16 experienced decrease on panic and agoraphobia. Those who completed the treatment that had depression also experienced remission in depression. One therapy completer experienced no response from the therapy because of his comorbid obsessive compulsive disorder. Four of the 21 patients were non-completers because they chose to drop-out of the treatment because they were not responding well to the therapy. Aronson et al.,(2001) says that the “patients were significantly impaired by panic and agoraphobia” prior to the study. Assessments were done based on measured outcome variables such as primary psychiatric symptoms, phobic sensitivity and overall quality of life. The recent studies reviewed in this paper only shows that it is important to do such research given that there are several treatment options for people with panic disorder with agoraphobia. Many have surmised that pharmacotherapy is advisable when it is done with cognitive-behavior therapy but studies on its efficiency are scarce. There are however numerous ongoing researches and research proposals on this assumption. In light of these studies and the other numerous studies that have taken place in the world of research on PDA treatments, their results will later help clinicians in determining the appropriate treatment for their patients. Reference Aronson, A. MD, Busch, F., MD, Goldman, H., MA, Leon, A.C., PhD, Milrod, B., MD, Richter, D., MD, Roiphe, J. MD, Rudden, M., MD, Shapiro, T., MD, Singer, M. MD, & Shear, M.K., MD (2001). A Pilot Open Trial of Brief Psychodynamic Psychotherapy for Panic Disorder. Journal of Psychotherapy Practice and Research. Retrieved 9 November 2006 from http://jppr.psychiatryonline.org/cgi/reprint/10/4/239. Asbahr, F.R., De Araujo, L.A., De Barros-Neto, T.P., Ito, L.M., Marks, I., & Tess, V.L.C. (2001). Self-exposure Therapy for Panic Disorder with Agoraphobia. Randomised Controlled Study of External v. Interoceptive Self-exposure. The British Journal of Psychiatry (2001) 178:331-336. Retrieved 7 November 2006 from http://bjp.rcpsych.org/cgi/reprint/178/4/331. Koponen, H., MD, PhD, Lehto, H. MSc, Leinonen, E., MD, PhD, Lepola, U., MD, PhD, Turtonen, J. MD, Wade, A., MD (2000). Citalopram Controls Phobic Symptoms in Patients with Panic Disorder: Randomized Controlled Trial. Revue de Psychiatrie et de Neuroscience Vol. 25 no. 1 2000. Retrieved 8 November 2006 from http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1407706&blobtype=pdf. Mavissakalian, M.R., MD, Perel, J.M., PhD (1999). Long-term Maintenance and Discontinuation of Imipramine Therapy in Panic Disorder with Agoraphobia. Archives of General Psychiatry. Retrieved 8 November 2006 from C:\Documents and Settings\ITOK\My Documents\Arch Gen Psychiatry -- Abstract Long-term Maintenance and Discontinuation of Imipramine Therapy in Panic Disorder With Agoraphobia, September 1999, Mavissakalian and Perel 56 (9) 821.htm Medline Plus. (2006). Panic Disorder with Agoraphobia. Medline Plus Medical Encyclopedia. Retrieved 7, November 2006 from http://www.nlm.nih.gov/medlineplus/ency/article/000923.htm Read More