TREATING PANIC DISORDER WITH AGORAPHOBIA

August 30, 2010 – 9:03 am

Running head: TREATING PANIC DISORDER WITH AGORAPHOBIA

Treating Panic Disorder with Agoraphobia:
Efficacy of Cognitive Behavioral Therapy and Other Treatment Approaches
Anthony J. Centore

Abstract
The following research investigates various contemporary treatments for panic disorder with agoraphobia, particular attention given to Cognitive-Behavioral Therapy (CBT) and drug treatments. Findings indicate both CBT and drug treatments are effective and useful in treating Panic disorder with agoraphobia. Additionally, spiritual issues are addressed and recommendations for further study are provided.

Treating Panic Disorder with Agoraphobia:
Efficacy of Cognitive Behavioral Therapy and Other Treatment Approaches

Anxiety is normal, and anthropologically designed as an instinctual human response to danger situations (Dugue & Neugroschl, 2002). In developed civilizations, anxiety is a common (and suitably adaptive) response to life stressors such as receiving bad news, relational tribulations, monetary debt, and medical illness.

Concurrently, an individual’s tolerance to—and ability to cope with—anxiety and worry depends on both life experience and personality (Dugue & Neugroschl, 2002). It is only when worry presents itself in pathological levels that it becomes maladaptive, and a diagnosis of anxiety disorder appropriate. However, in modern society excessive and maladaptive anxiety has become common plague (Hart, 1999; Short & Kitchner, 2002).

In discussing this, Archibald Hart (1999) states:
It is unlikely you can ever escape totally from this high-stress world…without forfeiting the opportunity to achieve anything meaningful with your life…How else can you achieve the American dream? Success demands that you pay the price of committing yourself to pursuing excellence. I wouldn’t really want to live any other way. But this approach to life has its penalties and pitfalls (p. 3).
Anxiety disorders affect more than 19 million American adults, and 25% of the general population. The most common, generalized anxiety disorder (GAD) and panic disorder (PD) (sometimes referred to as panic attack disorder), can greatly affect the quality of life for its sufferers (Short & Kitchner, 2002). Reportedly, 10-20% of those suffering from PD present agoraphobic symptoms in conjunction (Dugue & Neugroschl, 2002).

Panic Attack Defined

A panic attack is an explicit period of extreme discomfort or fear where at least four of the following criteria develop abruptly and peak within 10 minutes time: Palpitations (or excited heart rate), sweating, trembling or shaking, shortness of breath or smothered sensations, sensations of choking, chest pain or discomfort, nausea or abdominal discomfort, faintness, dizziness, unsteadiness, lightheadedness, feelings of unreality or detachment from reality (depersonalization), fear of losing control or “going crazy,” fear of death, numbness or tingling sensations, hot or cold flashes (DSM-IV, 2000, p. 432).

Though a significant psychological problem and physiological phenomenon, a panic attack alone is not a codeable diagnostic disorder. Panic disorder is not the occurrence of a panic attack but rather a condition that involves the presence of unexpected, recurrent panic attacks (usually with no known catalyst reported) (Barlow & Craske, 2001). Also, for an individual to qualify for PD diagnosis, he/she must present—following an attack—a minimum one month of concern/anxiety about enduring additional attacks; fear of the consequences of an attack such as losing control, dying, or “going crazy;” and a significant alteration of usual behavior, which is related to previous attacks (DSM-IV, 2000, p. 433). Furthermore, attacks cannot be due directly to drugs or physiology (i.e. cocaine, hyperthyroidism), and attacks are not better accounted for by another diagnosis (i.e. social phobia, obsessive compulsive disorder, separation anxiety) (DSM-IV, p. 440).

Agoraphobia Defined

Agoraphobia, which often accompanies PD (called panic disorder with agoraphobia) involves anxiety about being in places or situations from which escape might be difficult (or embarrassing), or where one could possibly suffer a panic attack (Barlow & Craske, 2001). These anxiety provoking situations often include crowds, busses or cars, bridges, trains, and places outside the home. These situations are avoided, or endured with noticeable distress, and often anxiety about having a panic attack (DSM-IV, 2000).

