Hanneke Rijken

Comorbidity among the anxiety disorders

This paper reports on the diagnoses of 120 consecutive referrals to an outpatient research program on anxiety disorders. Patients were diagnosed according to DSM-III-R criteria using a structured interview. Patterns of comorbidity among disorders were examined using two diagnostic procedures. One procedure was based on the temporal sequence of disorders, the other on the relative interference with patient functioning. The two procedures rendered different findings, with simple and social phobia more often assigned as primary diagnosis in the temporal procedure, and panic disorder with agoraphobia most often assigned as primary interference diagnosis. Comparison of comorbidity patterns for panic disorders patients with findings from an American sample revealed no significant differences. Findings from this study are discussed in terms of their implications for assessment and research. It is suggested that the diagnostic criteria for simple phobia are somewhat problematic.

Breathing retraining, exposure and a combination of both, in the treatment of panic disorder with agoraphobia

The present study investigates the differential effectiveness of three treatment packages for agoraphobia. Patients suffering from panic disorder with agoraphobia (DSM-III-R) received one of three treatments: Breathing Retraining with Cognitive Restructuring (BRCR), graded self-exposure in vivo (EXP), or a combination of BRCR and EXP. Treatments consisted of 8 sessions. Assessment consisted of self-report measures for panic, phobic anxiety and avoidance, depression, general anxiety, somatic complaints and fear of body sensations, and of two respiratory measures (respiratory rate and alveolar pCO2). The treatments resulted in a reduction in symptomatology on all self-report measures, except panic frequency, and in a decrease in respiratory rate. There was no evidence for a differential efficacy for any of the treatments on any of the variables. Contrary to expectation, and at odds with findings from earlier studies, BRCR had no significant effect on panic frequency. A detailed comparison of sample characteristics of patients in our study and previous studies, did not yield insight into possible causes for the failure to replicate earlier results. The limited effectiveness of breathing retraining in reducing panic, as observed in the present study, leads us to conclude that the role of hyperventilation in panic is less important than previously thought.

A comparison of ‘flooding’ and ‘successive approximation’ in the treatment of agoraphobia ☆

Abstract Flooding (in the imagination and in vivo ) and successive approximation were compared in a cross-over design with 14 agoraphobic patients. Assessments were made at the beginning of the treatment, at the cross-over, at the end of the treatment and at the follow-up 3 months later. The assessments were made by the therapist ( in vivo measurement) and by the client (phobic anxiety scale; phobic avoidance scale; FSS; MAS; I-E scale and a depression inventory). At the time of the pre-test and the posttest, an independent external judge scored the clients on the following items : anxious mood, specific phobias, obsessive compulsive symptoms, depersonalization and depressed mood. Both methods of treatment resulted in a significant improvement on the in vivo measurements, phobic anxiety scale, phobic avoidance scale and FSS. Successive approximation also led to a significant decrease on the MAS and the I-E scale. The only significant difference between the two methods was shown by the phobic anxiety scale, the mean of the flooding group being significantly higher.

THE HYPERVENTILATION SYNDROME IN PANIC DISORDER, AGORAPHOBIA AND GENERALIZED ANXIETY DISORDER*

The symptom complex of panic disorder and generalized anxiety disorder suggests an etiological role for hyperventilation. The present study investigates the overlap between DSM-III-R panic disorder, panic disorder with agoraphobia and generalized anxiety disorder with hyperventilation syndrome (HVS). The anxiety disorder diagnoses were based on a structured interview, and HVS syndrome (HVS). The anxiety disorder diagnoses were based on a structured interview, and HVS determined by the so-called hyperventilation provocation test (a brief period of voluntary hyperventilation with recognition of symptoms). The overlap rates with HVS were: 48% for panic disorder, 83% for panic disorder with agoraphobia and 82% for generalized anxiety disorder. However, a pilot study on transcutaneous monitoring of carbon dioxide tension leads us to question the validity of the voluntary hyperventilation method that we used to determine HVS-status. It is unclear whether hyperventilation plays an important role in panic and general anxiety, as our overlap findings suggest. For patients who recognize the symptoms induced by voluntary hyperventilation, the hyperventilation provocation procedure provides a therapeutic means of exposure to feared bodily sensations.

Clinical Aspects and Treatment of the Hyperventilation Syndrome

The Hyperventilation Syndrome is a common disorder and clinical psychologists will be regularly confronted with it, because the syndrome is closely interwoven with psychological problems. The literature is reviewed with respect to pathophysiology of the complaints, aetiology of the syndrome and treatment. A new developmental model is presented and directions for future research are proposed.

A follow-up study on short-term treatment of agoraphobia

The differential effectiveness of three treatment packages for agoraphobia was tested. Patients received one of three short-term treatments: Breathing Retraining and Cognitive Restructuring, graded Self-Exposure in vivo, or a combination of both. No differential effects were found between the treatment conditions at posttest and at an 18 months follow-up. Improvement at follow-up assessment was associated with whether patients had further treatment during the follow-up period. No relationship was found between further improvement and demographic variables, pre- and posttest scores on psychological questionnaires or the use of medication at follow-up. Implications of these findings are examined.

The role of hyperventilation in panic disorder: a response to Ley (1991)

Ley (Behaviour Research and Therapy, 29, 301-304, 1991) provided a reinterpretation of experimental findings on the efficacy of breathing retraining plus cognitive restructuring in reducing the symptomatology of patients with panic disorder with agoraphobia which were presented in a 1989 article in this journal. On the basis of his reinterpretation, they concluded that our findings supported the central role of hyperventilation in panic attacks. Leys arguments are discussed and we conclude that his reinterpretation provides new arguments against a hyperventilation theory of panic. Furthermore, recent evidence from empirical studies does not support a central role for hyperventilation in panic attacks.