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Therapy for Anxiety and Panic Disorders
10 CEUs I feel like I'm dying!- Treating Panic Attacks

Section 19
Panic Attacks and the Development of Agoraphobia

Question 19 | Test | Table of Contents | Anxiety CEU Courses
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Panic attacks and the development of agoraphobia appear to have a clear linkage: uncontrolled panic attacks often lead to the rapid development of phobic avoidance. Although some evidence suggests that phobic avoidance begins prior to the onset of panic attacks (1, 2), in most cases phobic avoidance develops after the onset of panic attacks.

The lifetime prevalence rate of panic attacks has been reported as 5.6–9% (3–5), but only a minority develop panic disorder, and even fewer develop agoraphobia. This raises the question of what factors increase the risk for the development of agoraphobia among patients with panic disorder. Some research has been conducted to examine the relationship between panic attacks and the development of phobic avoidance. Starcevic et al. (6) identified severity of panic attacks along with a variety of anticipatory fears about the consequences of the attacks as important factors for the development of agoraphobia in panic patients. Some studies have found that earlier age at onset (7, 8) or longer duration of illness (7, 9) and particular panic symptoms (e.g. personalization, chest pain, dyspnea and trembling) (10), are related to the development of phobic avoidance. Others have addressed the importance of cognitive or concern factors on the course of panic disorder (11, 12). Mavissakalian and Hamann (13) explored the relationship between panic attacks, phobic anxiety and anticipatory anxiety, and found that the impact of panic attacks on phobic and anticipatory anxiety was of particular significance. Telch et al. (14) observed that anticipated panic emerged as the most potent correlate of agoraphobic avoidance. Thus, although several factors, particularly attitudinal, are thought to be implicated in the development of agoraphobia, the findings are inconclusive.

Perfectionism has played a prominent role in theorizing about obsessive–compulsive disorder (OCD). Clinical findings suggest a link between perfectionism and OCD, but some researchers (15, 16) have found that perfectionism is not specific to one disorder, but a feature of many forms of psychopathology. Perfectionism has been identified as a predisposing factor in various disorders, including depression (17), OCD (18, 19), social phobia (20) and eating disorder (21).

Perfectionism has been studied in patients with panic disorder. Frost and Gross (18) reported that significant higher perfectionism in panic/agoraphobia patients compared with normal controls (NC) and no significant difference from OCD patients in this regard. Antony et al. (22) studied 44 panic disorder patients with or without agoraphobia, 45 with OCD, 70 with social phobia and 15 with specific phobia, as well as 49 non-clinical volunteers to explore the role of perfectionism across anxiety disorders, and reported that perfectionism was a feature of panic disorder. Matsunaga et al. (19) reported that panic disorder patients with or without agoraphobia scored similarly to OCD patients in Multidimensional Perfectionism Scale (FMPS) (23) scores. These studies have confirmed high levels of perfectionism in panic disorder patients with and without agoraphobia, but they did not extensively evaluate the possible differences between the latter two groups.

Iketani et al. (24) recently examined perfectionism in panic disorder patients with and without agoraphobia, using the FMPS (23). We found significantly higher score on FMPS subscales and total score in panic disorder patients with agoraphobia (PDA) compared with those without agoraphobia (PD). In stepwise logistic regression analyses, FMPS total score was identified as a robust correlate of agoraphobia in patients with panic disorder. Thus, perfectionistic beliefs and tendencies may be involved in the development and maintenance of agoraphobia in patients with panic

Why do panic/agoraphobic patients show perfectionistic tendencies? Is it a pre-existing risk factor or an effect of having a panic disorder or agoraphobia? Approximately 40–70% of panic disorder patients meet the criteria for a personality disorder (25, 26), particularly cluster C personality disorder, such as avoidant, dependent and obsessive– compulsive personality disorder (OCPD). PDA tend to display a higher prevalence of personality disorder diagnoses than do patients without agoraphobia (27). Perfectionism is one of the diagnostic criteria for OCPD. We therefore reasoned that it would be useful to examine the comorbidity of OCPD and other personality disorders in patients with panic disorder in order to better understand their relationship.

Relationship between perfectionism and the comorbidity of personality disorders
In this study, stepwise regression analyses revealed that the comorbidity of cluster C personality disorders, in particular, avoidant and OCPD, were the most robust indicators of perfectionism in patients with panic disorder.