It is notable that if such avoidance is limited to a few situations; it is likely better accounted for as a phobia, rather than agoraphobia. Also, if limited to only social situations, a diagnosis of social phobia is preferred (Leahy & Holland, 2000). In addition, like a panic attack agoraphobia is not a codable disorder with the Diagnostic and Statistical Manual for Mental Disorders IV (DSM IV). Instead, agoraphobia is diagnosed as an adjunct to a present panic disorder, titled Panic Disorder with Agoraphobia (DSM IV, 2000).

One research team warns that the conditions of PD are disabling in nature by themselves, and are complicated by other psychiatric conditions, delayed treatment, and the presence of agoraphobia—which is a negative prognostic indicator (Andrews, Oakley-Browne, Castle, Judd & Baillie, 2003).
Misdiagnosis

One of the criteria, listed above, for the diagnosis of PD is that the panic attacks cannot be accounted for by either drug inducement or a prevailing medical/physiological issue, for panic attacks under the DSM IV diagnosis of PD are physiologically present due to primarily psychological provocation (Barlow & Craske, 2001). For example, 25% of persons who visit an emergency room presenting chest pain and symptoms of a pulmonary embolism are actually suffering from PD (Lee, Dade, 2003).

A practitioner, during the diagnostic interview of a client is responsible for ruling out likely medical causes of panic attacks. Hence, an in depth interview is the first step in establishing a diagnostic profile for a client suspected of having PD. Notably, recommended by Barlow & Craske (2001) the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) is a useful tool in the clinical interview process and assesses anxiety, mood & somatoform disorders, and screens for possible psychotic and drug conditions.

Among the present medical conditions and drugs/medications that can facilitate a panic attack like experience are caffeine or amphetamine intoxication, thyroid conditions, drug withdrawal, and Pheochromocytoma (a rare adrenal gland tumor). Conditions known to exasperate PD like symptoms include Mitral Valve Prolapse, which induces heart palpitations; Asthma, for it induces shortness of breath (as do allergies); and hypoglycemia has been known to create feeling of weakness or dizziness, both common with panic attacks/PD (Leahy & Holland, 2000).

Hypothesis

Evidence-based treatments for PD and panic disorder with agoraphobia are now clear (Andrews, et al., 2003). In regards, one researcher writes:

Choice of therapy will depend on the skill of the therapist in applying psychological treatments as well as the preferences of the patient, but there is a role for both psychological and evidence-based pharmacological approaches (Andrews et al., 2003).

There are numerous methods in treating PD. One effective scheme is CBT which boats an efficacy rate in PD treatment that deems it one of the great successes of psychotherapy (Barlow & Craske, 2001).
This paper will look at methods for treating PD and panic disorder with agoraphobia, and in particular will compare how CBT rates in effectiveness to other therapies, including medical treatments. It is hypothesized that though medical treatments are effective, CBT alone proves more effective than medication alone, as a treatment. It is also hypothesized that varied medical treatments will differ in effectiveness and treatment outcome. The null hypothesis of this study is that there is no difference in efficacy between the treatments under investigation.

CBT Treatment

Miler (2003) declares that practitioners should not forget about psychotherapy when treating panic anxiety, and that though the American Psychiatric Association (APA) guidelines may rate SSRIs highest, CBT has proved as effective as medication for many persons, and other (non-CBT) methods of psychotherapy have a place as well in PD treatment. Furthermore, Miller continues that there is no therapeutic substitute for patient social support, education about anxiety symptoms, reaction managing (to anxiety provoking stimuli), addressing life circumstances, and resolving emotional conflicts that may contribute to panic anxiety.

In additional support of CBT treatment, when Andrews (2003) added together the medication cost and the cost of a psychiatrists’ time to diagnose and treat a PD patient over the period of 12 months, and compared accrued fees to CBT cost, despite common economic belief after one year the cost of CBT was reported to be less than the cost of the average drug therapy. Specifically, CBT becomes more affordable than paroxetine at eight months, clomipramine at 11 months, and cheaper than imipramine at 13 months. Additionly, during the second and subsequent years thereafter, the superiority of CBT was found to increase (both economically and functionally) whether or not drug treatment continued; for if drug treatment and CBT were continued costs differences continued to augment, and if both drug treatment and CBT treatment were discontinued, patients who had undergone drug treatment relapsed in approximately 50% of instances (relapse after one year CBT treatment was non-significant until after five years post treatment) (Andrews et al., 2003). Stated in summary (also see appendix):
Cognitive behaviour therapy is both more effective and cheaper than pharmacotherapy. Tricycliclic antidepressants and SSRIs are equal in efficacy and both are to be preferred to benzodiazepines. Treatment choice depends on the skill of the therapist and the wishes of the patient. Cognitive behaviour therapy is preferred but SSRIs are commonly used; however, effective drug treatment should include behavioural treatment to limit avoidance (Andrews et al., 2003).

