Introdução: O transtorno de ansiedade social (TAS) é uma condição que pode ser muito incapacitante, com considerável sofrimento subjetivo, alta prevalência de comorbidades psiquiátricas e impacto negativo no funcionamento psicossocial. Entretanto, existem poucos dados na literatura sobre a possível extensão deste comprometimento nos indivíduos com sinais e sintomas subclínicos do TAS. Além disso, a discussão sobre a associação entre o prolapso de valva mitral (PVM) e os transtornos de ansiedade, particularmente com o transtorno de pânico e o TAS, existe já há cerca de três décadas, mas os resultados publicados não são suficientes para definitivamente estabelecer ou excluir a associação entre essas condições, com prevalências variando de 0 a 57%. Método: O delineamento metodológico envolveu duas etapas. Na primeira, as comorbidades psiquiátricas e o comprometimento no funcionamento psicossocial foram avaliados em 355 estudantes universitários que haviam sido diagnosticados previamente como TAS (n=141), TAS subclínico (n=92) ou controles (n=122). Na segunda etapa, um total de 232 voluntários diagnosticados como transtorno de pânico (n=41), TAS (n=89) ou controles (n=102) foram avaliados em ecocardiografia quanto ao PVM. Os exames foram realizados por dois cardiologistas que estavam cegos em relação ao diagnóstico psiquiátrico dos participantes. Foram obtidas medidas utilizando os critérios atuais e antigos para o diagnóstico de PVM, para permitir a comparação e generalização dos resultados. Resultados: A taxa de comorbidade com outros transtornos psiquiátricos foi de 71,6% no grupo TAS e de 50% nos sujeitos com TAS subclínico, ambos significativamente maiores que os controles (28,7%). A presença de comorbidades foi progressivamente maior de acordo com o subtipo e a gravidade do TAS. Quanto ao funcionamento psicossocial o grupo TAS apresentou maior comprometimento que os outros dois grupos em todos os domínios avaliados, e os sujeitos com TAS subclínico apresentaram valores intermediários. Na segunda etapa, os resultados demonstraram que não há diferenças estatísticas entre os grupos quanto à prevalência de PVM, seja pelos critérios ecocardiográficos atuais para o diagnóstico de PVM (visão longitudinal paraesternal: pânico=2,4%, TAS=4,5%, controles=1,0%) ou pelos critérios antigos (visão apical de 4-câmaras: pânico=2,4%, TAS=4,5%, controles=10,8%; modo-M: pânico=2,4%, TAS=6,7%, controles=4,9%). Também não houve diferenças significativas em relação a outras características morfológicas, como presença de regurgitação mitral, espessamento valvar ou presença de alongamento de cordoalhas. Conclusões: A prevalência de comorbidades psiquiátricas e o comprometimento no funcionamento psicossocial aumentam progressivamente ao longo do espectro de ansiedade social. O fato de o TAS subclínico apresentar considerável incapacidade e sofrimento em comparação com sujeitos controles justifica uma revisão na validade desses critérios diagnósticos. Por outro lado, não houve associação entre o transtorno de pânico ou o TAS com o PVM em nossos resultados, independente dos critérios diagnósticos utilizados, com prevalências compatíveis com a esperada na população geral. Dessa forma, é preciso desmistificar a relação entre essa alteração cardíaca e o transtorno de pânico e o TAS, pelas repercussões que pode ter para o paciente e em seu tratamento psiquiátrico. / Background: Social anxiety disorder (SAD) is a highly disabling condition that causes considerable subjective suffering. It has a high prevalence rate of psychiatric comorbidities and a negative impact on psychosocial functioning. However, few data are available in the literature about the possible extent of this impairment in individuals with subthreshold signs and symptoms of SAD. In addition, the discussion about the association between mitral valve prolapse (MVP) and anxiety disorders, especially panic disorder and SAD, has been going on for over three decades, but the published results are insufficient to establish or to exclude an association between these conditions, with reported prevalence rates ranging from 0% to 57%. Method: The methodological design involved two stages. In the first, psychiatric comorbidities and psychosocial functioning impairment were evaluated in 355 college students diagnosed with SAD (n=141), subthreshold SAD (n=92) or as healthy controls (n=122) in a previous study. In the second