Orientador: Albina Robrigues Torres / Banca: Ricardo Torresan / Banca: Jair Sucro / Banca: Ana Teresa de Abreu Ramos Cerqueira / Resumo: Introdução: Os transtornos psiquiátricos são os principais fatores de risco para comportamentos suicidas ou "suicidalidade", mas são relativamente escassos os estudos sobre este tema com portadores de transtornos de ansiedade em geral e transtorno de pânico (TP) em particular. A maioria dos pacientes com TP que procura tratamento apresenta agorafobia associada. Pesquisas sobre suicidalidade em pacientes com TP ainda são poucas e inconclusivas, não havendo estudos nacionais publicados sobre o tema. Objetivos: Este estudo objetivou estimar a prevalência de vários comportamentos suicidas na vida (achar que não vale a pena viver, desejar estar morto, ideação suicida, planejamento e tentativas de suicídio) em pacientes com TP e agorafobia (TPA), assim como avaliar fatores sóciodemográficos e clínicos associados à ocorrência de tais comportamentos. Método: Estudo transversal, com uma amostra clínica de conveniência de pacientes adultos (18 anos ou mais) portadores de TPA (critérios do DSM-IV) em tratamento em uma clínica privada de Bauru e no ambulatório de transtornos ansiosos e obsessivo-compulsivos (ATAOC) da Faculdade de Medicina de Botucatu-Unesp de janeiro de 2011 a outubro de 2013. Os instrumentos de avaliação utilizados foram: um questionário especialmente elaborado para obtenção de dados sociodemográficos e clínicos, a Panic and Agoraphobia Scale (PAS) para avaliar a gravidade dos sintomas de TPA e a Mini International Neuropsychiatric Interview (M.I.N.I.) para avaliar a ocorrência de comorbidades psiquiátricas. Calculou-se a prevalência de comportamentos suicidas (desfechos de interesse) e, a seguir, foram feitas análises bivariadas entre estes e diversas variáveis sociodemográficas e clínicas. Para as variáveis categóricas foi utilizado o teste de qui-quadrado ou de Fisher, quando indicado, e para variáveis quantitativas (ex. idade, anos de escolaridade, pontuação na PAS) utilizaram-se os ... / Abstract: Introduction: Psychiatric disorders are the main risk factors for suicidal behaviors or 'suicidality', but there are few studies on this issue involving patients with anxiety disorders in general and panic disorder (PD) in particular. Most PD patients that seek treatment have agoraphobia associated to the disorder (PAD). Investigations of suicidality among PAD patients have been largely inconclusive and there are no Brazilian publications on this issue. Objectives: this study aimed to estimate the prevalence of various lifetime suicidal behaviors (feeling that life is not worth living, wishing to be dead, suicidal thoughts, plans and attempts) in PAD patients and to evaluate sociodemographic and clinical factors associated with these behaviors. Method: A cross-sectional study was conducted with a sample of adult patients presenting PAD (DSM-IV criteria) undergoing treatment in a private clinic in Bauru and in the outpatient service for anxiety and obsessive-compulsive disorders at Botucatu Medical School - São Paulo State University from January 2011 to October 2013. The assessment instruments used were: a questionnaire designed to collect sociodemographic and clinical data, the Panic and Agoraphobia Scale (PAS) to evaluate PAD clinical severity and the Mini International Neuropsychiatric Interview (M.I.N.I.) to evaluate the co-occurrence of other psychiatric disorders. Initially, the prevalence of the outcomes of interest (suicidal behaviors) was calculated; then, bivariate analyses were performed between these outcomes and several demographic and clinical variables. For the categorical explanatory variables the Chi-squared and the Fisher exact tests were used, whereas for the quantitative variables (e.g.: age, schooling years, PAS score) the Student t test (normal distribution) and the Mann-Whitney test (non-normal distribution) were used. Results: 45 patients (66.7% women and 33.3% men) were assessed. Ages ranged from 19 to 68; ... / Mestre

The present study was designed to test Frankel and Orne's hypothesis that persons with a clinically significant phobia also show high susceptibility to hypnosis. The hypnotic susceptibility scores of 10 persons who sought treatment with hypnosis for agoraphobia were compared with the susceptibility scores of a control group of 20 persons having comparable motivation to succeed in hypnosis. The susceptibility measure was the Stanford Hypnotic Susceptibility Scale: Form C (SHSS:C, Weitzenhoffer & Hilgard, 1962). The groups were also compared on: a) the Archaic Involvement Measure (AIM; Nash, 1984); b) the Field Depth Inventory (FDI; Field, 1965); and c) the Tellegen Absorption Scale (TAS; Tellegen & Atkinson, 1974). No significant differences were found between the groups on the dependent measures. Factors which qualify the results are discussed.