Rationale

Looking to the social causes for anxiety (though PD is mainly facilitated by anxiety dealing with internal physiological symptoms), psychotherapy can help patients to work through anxiety provoking psychosocial concerns—which can contribute to PD—such as family issues, money problems, and legitimate medical handicaps (Dugue & Neugroschl, 2002). The objective of CBT is to help the patient identify thoughts that are causing distress, and replacing those maladaptive thoughts with such that produce more favorable results (Dugue & Neugroschl, 2002).

The success of CBT on PD and panic disorder with agoraphobia, considered one of psychotherapies greatest achievements, boasts that 80-100% of clients in CBT treatment for PD will be without panic at the end of treatment (Barlow & Craske, 2001). These results are still existent during a two year follow-up, a dramatically higher rate than effective medications. Moreover, 50-80% of these clients are “cured” in that they present no symptomatology (and many of the remaining have only residual symptoms) (Barlow & Craske).

Negatively, as many as 50% of clients do retain substantial symptomatology post CBT
treatment, especially those with agoraphobic issues. Also, though many clients conclude treatment with 15-20 sessions, some clients necessitate significantly longer periods of CBT before meaningful real life (in vivo) improvement occurs (Barlow & Craske, 2001).

Basic Concepts of CBT

Cognitive restructuring is a major tenet of CBT, and involves replacing a thought held by
a client that is harmful, with a thought that is beneficial to the client’s psychological health. Much negative cognition is considered “automatic:” that is, the client has this thought automatically in response to a stimulus and often is unaware he/she even possesses such an cognition (Burns, 1999). This idea is dealt with by all cognitive theorists including Ellis (2003), in his discussion of irrational beliefs, Backus (2000) in his discussion of misbeliefs, and Beck (1979) in his discussion of illogical beliefs. Burns speaks about such cognitions and has labeled them by the harmful fallacies they hold such as “all or nothing thinking,” “fortune-telling,” “discounting the positive,” and “labeling” to name a few (p. 84, 99).

Breathing retraining has become a central component early in treatment for panic intervention because of the high instance of PD patients who report hyperventilatory symptoms (Barlow & Craske, 2001; Taylor, 2001). Notably however, less than 50% of PD patients show a reductions in blood levels of carbon dioxide insisting with PD hyperventilation might best be viewed as a stress-induce symptom that instigates fear, as opposed to a somatic issue (Barlow & Craske).

With this dimension in mind, though numerous studies suggest breathing retraining interventions to be effective in reducing panic attack frequency, concerns about its use have been raised (Taylor, 2001). According to Taylor, recent research suggests that since true biologically identifiable hyperventilation plays a limited role in producing panic attacks, breathing retraining may be counterproductive to treatment. In essence, attention to breathing retraining could prevent patients from learning about the true cause of their panic anxiety, which are unfounded catastrophic beliefs. There is a current warning to mental health practitioners that though breathing retraining may appear useful, clinicians must exercise care to ensure it is not misused by patients as a means of avoiding feared sensations.
Additional techniques include applied relaxation, to assist patients in preparing for, and coping with, stress inducing situations; interoceptive exposure, which is implemented to reduce the fear of one’s specific bodily cues (i.e. heart palpitations are harmless, and are not heart attacks); and in vivo exposure, which is presenting a client with a fear or anxiety provoking situation as a means of teaching the client the true powerlessness of the dreaded situation. If agoraphobia is present the goal includes the elimination of avoidant behaviors—to disconfirm and re-evaluate unhelpful appraisals (Short, 2002).

New CBT Methodology

In exposure therapy, the client is made to relax and imagine a stress inducing scenario (see above). With hope of improving this protocol, the idea of using virtual reality and home computer technology for the treatment of psychological disorders appeared first in the November of 1992 with the Human-Computer Interaction Group of Clark Atlanta University (Alcaniz, Botella, Ban, Perpina, Rey, Lozano, Guillen, Antonio, 2003).

