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Agoraphobia
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Nicola Toschi – One of the best experts on this subject based on the ideXlab platform.
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lower functional connectivity in vestibular limbic networks in individuals with subclinical Agoraphobia
Frontiers in Neurology, 2019Co-Authors: Iole Indovina, Nicola Toschi, Allegra Conti, Francesco Lacquaniti, Jeffrey P Staab, Luca PassamontiAbstract:Background: Agoraphobia was described in 1871 as a condition of fear-related alterations in spatial orientation and locomotor control triggered by places or situations that might cause a patient to panic and make feel trapped. In contemporary nosology, however, this original concept of Agoraphobia was split into two diagnostic entities, the modern anxiety disorder of Agoraphobia consisting solely of phobic/avoidant symptoms in public spaces and the recently defined vestibular disorder of persistent postural perceptual dizziness (PPPD) characterized by dizziness and unsteadiness exacerbated by visual motion stimuli. Previous neuroimaging studies found altered brain activity and connectivity in visual-vestibular networks of patients with PPPD versus healthy controls. Neuroticism and introversion, which predispose to both Agoraphobia and PPPD, influenced brain responses to vestibular and visual motion stimuli in patients with PPPD. Similar neuroimaging studies have not been undertaken in patients with currently defined Agoraphobia. Given their shared history and predisposing factors, we sought to test the hypotheses that individuals with agoraphobic symptoms have alterations in visual-vestibular networks similar to those of patients with PPPD and that these alterations are influenced by neuroticism and introversion. Methods: In the Human Connectome Project database, we matched 52 participants with sub-clinical Agoraphobia and 52 control subjects without agoraphobic symptoms on 19 demographic and psychological/psychiatric variables. We then employed a graph-theoretical framework to compare resting-state functional magnetic resonance images between groups. We evaluated the interactive effects of neuroticism and introversion on the brain signatures of Agoraphobia. Results: Individuals with subclinical Agoraphobia had lower global clustering, efficiency and transitivity relative to controls. They also had reduced connectivity metrics in two brain networks, one positioned to process incoming visual space-motion information, assess threat, and initiate/inhibit behavioral responses (visuospatial-emotional network) and one positioned to control and monitor locomotion (vestibular-navigational network). Introversion interacted with agoraphobic symptoms to reduce connectivity of the visuospatial-emotional network. This contrasted with previous findings of neuroticism-associated increased connectivity in a narrower visual-spatial-frontal network in patients with PPPD. Conclusion: Functional connectivity was decreased in two brain networks in subclinical Agoraphobia. These networks integrate visual vestibular and emotional response to guide movement in space.
Katja Petrowski – One of the best experts on this subject based on the ideXlab platform.
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Stress hormone response to the DEX-CRH test and its relation to psychotherapy outcome in panic disorder patients with and without Agoraphobia.
Translational Psychiatry, 2018Co-Authors: Susann Wichmann, Thomas Lorenz, Stefan R Bornstein, Katja PetrowskiAbstract:This study tested whether the hormonal stress response to the DEX–CRH test may be predictive of the psychotherapy success for panic disorder (PD). Thirty-four patients diagnosed either with Agoraphobia with PD or PD without Agoraphobia were subjected to cognitive behavioural therapy (CBT). Patients (pre-therapy) and healthy volunteers were exposed to the DEX–CRH test. Blood samples were taken for cortisol and adrenocorticotropic hormone (ACTH) assessment. Established panic-specific questionnaires were handed out for the pre-therapy and post-therapy evaluation of disease severity (with reference to panic beliefs and agoraphobic cognitions, fear of bodily sensations, agoraphobic avoidance behaviour). Repeated measures ANCOVA were conducted for the analysis of the pre-therapy hormonal response, and Pearson’s correlation analysis to test for associations with the psychotherapy outcome. Data analyses revealed large effect sizes for CBT in the clinical measures (η2 ≥ 0.321), main effects of time for cortisol and ACTH with no differences between both groups, and significant associations between cortisol release and agoraphobic cognitions for the patients. PD diagnosis had no impact on the hormonal response. However, those patients with higher cortisol release showed less improvement after CBT (significantly for agoraphobic cognitions). Clinical implications of these findings are the prediction of the therapy success from a potential endocrine correlate whose persistency (if assessed repeatedly) during the treatment may predict (non-)response to the current treatment, possibly representing a decision support for a change in treatment to avoid the continuation of an inefficient treatment.