A literature search, in addition to expert survey, was performed to estimate the size and burden of panic disorder in the European Union (EU). Epidemiologic data from EU countries were critically reviewed to determine the consistency of prevalence estimates across studies and to identify the most pressing questions for future research. A comprehensive literature search focusing on epidemiological studies in community and clinical settings in European countries since 1980 was conducted (Medline, Web of Science, Psychinfo). Only studies using established diagnostic instruments on the basis of DSM-III-R or DSM-IV, or ICD-10 were considered. Thirteen studies from a total of 14 countries were identified. Epidemiological findings are relatively consistent across the EU. The 12-month prevalence of panic disorder and agoraphobia without history of panic were estimated to be 1.8% (0.7–2.2) and 1.3% (0.7–2.0) respectively across studies. Rates are twice as high in females and age of first onset for both disorders is in adolescence or early adulthood. In addition to comorbidity with agoraphobia, panic disorder is strongly associated with other anxiety disorders, and a wide range of somatoform, affective and substance use disorders. Even subclinical forms of panic disorder (i.e., panic attacks) are associated with substantial distress, psychiatric comorbidity and functional impairment. In general health primary care settings, there appears to be substantial underdiagnosis and undertreatment of panic disorder. Moreover, panic disorder and agoraphobia are poorly recognized and rarely treated in mental health settings, despite high health care utilization rates and substantial long-term disability.

Orientadores: Giovanni Battista Cassano, Evandro Gomes de Matos, Luis Alberto Magna / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-04T19:45:50Z (GMT). No. of bitstreams: 1 Sardelli_LionelaRavera_M.pdf: 5978329 bytes, checksum: 971b584cbbbf0036bf7a9e97f8c70921 (MD5) Previous issue date: 2005 / Resumo: Objetivo ¿ A presente investigação é parte integrante do ¿Spectrum Project¿, projeto internacional de pesquisa desenvolvido na Europa e nos Estados Unidos, o qual propõe uma metodologia para avaliar características psicopatológicas e clínicas de sintomas relacionados aos transtornos de ansiedade (TA), com enfoque especial no Transtorno do Pânico (TP). Tem como objetivo principal detectar a prevalência de aspectos subclínicos do TP em uma amostra representativa da Região Metropolitana de Campinas (RMC), Brasil. Casuística e Método ¿ Realizou-se um estudo epidemiológico de corte transversal. A amostra de estudo constituiu-se de 405 sujeitos, equilibrada segundo sexo, idade e cidade de moradia da população da Região Metropolitana de Campinas (RMC), São Paulo. Utilizou-se o questionário de auto-avaliação ¿Panic Agoraphobic Spectrum-Self Report¿ (PAS-SR) que contém 114 perguntas divididas em 8 Domínios e 13 subdomínios. O total escore do PAS-SR (total de respostas positivas de cada questionário) permite uma avaliação quantitativa dos sintomas correlacionados ao transtorno do pânico (TP) em cada sujeito entrevistado. Resultados- A idade dos sujeitos da amostra variou entre 16 e 89 anos, com média de 36,82 anos e desvio padrão de 14,74. Em relação ao escore total obteve-se uma média de 31,61 e um desvio-padrão de 19,63. Não foram encontradas diferenças significativas quanto aos valores médios do escore total do PAS-SR em relação a: faixa etária (p=0,21), raça (p=0,59), grau de instrução (p=0,20), estado civil (p=0,21) e região (p=0,13). A diferença mais significativa foi encontrada entre os sexos (p=0,001), onde as mulheres apresentaram em média um valor de escore total de 37,45, enquanto os homens de 25,74. A análise fatorial, utilizada como método de validação de construto, indicou que o questionário possui adequadas características psicométricas. Conclusões: Os dados obtidos neste estudo corroboram os da literatura quanto aos fatores mais freqüentemente associados no TP. O instrumento PAS-SR, traduzido e validado para uso no Brasil foi bem compreendido e teve boa aceitação pelos sujeitos da pesquisa. Isso permitiu a individualização de uma faixa da população geral com maior freqüência de sintomas relacionados ao TP. Revelando-se um instrumento útil para avaliação em nosso meio / Abstract: Objective ¿ The current investigation is part of ¿Spectrum Project¿, an international research project already developed in Europe and in the United States, which proposes a methodology for the evaluation of psychopathologic and clinical characteristics of symptoms related to Anxiety Disorder (AD), with a special focus on Panic Disorder (PD). It aims mainly at detecting the prevalence of sub-clinical PD symptms in a representative sample in the Metropolitan Region of Campinas (RMC), Brazil. Method ¿ An epidemiological study of transversal cut was carried out. The sample for this study consisted of 405 subjects and was balanced according to sex, age and city where they live in the Metropolitan Region of Campinas (RMC), São Paulo. The Panic Agoraphobic Spectrum-Self Report (PAS-SR) questionnaire containing 114 questions divided into 8 fields and 13 sub-fields was applied. The total PAS-SR score (total of positive answers of each questionnaire) allows a quantitative evaluation of the symptoms associated with the Panic Disorder (PD) in each interviewed subject. Results ¿ The age of the subjects ranged from 16 to 89 years, mean 36.82 (±14.74) and the total 31.61 ( ±19.63). There were no significant differences in the median values of the PAS-SR total score in relation to age range (p=0.21), race (p=0.77), education level (p=0.20), marital status (p=0.21) and location (p=0.14). The most significant difference was the one found between both sexes (p=0.001). Females presented a mean value of total score of 37.45, while males presented the average of 25.74. Conclusion ¿ The findings agreed substantially with those found in the literature concerning the most frequent factors associated with PD. The PAS-SR instrument, which was translated and validated for use in Brazil, had a good acceptance and was well understood by the subjects who underwent the research. It allowed the individualization of a sample of general population with greater frequency of symptoms related to PD. Thus, it was revealed as a useful instrument for evaluation in our environment / Mestrado / Ciencias Biomedicas / Mestre em Ciências Médicas