In the investigation of the efficacy of new technology in CBT treatment, one study attempted the use of virtual reality equipment to increase effectiveness of exposures (Dong, Jang, Jeong, Shin, Choi, Kim, 2000). Although, possibly due to technological insufficiencies, the process proved cumbersome and ineffective (Dong et al., 2000). In contradiction, one meta study found patients had a significantly reduced amount of agoraphobic symptomology after using virtual reality equipment in the simulation of a fear provoking scenarios (such as an elevator ride) (Wiederhold & Wiederhold, 2003). Alcaniz et al (2003) found the use of virtual reality equipment, and home personal computer technology effective in the treatment of panic anxiety. The use of the internet has also been found useful for specific treatment of PD (Alcaniz et al., 2003; Richards & Alvareng, 2002), as has the implementation of CBT treatment of panic disorder with agoraphobia over video teleconference (Bouchard, Payeur, Rivard, Allard, Paquin, Ranaud, Goyer, 2000). This research shows some promise for further evolution of effective CBT treatment methods.

If CBT is Not Working

If there is an inadequate response after an adequate trial of CBT treatment, it may be wise to switch to another evidence-based treatment (Andrews, Oakley-Brown, Castle, Judd, Baillie, 2003). Andrews also notes, if PD is more severe than other co-occurring conditions (determined by impairment of daily living, and distress from symptoms), panic should be the initial focus of treatment, regardless of chronological onset. Also, while the presence of agoraphobia leads to a more negative prognosis; common co-morbid depression has no significant effect on outcome.

Medical Treatments

Antidepressants offer the most effective pharmacologic intervention for anxiety disorders (Dugue & Neugroschl, 2002). Four classes of antidepressant medication including selective serotonin reuptake inhibitors (SSRIs), high potency benzodiazepines, trycyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs) may be considered for the treatment of PD (Short & Kitchner, 2002).
Benzodiazepines vs. SSRIs

To begin, Miller (2003) remarks:
The American Psychiatric Association’s current guidelines stress the advantages of antidepressant treatment. Selective serotonin reuptake inhibitors (SSRIs) like fluoxetine
(Prozac), sertraline (Zoloft), and paroxetine (Paxil) are most popular, but other antidepressants—for example, the newer drug venlafaxine (Effexor) and the older tricyclics and monoamine oxidase inhibitors — are equally effective. And so are benzodiazepines, including, alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin). The choice depends on individual circumstances and side effects.

Benzodiazepines have been effective in treating PD for over 20 years. However, with recent concerns of drug abuse, addiction, Central Nervous System (CNS) side effects (i.e. sedation), long term use of these drugs is no longer considered optimal (Brown & Harvard, 2003). In investigating the drug of preference, there is little research comparing SSRIs head-to-head with benzodiazepines, though the research that is available suggests that in most cases SSRIs will win the risk-benefit comparison to benzodiazepines, for though SSRIs do have side effects (i.e. sexual dysfunction, insomnia, and upset stomach) they lack the benzodiazepines freqency physical or psychological dependence (Miller, 2003). Short & Kitchner (2002) elaborate stating that emerging clinical data suggests SSRIs to be the current first line of treatment, with paroxitine and sertraline being the most favorable of the SSRI group.
Contrarily, one study by Brown & Harvard University (2003) found that from 1991-2001 SSRI only prescriptions for PD increased from four to 11.2%, while benzodiazepine only treatment declined from 54.5 to 36.2%. This, showing a definite recent sway from benzodiazepine use to SSRI prescription, also displays that benzodiazepine only prescription is still considerably higher that SSRI, for PD treatment.

Miller (2003), in review of a Harvard & Brown anxiety research project involving the treatment of over 400 New Englanders, describes the use of SSRIs as “surprisingly low,” especially for patients who didn’t have symptoms of depression as well as anxiety. Miller continues to write that benzodiazepines are still the drugs most commonly used to treat PD and that even for panic patients with substance abuse problems, physicians prescribed benzodiazepines more often than SSRIs.