stage, a total of 232 volunteers previously diagnosed with panic disorder (n=41), SAD (n=89) or as healthy controls (n=102) underwent echocardiographic evaluation for MVP. The exams were performed by two cardiologists who were blind to the psychiatric diagnosis of the participants. Measurements based on current and earlier MVP diagnostic criteria were taken in order to permit the comparison and generalization of the results. Results: The rate of comorbidity with other psychiatric disorders was 71.6% in the SAD group and 50% in subjects with subthreshold SAD, both significantly greater than controls (28.7%). The presence of comorbidities increased progressively according to SAD subtype and severity. Concerning psychosocial functioning, the SAD group had greater impairment than the other two groups in all domains evaluated, and subjects with subthreshold SAD presented intermediate values. In the second stage, the results demonstrated that there were no statistically significant differences among the groups in terms of MVP prevalence, whether using current diagnostic criteria (long-axis view: panic=2.4%, SAD=4.5%, control=1.0%) or earlier criteria (apical four-chamber view: panic=2.4%, SAD=4.5%, control=10.8%; M-mode: panic=2.4%, SAD=6.7%, control=4.9%). Also, there were no significant differences regarding other morphological characteristics, such as presence of mitral regurgitation, mean valve thickness or elongation of chordae. Conclusions: The rates of psychiatric comorbidities and the psychosocial functioning impairment increase progressively along the spectrum of social anxiety. The fact that subthreshold SAD causes considerable disability and suffering in comparison with control subjects justifies a review of the validity of current diagnostic criteria. On the other hand, in this investigation no association between panic disorder or SAD and MVP was documented, regardless of the diagnostic criteria used, with prevalence rates similar to those reported for the general population. Thus, it seems necessary to demystify the relationship between this cardiac alteration and panic disorder and SAD in order to avoid unwanted influences for the patient and his psychiatric treatment.

Introdução: O transtorno de ansiedade social (TAS) é uma condição que pode ser muito incapacitante, com considerável sofrimento subjetivo, alta prevalência de comorbidades psiquiátricas e impacto negativo no funcionamento psicossocial. Entretanto, existem poucos dados na literatura sobre a possível extensão deste comprometimento nos indivíduos com sinais e sintomas subclínicos do TAS. Além disso, a discussão sobre a associação entre o prolapso de valva mitral (PVM) e os transtornos de ansiedade, particularmente com o transtorno de pânico e o TAS, existe já há cerca de três décadas, mas os resultados publicados não são suficientes para definitivamente estabelecer ou excluir a associação entre essas condições, com prevalências variando de 0 a 57%. Método: O delineamento metodológico envolveu duas etapas. Na primeira, as comorbidades psiquiátricas e o comprometimento no funcionamento psicossocial foram avaliados em 355 estudantes universitários que haviam sido diagnosticados previamente como TAS (n=141), TAS subclínico (n=92) ou controles (n=122). Na segunda etapa, um total de 232 voluntários diagnosticados como transtorno de pânico (n=41), TAS (n=89) ou controles (n=102) foram avaliados em ecocardiografia quanto ao PVM. Os exames foram realizados por dois cardiologistas que estavam cegos em relação ao diagnóstico psiquiátrico dos participantes. Foram obtidas medidas utilizando os critérios atuais e antigos para o diagnóstico de PVM, para permitir a comparação e generalização dos resultados. Resultados: A taxa de comorbidade com outros transtornos psiquiátricos foi de 71,6% no grupo TAS e de 50% nos sujeitos com TAS subclínico, ambos significativamente maiores que os controles (28,7%). A presença de comorbidades foi progressivamente maior de acordo com o subtipo e a gravidade do TAS. Quanto ao funcionamento psicossocial o grupo TAS apresentou maior comprometimento que os outros dois grupos em todos os domínios avaliados, e os sujeitos com TAS subclínico apresentaram valores intermediários. Na segunda etapa, os resultados demonstraram que não há diferenças estatísticas entre os grupos quanto à prevalência de PVM, seja pelos critérios ecocardiográficos atuais para o diagnóstico de