Panikstörung und Agoraphobie sind häufig auftretende Angststörungen, die mit einer hohen individuellen aber auch gesellschaftlichen Belastung einhergehen. Es existieren sehr erfolgreiche, aber auch aufwändige Behandlungsmethoden. Trotz einer hohen Erfolgsquote dieser Behandlungen kommt es immer wieder zu einer nicht ausreichenden Verbesserung der Beschwerden oder auch Therapieabbrüchen. Zu möglichen Einflussfaktoren auf den Therapieerfolg, -misserfolg oder Abbrüche wurde bereits mit widersprüchlichen Ergebnissen geforscht. Es erscheint sinnvoll, diese Faktoren zu kennen, um Fehlindikationen in ein aufwändiges Therapieverfahren zu vermeiden und den Leidensdruck der Patient:innen gegebenenfalls mit einem anderen Verfahren schneller zu lindern. Die vorliegende Arbeit untersucht, ob solche Prädiktoren für den Nicht-Erfolg im Kontext eines naturalistischen Behandlungssettings in der Angst-Tagesklinik an der Klinik und Poliklinik für Psychotherapie und Psychosomatik des Universitätsklinikums Carl Gustav Carus identifiziert werden können. Dazu wurde der Therapieeffekt anhand 214 Patient:innen geprüft. Weiterhin wurden sie hinsichtlich demografischer, sozialmedizinischer und störungsspezifischer Kennwerte am Anfang und am Ende der Behandlung untersucht und am Grad der Veränderung angstspezifischer Kennwerte in Responder und Non-Responder unterteilt. Anschließend wurden über logistische Regressionen Faktoren für die Non-Response identifiziert. Es stellte sich heraus, dass die Behandlung einen mittleren bis großen Effekt auf verschiedene Störungsmaße aufwies, jedoch ca. 57,5% der Patient:innen keine oder eine im klinischen Sinne unzureichende Verbesserung erlebt hatten. Dabei zeigte sich, dass sich die Betrachtung des Familienstands, des Ausmaßes der Angst vor körperlichen Krisen und die Mobilitätsvermeidung ohne Begleitperson gemeinsam am besten eignen, um eine mögliche Non-Response vorherzusagen. Das errechnete Modell fällte dabei auf Basis der Aufnahmedaten in 62,8% der Fälle die korrekte Entscheidung zur Zuordnung in die Gruppen der Responder und Non-Responder. Somit ist das Modell leider nicht ausreichend, um zweifelsfrei im Vorfeld einer Behandlung individuell zu entscheiden, ob die angebotene Expositionsbehandlung zielführend ist oder nicht. Das Modell gibt allerdings wichtige Hinweise auf mögliche Einflussfaktoren auf die Eignung zur Behandlung, auch wenn weitere, nicht untersuchte oder nicht messbare Faktoren bedeutsam sein könnten. / Panic disorder and agoraphobia are common anxiety disorders that are associated with a high individual burden, but also social burden. There are very successful, but also costly treatment methods. Despite a high success rate of these treatments, there sometimes is an insufficient reduction of symptoms or even therapy discontinuation in individual patients. Research has already been done on possible factors influencing the success, failure or discontinuation of therapy, with contradictory results. It makes sense to know these factors in order to avoid wrong indications for a complex therapy procedure and to alleviate the patients' suffering more quickly with another procedure. This study investigates whether such predictors of non-response can be identified in the context of a naturalistic treatment setting in the Angst-Tagesklinik at the Klinik und Poliklinik für Psychotherapie und Psychosomatik of the University Hospital Carl Gustav Carus Dresden. For this purpose, the therapy’s effect was tested on 214 patients. Furthermore, they were examined with regard to demographic, socio-medical and disorder-specific parameters at the beginning and end of treatment and divided into responders and non-responders according to the degree of change in anxiety-specific parameters. Subsequently, logistic regressions were used to identify factors for non-response. It was found that the treatment had a medium to large effect on various disorder specific measures, but that about 57.5% of the patients had experienced no improvement or insufficient improvement in the clinical sense. It was found that looking at marital status, level of fear of physical crises and mobility avoidance without a companion were best suited to predict a possible non-response to the treatment. Based on the patients’ admission data, the calculated predictor model made the correct decision to assign the patient to the responder and non-responder groups in 62,8% of the cases. In conclusion, the model is not sufficient to predict, whether the exposure treatment will be successful or not. However, the model provides important indications of possible factors influencing the suitability for treatment, even though other factors that have not been investigated or that are not measurable could be significant.