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Effects of the cortisol stress response on the psychotherapy outcome of panic disorder patients.
Psychoneuroendocrinology, 2016Co-Authors: Susann Wichmann, Clemens Kirschbaum, Thomas Lorenz, Katja PetrowskiAbstract:Abstract Background A proportion of patients with panic disorder (PD) fail to show a remission after psychotherapy. Biological correlates of psychotherapy non-response have rarely been described in the literature. The aim of the present study was to research the relationship between the cortisol stress response and the psychotherapy outcome in PD patients. Methods Twenty-eight PD patients (20 females, mean age ± SD: 35.71 ± 13.18) seeking psychological treatment for PD and n = 32 age- and sex-matched healthy control participants (21 females, aged 34.66 ± 12.07) participated in this study. The patients underwent five weeks of cognitive behavioural therapy (CBT). Within the first two weeks of the CBT, both study groups were confronted with the Trier Social Stress Test (TSST). Blood sampling for cortisol and adrenocorticotropic hormone (ACTH) evaluation as well as fear-rating (Visual Analogue Scale; Primary Appraisal and Secondary Appraisal Questionnaire, PASA) accompanied the TSST. The global severity of PD (Panic & Agoraphobia Scale; PAS), agoraphobic cognitions (Agoraphobic Cognitions Questionnaire; ACQ), fear of bodily sensations (Bodily Sensations Questionnaire; BSQ), agoraphobic avoidance (Mobility Inventory; MI), and depressiveness (Beck DeprDepression Inventory; BDI) were assessed before and after the CBT (except the BDI). Results The statistical analysis revealed significant main effects of time for cortisol and the ACTH concentration in response to the TSST, independently of the study group. 42.9% of the PD patients and 65.6% of the healthy control participants showed a cortisol stress response to the TSST ≥ 55.2 nmol/l (descriptive finding). The data showed a significant inverse association of the TSST cortisol stress response with the MI total score when accompanied. Further, a significant association of the PASA subjective level of fear and the BSQ as well as a trend for an association of the PASA with the ACQ were observed. Conclusion Consistent with prior research, we could replicate findings of decreased cortisol concentrations in the PD patients in comparison to the healthy control participants. Furthermore, our findings agree with previous data showing an association of the attenuated cortisol stress response with the psychotherapy non-response. In the present sample, those patients with the lowest cortisol concentrations showed the least improvement in agoraphobic avoidance after psychotherapy. The patients with the highest level of fear showed the most improvement in fear of bodily sensations. Study limitations as well as implications for future studies will be discussed.
Susann Wichmann – One of the best experts on this subject based on the ideXlab platform.
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Stress hormone response to the DEX-CRH test and its relation to psychotherapy outcome in panic disorder patients with and without Agoraphobia.