PVM (visão longitudinal paraesternal: pânico=2,4%, TAS=4,5%, controles=1,0%) ou pelos critérios antigos (visão apical de 4-câmaras: pânico=2,4%, TAS=4,5%, controles=10,8%; modo-M: pânico=2,4%, TAS=6,7%, controles=4,9%). Também não houve diferenças significativas em relação a outras características morfológicas, como presença de regurgitação mitral, espessamento valvar ou presença de alongamento de cordoalhas. Conclusões: A prevalência de comorbidades psiquiátricas e o comprometimento no funcionamento psicossocial aumentam progressivamente ao longo do espectro de ansiedade social. O fato de o TAS subclínico apresentar considerável incapacidade e sofrimento em comparação com sujeitos controles justifica uma revisão na validade desses critérios diagnósticos. Por outro lado, não houve associação entre o transtorno de pânico ou o TAS com o PVM em nossos resultados, independente dos critérios diagnósticos utilizados, com prevalências compatíveis com a esperada na população geral. Dessa forma, é preciso desmistificar a relação entre essa alteração cardíaca e o transtorno de pânico e o TAS, pelas repercussões que pode ter para o paciente e em seu tratamento psiquiátrico. / Background: Social anxiety disorder (SAD) is a highly disabling condition that causes considerable subjective suffering. It has a high prevalence rate of psychiatric comorbidities and a negative impact on psychosocial functioning. However, few data are available in the literature about the possible extent of this impairment in individuals with subthreshold signs and symptoms of SAD. In addition, the discussion about the association between mitral valve prolapse (MVP) and anxiety disorders, especially panic disorder and SAD, has been going on for over three decades, but the published results are insufficient to establish or to exclude an association between these conditions, with reported prevalence rates ranging from 0% to 57%. Method: The methodological design involved two stages. In the first, psychiatric comorbidities and psychosocial functioning impairment were evaluated in 355 college students diagnosed with SAD (n=141), subthreshold SAD (n=92) or as healthy controls (n=122) in a previous study. In the second stage, a total of 232 volunteers previously diagnosed with panic disorder (n=41), SAD (n=89) or as healthy controls (n=102) underwent echocardiographic evaluation for MVP. The exams were performed by two cardiologists who were blind to the psychiatric diagnosis of the participants. Measurements based on current and earlier MVP diagnostic criteria were taken in order to permit the comparison and generalization of the results. Results: The rate of comorbidity with other psychiatric disorders was 71.6% in the SAD group and 50% in subjects with subthreshold SAD, both significantly greater than controls (28.7%). The presence of comorbidities increased progressively according to SAD subtype and severity. Concerning psychosocial functioning, the SAD group had greater impairment than the other two groups in all domains evaluated, and subjects with subthreshold SAD presented intermediate values. In the second stage, the results demonstrated that there were no statistically significant differences among the groups in terms of MVP prevalence, whether using current diagnostic criteria (long-axis view: panic=2.4%, SAD=4.5%, control=1.0%) or earlier criteria (apical four-chamber view: panic=2.4%, SAD=4.5%, control=10.8%; M-mode: panic=2.4%, SAD=6.7%, control=4.9%). Also, there were no significant differences regarding other morphological characteristics, such as presence of mitral regurgitation, mean valve thickness or elongation of chordae. Conclusions: The rates of psychiatric comorbidities and the psychosocial functioning impairment increase progressively along the spectrum of social anxiety. The fact that subthreshold SAD causes considerable disability and suffering in comparison with control subjects justifies a review of the validity of current diagnostic criteria. On the other hand, in this investigation no association between panic disorder or SAD and MVP was documented, regardless of the diagnostic criteria used, with prevalence rates similar to those reported for the general population. Thus, it seems necessary to demystify the relationship between this cardiac alteration and panic disorder and SAD in order to avoid unwanted influences for the patient and his psychiatric treatment.