A recent study suggested that bibliotherapy may be an effective intervention for panic disordered individuals with agoraphobia. The present study attempted to enhance this bibliotherapy intervention by adding audio- and videotape self-help supplements. Thirty subjects suffering panic disorder with mild to moderate agoraphobia were matched on level of avoidance and then randomly assigned to 1) a Wait-list control condition (WL). or 2) a Self-help condition (SH). The intervention lasted four weeks followed by an eight week post treatment phase. and follow-up measures at the end of this phase. Results indicated that, from pre-treatment to follow-up, SH subjects improved significantly on 11 of the 12 dependent measures used in this study. while WL subjects did not. Furthermore. SH subjects were significantly more improved than WL subjects at follow-up with regard to agoraphobic avoidance, coping with panic attacks, self efficacy for mild, moderate and severe attacks, and for two critical measures of distress: frequency of panic attacks. and total severity of each attack. Clinical outcome measures also supported the effectiveness of the self-help approach. More than two-thirds of SH subjects met the criteria for clinical improvement. While only one-quarter of WL subjects met these criteria. Implications for the treatment of panic disordered individuals are discussed, as is the role of self-efficacy in mediating clinical change. / Ph. D.

Twenty-four anxiety disorder subjects. 12 simple phobics and 12 panic disorders with agoraphobia, were assessed for physiological response (SCL, HR and EMG) to phobic imagery scripts. Subjects were instructed to image during tape-recorded scripts of standardized neutral (Neutral) and personally relevant fear (Phobic) scripts. All scripts contained both stimulus and response cues; however, subjects were presented four versions of a script which varied in response cue (propositional) content and presentation style: a version presented non-interactively which contained no cognitive cues (meaning propositions), a version presented non-interactively which contained cognitive cues, a version presented interactively which contained no cognitive cues, and a version presented interactively which contained cognitive cues. Both diagnostic groups produced significantly increased HR and SCL in response to Phobic scripts which contained cognitive cues and were presented interactively. Phobic Scripts which contained cognitive cues and were presented non-interactively produced significantly increased arousal only in the panic disorder group as measured by HR. Simple phobics also responded with significantly increased SCL to Phobic scripts presented interactively with no cognitive cues. Neither diagnostic group responded with increased arousal to the Phobic script presented non-interactively with no cognitive cues. Contrary to previous research, these results indicate that subjects with panic disorder with agoraphobia are capable of producing significantly increased physiological arousal in response to phobic imagery. The crucial importance of imagery script content and presentation style are highlighted by the results. Furthermore, the current investigation differed from previous investigations in that the parameters of an actual therapy session were more closely approximated by having the subjects image during script presentation rather than subsequent to script presentation. Finally, frontalis EMG did not prove to be a sensitive measure of anxiety in these subject populations pointing to the need for multiple channels of physiological measurement. Implications for content and methodology of future research studies in this area are discussed. / Ph. D.