Translational Psychiatry, 2018Co-Authors: Susann Wichmann, Thomas Lorenz, Stefan R Bornstein, Katja PetrowskiAbstract:This study tested whether the hormonal stress response to the DEX–CRH test may be predictive of the psychotherapy success for panic disorder (PD). Thirty-four patients diagnosed either with Agoraphobia with PD or PD without Agoraphobia were subjected to cognitive behavioural therapy (CBT). Patients (pre-therapy) and healthy volunteers were exposed to the DEX–CRH test. Blood samples were taken for cortisol and adrenocorticotropic hormone (ACTH) assessment. Established panic-specific questionnaires were handed out for the pre-therapy and post-therapy evaluation of disease severity (with reference to panic beliefs and agoraphobic cognitions, fear of bodily sensations, agoraphobic avoidance behaviour). Repeated measures ANCOVA were conducted for the analysis of the pre-therapy hormonal response, and Pearson’s correlation analysis to test for associations with the psychotherapy outcome. Data analyses revealed large effect sizes for CBT in the clinical measures (η2 ≥ 0.321), main effects of time for cortisol and ACTH with no differences between both groups, and significant associations between cortisol release and agoraphobic cognitions for the patients. PD diagnosis had no impact on the hormonal response. However, those patients with higher cortisol release showed less improvement after CBT (significantly for agoraphobic cognitions). Clinical implications of these findings are the prediction of the therapy success from a potential endocrine correlate whose persistency (if assessed repeatedly) during the treatment may predict (non-)response to the current treatment, possibly representing a decision support for a change in treatment to avoid the continuation of an inefficient treatment.
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Effects of the cortisol stress response on the psychotherapy outcome of panic disorder patients.
Psychoneuroendocrinology, 2016Co-Authors: Susann Wichmann, Clemens Kirschbaum, Thomas Lorenz, Katja PetrowskiAbstract:Abstract Background A proportion of patients with panic disorder (PD) fail to show a remission after psychotherapy. Biological correlates of psychotherapy non-response have rarely been described in the literature. The aim of the present study was to research the relationship between the cortisol stress response and the psychotherapy outcome in PD patients. Methods Twenty-eight PD patients (20 females, mean age ± SD: 35.71 ± 13.18) seeking psychological treatment for PD and n = 32 age- and sex-matched healthy control participants (21 females, aged 34.66 ± 12.07) participated in this study. The patients underwent five weeks of cognitive behavioural therapy (CBT). Within the first two weeks of the CBT, both study groups were confronted with the Trier Social Stress Test (TSST). Blood sampling for cortisol and adrenocorticotropic hormone (ACTH) evaluation as well as fear-rating (Visual Analogue Scale; Primary Appraisal and Secondary Appraisal Questionnaire, PASA) accompanied the TSST. The global severity of PD (Panic & Agoraphobia Scale; PAS), agoraphobic cognitions (Agoraphobic Cognitions Questionnaire; ACQ), fear of bodily sensations (Bodily Sensations Questionnaire; BSQ), agoraphobic avoidance (Mobility Inventory; MI), and depressiveness (Beck Depression Inventory; BDI) were assessed before and after the CBT (except the BDI). Results The statistical analysis revealed significant main effects of time for cortisol and the ACTH concentration in response to the TSST, independently of the study group. 42.9% of the PD patients and 65.6% of the healthy control participants showed a cortisol stress response to the TSST ≥ 55.2 nmol/l (descriptive finding). The data showed a significant inverse association of the TSST cortisol stress response with the MI total score when accompanied. Further, a significant association of the PASA subjective level of fear and the BSQ as well as a trend for an association of the PASA with the ACQ were observed. Conclusion Consistent with prior research, we could replicate findings of decreased cortisol concentrations in the PD patients in comparison to the healthy control participants. Furthermore, our findings agree with previous data showing an association of the attenuated cortisol stress response with the psychotherapy non-response. In the present sample, those patients with the lowest cortisol concentrations showed the least improvement in agoraphobic avoidance after psychotherapy. The patients with the highest level of fear showed the most improvement in fear of bodily sensations. Study limitations as well as implications for future studies will be discussed.
Georg W Alpers – One of the best experts on this subject based on the ideXlab platform.