A presente pesquisa teve como objetivo caracterizar os elementos de personalidade de pacientes com transtorno de pânico a partir dos dados obtidos pelo Método de Rorschach, segundo o sistema compreensivo. Em linhas gerais, o transtorno de pânico pode ser caracterizado pela vivência recorrente de ataques de pânico, em virtude de crises agudas de ansiedade, onde o indivíduo passa por um mal-estar intenso e uma sensação iminente de perigo e ou morte. Participaram do estudo 60 colaboradores divididos igualmente em quatro grupos: pacientes com pânico do sexo feminino, pacientes com pânico do sexo masculino, não pacientes do sexo feminino e não pacientes do sexo masculino. Os participantes do grupo de não pacientes foram avaliados pelo Questionário de Saúde Geral para verificação de seu estado geral de saúde mental e todos os colaboradores submeteram-se ao Método de Rorschach, conforme as especificações técnicas do sistema compreensivo. As respostas foram codificadas por juízes independentes e os índices obtidos foram submetidos à análise estatística por meio do teste de Kruskal-Wallis e do teste post-hoc de Dunn, comparando-se os quatro grupos. Os resultados com diferença estatisticamente significativa apresentados para os colaboradores com transtorno de pânico foram os seguintes: presença do Índice de Depressão (p = 0,009), indicando depressão e sintomas depressivos ou algum tipo de transtorno afetivo; rebaixamento do Índice Lambda (p = 0,008), demonstrando dificuldade na discriminação entre informações importantes e irrelevantes; predomínio de cor acromática e sombreados na Experiência de Base (p = 0,010), caracterizando dor e sofrimento psíquicos em demasia, além de aumento da tensão interna; elevação da Estimulação Sentida (p 0,001), indicando uma vivência de extrema irritação, desconforto e incômodo internos; rebaixamento da Nota D (p 0,001), que revela grande vivência de estresse, associado à falta de recursos internos para enfrentá-lo; elevação das determinantes de sombreado com característica de difusão (p 0,001), que indica extremo desconforto emocional, sofrimento interno e desamparo emocional; elevação de determinantes mistos de cor e sombreado (p = 0,004), que propõe vivências afetivas carregadas de ambivalência e sofrimento e perturbação afetiva; predomínio das respostas empobrecidas de conteúdo humano (p = 0,011), que demonstra dificuldade de adaptação nas relações sociais; rebaixamento das respostas de movimento cooperativo (p = 0,006), revelando dificuldade em estabelecer vínculos positivos e construtivos com outros indivíduos. Em síntese, os aspectos de personalidade observados nos colaboradores com pânico mostram tratar-se de indivíduos que internamente apresentam grande sofrimento psicológico, tensão interna e dificuldades afetivas; não possuem recursos de enfrentamento das situações estressantes e ansiógenas, levando-os a dificuldade de relacionamento adequado. Os quadros de pânico são decorrentes dessa estrutura frágil e comprometida. Embora os dados sejam conclusivos, existe a necessidade de constantes investigações para a melhor compreensão desse quadro psicopatológico que tanto causa sofrimento em seus portadores. / The objective of this research was to characterize the personality elements of patients with panic disorder from data obtained by the Rorschach Method following the comprehensive system. In general terms, the panic disorder can be characterized by the repeated experience of panic attacks due to acute anxiety, in which the individual suddenly develops a severe discomfort or fear of danger and or death. 60 subjects participated in the study, equally divided into four groups: female patients with panic, male patients with panic, female nonpatients and male nonpatients. The nonpatient group was assessed through the General Health Questionnaire for a general mental health assessment, and all subjects were submitted to the Rorschach Method, following the comprehensive system technical specifications. The responses were codified by independent raters and the indices obtained were subjected to statistical analysis using the Kruskal-Wallis test followed by Dunns post-hoc test, comparing the four groups. The results with statistically significant difference presented regarding subjects com panic disorder were the following: presence of Depression Index (p = 0.009), indicating depression and depressive symptoms or some kind of affective disorder; lower Lambda (p = 0.008), showing difficulty to distinguish between important and irrelevant information; prevalence of achromatic and shading colors in the Experience Base (p = 0.010), characterizing overwhelming psychic pain and suffering, in addition to increased inner stress; higher Experienced Stimulation (p 0.001), showing an experience of extreme inner irritation, discomfort and uneasiness; lower D Score (p 0.001), showing great stress experience associated with lack of inner coping resources; increase in the shading with diffusion feature determinants (p 0.001), indicating extreme emotional discomfort, inner suffering and emotional helplessness; increase in mixed color and shading determinants (p = 0.004), suggesting affective experiences full of ambivalence and suffering and affective disturbance; predominance of impoverished human content responses (p = 0.011), showing difficulty in adapting to social relationships; fewer cooperative movement responses (p = 0.006), showing difficulty in establishing positive and constructive bonds with other individuals. In summary, the personality aspects observed in the subjects with panic show they are individuals presenting deep psychological suffering, inner tension and affective difficulties; they lack coping resources to handle stressful and anxious situations, leading them to difficulty in proper interpersonal relationship. The panic disorder results from this fragile and vulnerable structure. Although data is conclusive, permanent investigation is necessary in order to better understand this psychopathologic condition that causes so much pain to those who suffer from it.