The effects of physiological arousal and panic expectancy on anxiety and agoraphobic avoidance were evaluated on thirty-six Ss diagnosed with panic disorder. It was hypothesized that there would be main effects of increased physiological arousal and increased panic expectancy on anxiety and avoidance, as well as an interaction of these two factors, in a behavioral avoidance test containing agoraphobic situations. Physiological arousal induced through hyperventilation raised anxiety immediately following induction, but did not affect anxiety or avoidance on the subsequent walk. Although panic expectancy did not change as a result of the manipulations, initial panic expectancy was the strongest predictor of anxiety on the walk, and the best predictor of general agoraphobia measured by the Chambless Mobility Inventory. Absence of reliable changes in panic expectancy and significant results are discussed in terms of possible pretest sensitization, nature of the sample and subject selection, floor and ceiling effects, experimental demand characteristics, a relatively weak expectancy manipulation, and statistical issues such as large pre-group differences and large within-group variability. This research does however support previous studies which have found a strong correlational relationship between panic expectancy and agoraphobia. / Ph. D.

<p>The present dissertation comprises four empirical studies within the area of behavioral treatment of panic disorder with agoraphobia. The focus is on studying issues pertaining to outcome, treatment process and determinants of change. The first study is a randomized controlled treatment study of 73 patients undergoing 16 sessions of either exposure in vivo (E), or cognitive behavior therapy (CBT). Both treatments showed clear improvements at post-treatment that were well maintained at 1-year follow up, and there were no significant differences between the treatments.</p><p>The second study concerned prediction of outcome in the same sample. From a variety of pre-treatment characteristics severity of avoidance was the one most related to outcome. Most predictors were found unrelated. Two approaches of prediction were also compared: treating outcome as a categorical vs. continuous variable. The different approaches yielded a somewhat dissimilar picture of the impact of pre-treatment severity of avoidance. The third study examined different aspects of the therapeutic relationship, and their relation to outcome. Clients’ perceptions of therapists and their ratings of the working alliance were generally not related to outcome at any point. On the other hand, therapists’ perceptions of patients as showing goal-direction and active participation were related to outcome from early on in therapy. The fourth study examined different aspects of change. It was found that change in indices of the frequency of panic attacks was not closely related to change in agoraphobic avoidance at post-treatment. Change in avoidance was also more related to other aspects of outcome. At one-year follow-up, a more unitary picture, regarding the different aspects of change was observed.</p>

<p>As evidenced by several trials, cognitive behavior therapy (CBT) is a highly effective treatment for Panic disorder with or without agoraphobia (PD). However, therapists are short in supply, and patients with agoraphobia may not seek therapy due to fear of leaving their homes or traveling certain distances. A major challenge therefore is to increase the accessibility and affordability of evidence-based psychological treatments.</p><p>This thesis is based on five studies; three treatment studies set up as randomized controlled trails (RCT), one prevalence study, and one study testing the equivalence of an Internet-administered diagnostic assessment tool with a clinician-administered interview.</p><p>Study I showed that the Swedish 12-month PD prevalence is consistent with findings in most other parts of the Western world (2.2%; CI 95% 1.0%-3.4%). There was a significant sex difference, with a greater prevalence for women (3.6%) compared to men (0.7%).</p><p>Study II showed that the validity of the computerized diagnostic interview (CIDI-SF) was generally low. However, the agoraphobia and obsessive-compulsive disorder modules had good specificity and sensitivity, respectively.</p><p>The three RCTs showed, directly or indirectly, that Internet-based self-help is superior to a waiting-list. When 10 individual weekly sessions of CBT for PD was compared with a 10-module self-help program on the Internet, the results suggest that Internet-administered self-help, plus minimal therapist contact via e-mail, is as effective as traditional individual CBT (80% vs. 67% no longer met criteria for panic disorder; composite within-group effect size was Cohen’s <i>d</i>= 0.78 vs. 0.99). One-year follow-up confirmed the results (92% vs. 88% no longer met criteria for panic disorder; <i>d</i>= 0.80 vs. 0.93). The results generally provide evidence to support the continued use and development of Internet-distributed self-help programs.</p>