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timing matters change depends on the stage of treatment in cognitive behavioral therapy for panic disorder with Agoraphobia
Journal of Consulting and Clinical Psychology, 2014Co-Authors: Andrew T Gloster, Georg W Alpers, Alfons O Hamm, Jens Klotsche, Alexander L Gerlach, Andreas Strohle, Siegried Gauggel, Tilo Kircher, Jurgen Deckert, Hans Ullrich WittchenAbstract:The mechanisms of action underlying treatment are inadequately understood. This study examined 5 variables implicated in the treatment of panic disorder with Agoraphobia (PD/AG): catastrophic agoraphobic cognitions, anxiety about bodily sensations, agoraphobic avoidance, anxiety sensitivity, and psychological flexibility. The relative importance of these process variables was examined across treatment phases: (a) psychoeducation/interoceptive exposure, (b) in situ exposure, and (c) generalization/follow-up.; Data came from a randomized controlled trial of cognitive behavioral therapy for PD/AG (n = 301). Outcomes were the Panic and Agoraphobia Scale (Bandelow, 1995) and functioning as measured in the Clinical Global Impression scale (Guy, 1976). The effect of process variables on subsequent change in outcome variables was calculated using bivariate latent difference score modeling. Change in panic symptomatology was preceded by catastrophic appraisal and agoraphobic avoidance across all phases of treatment, by anxiety sensitivity during generalization/follow-up, and by psychological flexibility during exposure in situ. Change in functioning was preceded by agoraphobic avoidance and psychological flexibility across all phases of treatment, by fear of bodily symptoms during generalization/follow-up, and by anxiety sensitivity during exposure.; The effects of process variables on outcomes differ across treatment phases and outcomes (i.e., symptomatology vs. functioning). Agoraphobic avoidance and psychological flexibility should be investigated and therapeutically targeted in addition to cognitive variables.
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Psychological treatment for panic disorder with Agoraphobia: A randomized controlled trial to examine the role of therapist-guided exposure in situ in CBT
Journal of Consulting and Clinical Psychology, 2011Co-Authors: Andrew T Gloster, Hans Ullrich Wittchen, Franziska Einsle, Thomas Lang, Sylvia Helbig-lang, Thomas Fydrich, Lydia Fehm, Alfons O Hamm, Jan Richter, Georg W AlpersAbstract:Objective: Cognitive– behavioral therapy (CBT) is a first-line treatment for panic disorder with Agoraphobia (PD/AG). Nevertheless, an understanding of its mechanisms and particularly the role of therapist-guided exposure is lacking. This study was aimed to evaluate whether therapist-guided exposure in situ is associated with more pervasive and long-lasting effects than therapist-prescribed exposure in situ. Method: A multicenter randomized controlled trial, in which 369 PD/AG patients were treated and followed up for 6 months. Patients were randomized to 2 manual-based variants of CBT (Tϩ/TϪ) or a wait-list control group (WL; n ϭ 68) and were treated twice weekly for 12 sessions. CBT variants were identical in content, structure, and length, except for implementation of exposure in situ: In the Tϩ variant (n ϭ 163), therapists planned and supervised exposure in situ exercises outside the therapy room; in the TϪ group (n ϭ 138), therapists planned and discussed patients’ in situ exposure exercises but did not accompany them. Primary outcome measures were (a) Hamilton Anxiety Scale, (b) Clinical Global Impression, (c) number of panic attacks, and (d) agoraphobic avoidance (Mobility Inventory). Results: For Tϩ and TϪ compared with WL, all outcome measures improved significantly with large effect sizes from baseline to post (range ϭ Ϫ0.5 to Ϫ2.5) and from post to follow-up (range ϭ Ϫ0.02 to Ϫ1.0). Tϩ improved more than TϪ on the Clinical Global Impression and Mobility Inventory at post and follow-up and had greater reduction in panic attacks during the follow-up period. Reduction in agoraphobic avoidance accelerated after exposure was introduced. A dose–response relation was found for Time ϫ Frequency of Exposure and reduction in agoraphobic avoidance. Conclusions: Therapist-guided exposure is more effective for agoraphobic avoidance, overall functioning, and panic attacks in the follow-up period than is CBT without therapist-guided exposure. Therapist-guided exposure promotes additional therapeutic improvement—possibly mediated by increased physical engagement in feared situa-tions— beyond the effects of a CBT treatment in which exposure is simply instructed.