The diagnostic criteria of OCPD includes perfectionism, Frost and Gross (18) found that measures of compulsive-hoarding were not related to overall measures of OCPD, but were correlated with certain OCPD symptoms, specifically, perfectionism. In DSM-IV (29) criteria of OCPD, perfectionism is characterized as follows ‘the perfectionism and self-imposed high standards of performance cause significant dysfunction and distress in these individuals. They may become so involved in making every detail of a project absolutely perfect that the project is never finished’.

Individuals with this disorder show rigidity and stubbornness, and are concerned about having things done their own way. These behavioral characteristics are very alike to those of panic/ agoraphobic patients, who show avoidance against unpredictable and uncontrollable events, while setting extremely high standards to prevent panic attacks and resist changing their phobic avoidant behavior.

As previously found by some researchers (42, 43), avoidant personality trait or disorder is manifest in panic disorder patients with or without agoraphobia. Avoidant personality disorder is essentially characterized by a pervasive pattern of social inhibition and hypersensitivity to negative evaluation. Individuals with avoidant personality disorder
avoid social situations because of fear of criticism, disapproval, or rejection and have low self-esteem. They are prone to overvalue the potential danger of ordinary situations and therefore set high standards to ensure their need for certainty and security, and consequently restrict their lifestyle. These behavioral patterns are very similar to those of PDA, who have a stronger tendency than PD patients to perceive failure (i.e. a panic attack or the need to escape if one were to occur as intolerable). Therefore, PDA patients may set excessively high standards to avoid panic attacks or situations, which they believe may lead to panic attacks. Moreover, PDA patients may have a stronger tendency to doubt whether they can behave adequately if a panic attack happens, and so they choose to stay in a safety zone to prevent panic attacks and avoid fearful situations completely. Thus, these behavior and beliefs in panic/agoraphobic patients may derive from these temperamental characteristics of avoidant personality disorder. Taken together, perfectionistic beliefs and behavior may be attributable to the comorbidity of avoidant disorder or OCPD in PDA.

A number of limitations in our study must be considered in interpreting our results. We should consider whether these personality traits reflect a premorbid personality disorder or arise from the effect of having panic disorder or enduring lifestyle changes induced by agoraphobia. Several researchers reported that some personality traits, such as dependent, might improve with treatment, but other traits, such as histrionic and avoidant, might be more resistant to change even after recovery of panic disorder (44). Further, prospective studies to evaluate the comorbidity of personality disorders before and after onset of panic Iketani et al. disorder and agoraphobia or a longitudinal study that evaluates patients before and after recovering from panic disorder and agoraphobia, will be needed to confirm our results.

In conclusion, we found significantly higher levels of perfectionism in panic/agoraphobic patients than PD. PDA also had a significantly higher prevalence of personality disorders than PD, in particular avoidant, obsessive–compulsive
and paranoid personality disorders. With stepwise regression analyses, avoidant disorder and OCPD emerged as salient indicators of perfectionism in patients with panic disorder. Taking these findings into account, perfectionism in panic/agoraphobic patients may be attributable, at least in part, to the comorbidity of avoidant disorder and OCPD. We infer from these findings that it may be useful to take comorbidity of avoidant disorder and OCPD into account when designing an effective treatment plan because these personality disorders may play a role in the onset or maintenance of agoraphobia. Further research is required to investigate whether or not there is a functional relationship between perfectionism and comorbidity with avoidant disorder and OCPD. Our results suggest that perfectionism in panic disorder patients may be more common in those with comorbid personality disorders, and may be an important target for preventive and therapeutic efforts.
-Iketani, T., Kiriike, N., Stein, M. B., Nagao, K., Nagata, T., Minamikawa, N., Fukuhara, H. (2002). Relationship between perfectionism, personality disorders and agoraphobia in patients with panic disorder. Acta Psychiatrica Scandinavica, 106(3), 171-178. doi:10.1034/j.1600-0447.2002.02361.x
The box directly below contains references for the above article.


The Development of Agoraphobia is Associated with the Symptoms
and Location of a Patient's First Panic Attack

- Hara, N., Nishimura, Y., Yokoyama, C., Inoue, K., Nishida, A., Tanii, H., . . . Okazaki, Y. (2012). The development of agoraphobia is associated with the symptoms and location of a patients first panic attack. BioPsychoSocial Medicine, 6(12), 1-8. doi:10.1186/1751-0759-6-12

Personal Reflection Exercise #5
The preceding section contained information about panic attacks and the development of agoraphobia.  Write three case study examples regarding how you might use the content of this section in your practice.

What are the behavioral characteristics of panic/agoraphobic clients?  Record the letter of the correct answer the Test.

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