SSRIs have been around now for almost 15 years and have become the treatment of choice for some anxiety disorders, like obsessive-compulsive disorder (Miller 2003). However, due to the almost immediate relief benzodiazepines produce, compared to the several week delay with SSRIs, with PD patients benzodiazepines are greatly preferred. In addition, many patients find benzodiazepines more tolerable than SSRIs for while 50% of PD suffers discontinue SSRI use due to side effects, less than 10% discontinue benzodiazepines. Lastly, miller states concern over chemical dependence with benzodiazepines may be exaggerated for vast majority of persons with PD who are prescribed benzodiazepines do not after time necessitate higher doses, nor do they take the drugs for recreational purposes. This is a direct contradiction to research of benzodiazepines such as Clonazepam; brand name Klonopin (Physicians Desk Reference, 2002, p. 93). Explicitly, “Concern about physical or psychological dependence is reasonable but should not be exaggerated” (Miller).
To reap the benefits of both medications, Miller (2003) suggests a practitioner could prescribe both a benzodiazepine and an antidepressant at the onset of treatment. After suitable time has passed for the SSRI to take effect, the benzodiazepine can be gradually withdrawn. In this way, a PD patient receives the immediate benefits of a benzodiazepine, and the long term safety of an SSRI.

TCA vs SSRI

Due to side effect and tolerability concerns, SSRIs are often preferable to tricyclic andtidepressant medications which produce anti-cholinergic and cardiovascular effects (Dugue & Neugroschl, 2002). The objective of a recent study was to compare the short-term efficacy of SSRIs against TCAs in the treatment of PD. For this a meta-analysis was conducted that concluded there were no differences between SSRIs and TCAs on any of the effect sizes (drug effectiveness), indicating that both groups of antidepressants are equally effective in reducing panic symptoms, agoraphobic avoidance, depressive symptomatology and general anxiety. Moreover the percentage of patients free of panic attacks at post-test did not differ (Bakker, Balkom, Spinhoven, 2002).

Medication choice was not found to be equal however, for the number of patient drop-out was significantly lower in the group of patients treated with SSRI medications (18%) as opposed to patients treated with TCAs (31%). In summary, SSRIs and TCAs were found to be equal in efficacy for the treatment of PD, but SSRIs are more tolerable (Bakker et al., 2002).
HCL Medications

First, it must be explained that not all HCL treatments for PD are equal. The results of one randomized, double-blind, 15-week study with 225 patients who were treated with either sertraline HCl or paroxetine HCl—for PD—demonstrated comparable alleviation of symptoms during the 12-week treatment phase. However, during the following 3-weeks during dose tapering, the efficacy of sertraline HCl was maintained whereas participants administered paroxetine HCl demonstrated significant relapse and a greater number of withdrawal symptoms when compared to sertraline HCl. The most common side effects included upset stomach/diarrhea, insomnia, drowsiness, dry mouth, sexual side effects, tremors, sweating, feelings of agitation, and loss of appetite. Explained, “These findings suggest that patients taking sertraline HCl will maintain response, while patients on paroxetine HCl will have more panic attacks and show overall worsening during the dose tapering and discontinuation process” (Bandelow, 2003).

Experience of Psychiatrist

There is a considerable amount of research that considers the possibility that psychotherapist characteristics may influence the outcome of treatment. Not surprisingly,
therapist variables that may affect psychotherapy outcome include warmth, and supportiveness—though neither age, ethnicity, nor gender affect significantly therapy outcome (Gorman, Martinez, Goetz, Huppert, Ray, Barlow, Shear, Woods, 2003). This has held consistent with CBT treatment for PD and Panic Disorder with Agoraphobia.

Contrarily, much less research has been conducted considering psychiatrist expertise effect on the outcome of pharmacotherapy. In regards to practitioner experience, age, and gender with psychopharmacological treatments of the anti panic drug imipramine, one study’s results show that greater years of experience held by a psychiatrist was a significant predictor of better outcome with imipramine drug treatment (while psychiatrist age and gender were less relevant) (Gorman et al., 2003).

Japanese Herbal & Alternative Medications

According to one study, Japanese herbal supplements, known as Kampo medicines have been used to treat patients with psychological disorders since ancient times (Mantani, Hisanaga, Kogure, Toshiaki, Shmada, Terasawa, 2002).

More contemporarily, there has been a spawned interest in ancient, herbal, and alternative medications. One recent study investigates four case studies of individuals suffering from panic disorder with agoraphobia, and their success with Kampo medication treatment.
Reportedly, the Kampo medicine—Kami-shoyo-san (TJ-24)—relieved panic attacks, anticipatory anxiety and agoraphobia in two of the patients researched, and Kampo medicine Hange-koboku-to (TJ-16) relieved these symptoms in the other two patients (Mantani et al., 2002). The patients in whom Kami-shoyo-san was effective were older (59 & 53 as compared to 33 & 45) and complained of more symptoms than those in whom Hange-koboku-to was effective (Mantani et al).