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Evidence-based psychotherapy of panic disorder with or without Agoraphobia
Psychotherapeut, 2011Co-Authors: Georg W Alpers, Alexander L Gerlach, Nina HeinrichsAbstract:From the evidence reported in the recent guidelines [Heinrichs et al. (2009) Evidenzbasierte Leitlinie zur Psychotherapie der Panikstorung mit und ohne Agoraphobie. Hogrefe, Gottingen] the following conclusions can be drawn with respect to the treatment of panic disorder with or without Agoraphobia, as well as for Agoraphobia without panic disorder: Every psychotherapy should be preceded by suitable diagnostics and a case formulation. The effectiveness of every psychotherapy should be evaluated with well established measures. For the treatment of panic disorder without Agoraphobia, cognitive behavioral treatment (CBT) and applied relaxation have been shown to be effective (evidence grade 1). For panic disorder with Agoraphobia, CBT, combination treatment (CBT plus medication), as well as panic-focused psychodynamic psychotherapy in the outpatient setting have shown short-term effectiveness (evidence grade 1). Longer lasting effects have been documented for CBT (evidence grade 1). For Agoraphobia without panic disorder, CBT with a focus on situational exposure can be recommended (evidence grade 1).
Luca Passamonti – One of the best experts on this subject based on the ideXlab platform.
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lower functional connectivity in vestibular limbic networks in individuals with subclinical Agoraphobia
Frontiers in Neurology, 2019Co-Authors: Iole Indovina, Nicola Toschi, Allegra Conti, Francesco Lacquaniti, Jeffrey P Staab, Luca PassamontiAbstract:Background: Agoraphobia was described in 1871 as a condition of fear-related alterations in spatial orientation and locomotor control triggered by places or situations that might cause a patient to panic and make feel trapped. In contemporary nosology, however, this original concept of Agoraphobia was split into two diagnostic entities, the modern anxiety disorder of Agoraphobia consisting solely of phobic/avoidant symptoms in public spaces and the recently defined vestibular disorder of persistent postural perceptual dizziness (PPPD) characterized by dizziness and unsteadiness exacerbated by visual motion stimuli. Previous neuroimaging studies found altered brain activity and connectivity in visual-vestibular networks of patients with PPPD versus healthy controls. Neuroticism and introversion, which predispose to both Agoraphobia and PPPD, influenced brain responses to vestibular and visual motion stimuli in patients with PPPD. Similar neuroimaging studies have not been undertaken in patients with currently defined Agoraphobia. Given their shared history and predisposing factors, we sought to test the hypotheses that individuals with agoraphobic symptoms have alterations in visual-vestibular networks similar to those of patients with PPPD and that these alterations are influenced by neuroticism and introversion. Methods: In the Human Connectome Project database, we matched 52 participants with sub-clinical Agoraphobia and 52 control subjects without agoraphobic symptoms on 19 demographic and psychological/psychiatric variables. We then employed a graph-theoretical framework to compare resting-state functional magnetic resonance images between groups. We evaluated the interactive effects of neuroticism and introversion on the brain signatures of Agoraphobia. Results: Individuals with subclinical Agoraphobia had lower global clustering, efficiency and transitivity relative to controls. They also had reduced connectivity metrics in two brain networks, one positioned to process incoming visual space-motion information, assess threat, and initiate/inhibit behavioral responses (visuospatial-emotional network) and one positioned to control and monitor locomotion (vestibular-navigational network). Introversion interacted with agoraphobic symptoms to reduce connectivity of the visuospatial-emotional network. This contrasted with previous findings of neuroticism-associated increased connectivity in a narrower visual-spatial-frontal network in patients with PPPD. Conclusion: Functional connectivity was decreased in two brain networks in subclinical Agoraphobia. These networks integrate visual vestibular and emotional response to guide movement in space.