A presente pesquisa teve como objetivo caracterizar os elementos de personalidade de pacientes com transtorno de pânico a partir dos dados obtidos pelo Método de Rorschach, segundo o sistema compreensivo. Em linhas gerais, o transtorno de pânico pode ser caracterizado pela vivência recorrente de ataques de pânico, em virtude de crises agudas de ansiedade, onde o indivíduo passa por um mal-estar intenso e uma sensação iminente de perigo e ou morte. Participaram do estudo 60 colaboradores divididos igualmente em quatro grupos: pacientes com pânico do sexo feminino, pacientes com pânico do sexo masculino, não pacientes do sexo feminino e não pacientes do sexo masculino. Os participantes do grupo de não pacientes foram avaliados pelo Questionário de Saúde Geral para verificação de seu estado geral de saúde mental e todos os colaboradores submeteram-se ao Método de Rorschach, conforme as especificações técnicas do sistema compreensivo. As respostas foram codificadas por juízes independentes e os índices obtidos foram submetidos à análise estatística por meio do teste de Kruskal-Wallis e do teste post-hoc de Dunn, comparando-se os quatro grupos. Os resultados com diferença estatisticamente significativa apresentados para os colaboradores com transtorno de pânico foram os seguintes: presença do Índice de Depressão (p = 0,009), indicando depressão e sintomas depressivos ou algum tipo de transtorno afetivo; rebaixamento do Índice Lambda (p = 0,008), demonstrando dificuldade na discriminação entre informações importantes e irrelevantes; predomínio de cor acromática e sombreados na Experiência de Base (p = 0,010), caracterizando dor e sofrimento psíquicos em demasia, além de aumento da tensão interna; elevação da Estimulação Sentida (p 0,001), indicando uma vivência de extrema irritação, desconforto e incômodo internos; rebaixamento da Nota D (p 0,001), que revela grande vivência de estresse, associado à falta de recursos internos para enfrentá-lo; elevação das determinantes de sombreado com característica de difusão (p 0,001), que indica extremo desconforto emocional, sofrimento interno e desamparo emocional; elevação de determinantes mistos de cor e sombreado (p = 0,004), que propõe vivências afetivas carregadas de ambivalência e sofrimento e perturbação afetiva; predomínio das respostas empobrecidas de conteúdo humano (p = 0,011), que demonstra dificuldade de adaptação nas relações sociais; rebaixamento das respostas de movimento cooperativo (p = 0,006), revelando dificuldade em estabelecer vínculos positivos e construtivos com outros indivíduos. Em síntese, os aspectos de personalidade observados nos colaboradores com pânico mostram tratar-se de indivíduos que internamente apresentam grande sofrimento psicológico, tensão interna e dificuldades afetivas; não possuem recursos de enfrentamento das situações estressantes e ansiógenas, levando-os a dificuldade de relacionamento adequado. Os quadros de pânico são decorrentes dessa estrutura frágil e comprometida. Embora os dados sejam conclusivos, existe a necessidade de constantes investigações para a melhor compreensão desse quadro psicopatológico que tanto causa sofrimento em seus portadores. / The objective of this research was to characterize the personality elements of patients with panic disorder from data obtained by the Rorschach Method following the comprehensive system. In general terms, the panic disorder can be characterized by the repeated experience of panic attacks due to acute anxiety, in which the individual suddenly develops a severe discomfort or fear of danger and or death. 60 subjects participated in the study, equally divided into four groups: female patients with panic, male patients with panic, female nonpatients and male nonpatients. The nonpatient group was assessed through the General Health Questionnaire for a general mental health assessment, and all subjects were submitted to the Rorschach Method, following the comprehensive system technical specifications. The responses were codified by independent raters and the indices obtained were subjected to statistical analysis using the Kruskal-Wallis test followed by Dunns post-hoc test, comparing the four groups. The results with statistically significant difference presented regarding subjects com panic disorder were the following: presence of Depression Index (p = 0.009), indicating depression and depressive symptoms or some kind of affective disorder; lower Lambda (p = 0.008), showing difficulty to distinguish between important and irrelevant information; prevalence of achromatic and shading colors in the Experience Base (p = 0.010), characterizing overwhelming psychic pain and suffering, in addition to increased inner stress; higher Experienced