Though this and other studies suggest Kampo medicines and other alternative herbal remedies may be useful as additional or alternative treatments for PD, patients should be warned of the risks of taking herbal, non-federally governed substances. More specifically, herbal supplements are not regulated by the food and drug administration, and are often sold without appropriate concern of safety, dosage, side effects, and drug interactions. Though herbal supplements can be effective, they can also be effectively destructive (Hart, 2003).

Spiritual Issues

No one is as well versed regarding the topic of spiritual issues in panic disorder as Dr. Archibald Hart of Fuller Theological Seminary. In one of his many texts, Hart (1999) addresses a scenario he has seen many times with Christian individuals who suffer from PD.

As a prelude to the vignette, a client named Susan has suffered from anxiety her entire life. This condition persisted until college when Susan became a Christian. Accordingly, she learned to pray, study scripture, and for the first time in her life experienced a hiatus in anxiety for she found much hope and reassurance in these spiritual disciplines.

However, one day Susan awakes to find her new sense of peace has left and that her feelings of anxiety have returned, intensified (Hart, 1999). She seeks therapy asking the questions, “what happened?” and “had God deserted me?” Hart responds:
Susan’s experience is a common one. Conversion often brings a wonderful sense of comfort and release from anxiety. It is the honeymoon phase of faith, and new believers often experience great excitement over a newfound prayer life and fresh insights from scripture. God’s Spirit seems very close and His comfort very real, which they are.

But anxiety can become deeply routed in our personalities, and while God sometimes provides a miraculous removal of these routes, more often He calls upon us to begin and then continue the process of sanctification…(p. 53).

Hart (1999) first assures the client that God has not deserted her. After that he discusses how healthy faith can foster protection from panic anxiety (p. 256), often using stories of Christ’s balanced life (p. 257). According to Hart, spirituality can both increase an individual’s anxiety, and alleviate it.
Other Christian practitioners have also considered issues of spirituality in psychological disorders (often with varying conclusions). For example, McMinn (1996) would entertain the possibility of spiritual sin being a cause of PD, while Adams (1970) believes all psychological disorders to be partly manifested due to the spiritual sin of the client.

Discussion

This document has investigated the issues of PD, and panic disorder with agoraphobia. Specifically, the ailments were defined, suggestions and warnings were given for the diagnosis of these disorders, as well as an investigation of several treatments for PD and panic disorder with agoraphobia.
According to the American Psychiatric Association, medical treatments are first in que, before CBT treatments, though the studies that compared medical treatments against CBT provided results that suggest CBT to be equally effective to medications during treatment, less expensive than chemical treatments after one year of treatment, and CBT was found to have better result (less relapse) than chemical treatments, whose results seems to dissipate quickly after the withdrawal of the medication (Andrews et al., 2003). This supports the hypothesis of this study.

However, the null hypothesis could not be rejected in regards to the comparative analysis of effectiveness of differing chemical interventions for PD, for all the medication investigated in this study were very effective for the treatment of PD and equally effective for the treatment of panic disorder with agoraphobia (Miller, 2003). The main differences between medications dealt with compliance levels in patients and the side effects produced by different medications (Bakker, Balkony & Spinhoven, 2002).

In addition to this, for both CBT and medical treatments, unorthodox subcategories of treatment were researched, namely the use of electronic media in CBT treatment, and alternative herbal supplements in medical treatment. Both “unorthodox” treatments showed significant levels of effectiveness and are of suitable worth for further investigation (Weiderhold & Weiderhold, 2003; Mantani et al., 2002; Dong et al., 2000).

Lastly, Spiritual issues in PD and anxiety were addressed by looking at Archibald Hart’s (1999) model and insight regarding the issues of spirituality (Christian specifically) in the treatment and presentation of anxiety issues.