Stimulation (p 0.001), showing an experience of extreme inner irritation, discomfort and uneasiness; lower D Score (p 0.001), showing great stress experience associated with lack of inner coping resources; increase in the shading with diffusion feature determinants (p 0.001), indicating extreme emotional discomfort, inner suffering and emotional helplessness; increase in mixed color and shading determinants (p = 0.004), suggesting affective experiences full of ambivalence and suffering and affective disturbance; predominance of impoverished human content responses (p = 0.011), showing difficulty in adapting to social relationships; fewer cooperative movement responses (p = 0.006), showing difficulty in establishing positive and constructive bonds with other individuals. In summary, the personality aspects observed in the subjects with panic show they are individuals presenting deep psychological suffering, inner tension and affective difficulties; they lack coping resources to handle stressful and anxious situations, leading them to difficulty in proper interpersonal relationship. The panic disorder results from this fragile and vulnerable structure. Although data is conclusive, permanent investigation is necessary in order to better understand this psychopathologic condition that causes so much pain to those who suffer from it.

<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>

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. 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. 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%). 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. 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 d= 0.78 vs. 0.99). One-year follow-up confirmed the results (92% vs. 88% no longer met criteria for panic disorder; d= 0.80 vs. 0.93). The results generally provide evidence to support the continued use and development of Internet-distributed self-help programs.

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. 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.

Background: The relationship of panic attacks (PA), panic disorder (PD) and agoraphobia (AG) is controversial. The aim of the current study is to prospectively examine the 10-year natural course of PA, PD and AG in the first three decades of life, their stability and their reciprocal transitions. Methods: DSM-IV syndromes were assessed via Composite International Diagnostic Interview – Munich version in a 10-year prospective-longitudinal community study of 3,021 subjects aged 14–24 years at baseline. Results: (1) Incidence patterns for PA (9.4%), PD (with and without AG: 3.4%) and AG (5.3%) revealed differences in age of onset, incidence risk and gender differentiation. (2) Temporally primary PA and PD revealed only a moderately increased risk for subsequent onset of AG, and primary AG had an even lower risk for subsequent PA and PD. (3) In strictly prospective analyses, all baseline groups (PA, PD, AG) had low remission rates (0–23%). Baseline PD with AG or AG with PA were more likely to have follow-up AG, PA and other anxiety disorders and more frequent complications (impairment, disability, help-seeking, comorbidity) as compared to PD without AG and AG without PA. Conclusions: Differences in incidence patterns, syndrome progression and outcome, and syndrome stability over time indicate that AG exists as a clinically significant phobic condition independent of PD. The majority of agoraphobic subjects in this community sample never experienced PA, calling into question the current pathogenic assumptions underlying the classification of AG as merely a consequence of panic. The findings point to the necessity of rethinking diagnostic concepts and DSM diagnostic hierarchies.

Panikattacken sind mit einer Lebenszeitprävalenz von ungefähr 15% ein relativ häufiges Phänomen im Gegensatz zu einer vollen Panikstörung, die eine Prävalenz von 2,3–3% aufweist. In der vorliegenden epidemiologischen Untersuchung (n = 481) einer bundesweiten repräsentativen Stichprobe wurde geprüft, ob früh (vor dem 25. Lebensjahr) und spat auftretende Panikattacken sich hinsichtlich Symptomatik, Verlaufs- und Komorbiditätsmustern unterscheiden. Neben einer erhöhten Angstsymptomatik, insbesondere bezüglich respiratorischer Beschwerden und der Angst zu sterben, zeigte sich bei Panikattacken mit spätem Beginn ein erhöhtes Risiko für Multimorbidität. Auch entwickelten sich bei dieser Gruppe komorbide Bedingungen schneller. Dagegen waren Panikattacken mit frühem Beginn und einem erhöhten Risiko für Agoraphobie sowie phobische Störungen verbunden. Die Ergebnisse werden im Hinblick auf pathogenetische Mechanismen und Implikationen für die Planung therapeutischer Interventionen diskutiert.