References

Adams, J. (1970). Competent to counsel. United States: Presbyterian and Reformed Publishing
Company.
Alcaniz, M., Botalla, C., Ban, R., Perpina, C., Rey, B., Lozano, J., Guillen, V., Barrera, B., Gil,
J. (2003). Internet-based telehealth system for the treatment of agoraphobia.
Cyberpsychology & Behaviour, 6(4).
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
(4th ed.). Washington, DC: Author.
Andrews, G., Oakley-Browne, M., Castle, D., Judd, F., & Baillie, A. (2003, March). Summary of
guideline for the treatment of panic disorder and agoraphobia. Australian Psychiatry,
11(1).
Backus, W., Chapian, M. (2000, February). Telling yourself the truth. United States: Bethany
House Publishers.
Bakker A., Balkom, A., Spinhoven P. (2002). SSRIs vs. TCAs in the treatment of panic
disorder: a meta-analysis. ACTA Psychiatrica Scandinavica, 106, 163–167.
Bandelow, Biotech Week (ed.). (2003). Study shows tolerability advantages of sertraline HCL
over paroxetine. Biotech Week via NewsRx.com.
Barlow, D.H., Craske, M. (2001). Panic disorder and agoraphobia. Clinical Handbook of
Psychological Disorders: A Step-by-Step Treatment Manual (3rd ed.). New York: Guilford Press.
Beck, A., (1979). Cognitive therapy and the emotional disorders. United states: Meridian.
Bouchard, S., Payeur, R., Rivard, V., Allard, M., Paquin, B., Ranaud, P., Goyer, L. (2000).
Cognitive behavior therapy for panic disorder with agoraphobia in videoconference: Preliminary results. Cyberpsychology & Behavior, 3(6).
Brown and Harvard (2003, September). Guidelines recommend SSRIs but benzodiazepines still
most often prescribed for panic disorder. The Brown University Psychopharmacology Update, 14(9).
Burns, D. (1999). The feeling good handbook. United States: Plume
Dong, J., Jeong, H., Min, B., Shin, B., Young, C, Sun, K. (2000). Objective validation of the
effectiveness of virtual reality psychotherapy. Cyberpsychology & Behavior, 3(3).
Dugue, M., Neugroschl, J. (2002, August). Anxiety disorders: Helping patients regain stability
and calm. Geriatrics, 57(8).
Ellis, A., Maclaren, C. (2003, January). Rational Emotive Behavioral Therapy: A therapist’s
guide. Atascadero, CA: Impact Publishers.
Gorman, J., Martinez, J., Goetz, R., Huppert, J., Ray, S., Barlow, D., Shear, K., Woods, S.
(2003). The effect of pharmacotherapist characteristics on treatment outcome in panic disorder. Depression and Anxiety, 17(88), 93.
Hart, A. (1999) The anxiety cure: You can find emotional tranquility and wholeness. United
States: W Publishing Group.
Hart, A. (2003, August) Lecture given at Liberty University. Advanced Psychopharmacology.
Leahy R., Holland, S. (2000). Treatment plans and interventions for depression and anxiety
disorders. New York: Guilford Press.
Lee, J., Dade, L. (2003, July). The buck stops where? What is the role of the emergency
physician in managing panic disorder in chest pain patients? Journal of the Canadian Association of Emergency Physicians, 5(4), 237-238.
Mantani, N., Hisanga, A., Kogure, T., Kita, T., Shimada, Y., Terasawa, K. (2002). Four cases of
panic disorder successfully treated with Kampo (Japanese herbal) medicines: Kami-shoyo-san and Hange-koboku-to. Psychiatry and Clinical Neurosciences 56, 617–620.
McMinn, M. (1996). Psychology, theology, and spirituality in Christian counseling. Wheaton, IL: Tyndale House Publishers.
Miller, M.C. (2003, November). Questions and answers. Harvard Mental Health Letter.
Harvard Medical School Health: Harvard Health Publications.
Richards, J., & Alvarenga, M. (2002). Extension and replication of an Internet-based
treatment program for panic disorder. Cognitive Behaviour Therapy, 31(5), 41–47.
Short, N., Kitchner, N. (2002, April) Panic disorder: Nature assessment and treatment.
Continuing Professional Development. Royal College of nursing 5(7).
Taylor, S. (2001). Breathing retraining in the treatment of panic disorder: Efficacy, caveats and
indications. Scandinavian Journal of Behaviour Therapy, 30(2), 49–56.
Wiederhold B., Wiederhold, M. (2003, July) A new approach: Using virtual reality
psychotherapy in panic disorder with agoraphobia. Psychiatric Times.
_______. (2002). PDR: Drug guide for mental health professionals. Montvale, NJ: Thompson.