ORIGINAL ARTICLE
Agoraphobia With and Without Panic Disorder
A 20-Year Follow-up of Integrated Exposure and Psychodynamic Therapy
Asle Hoffart, PhD,*† Liv M. Hedley, PhD,* Karol Svanøe, MSW,‡
Tomas Formo Langkaas, CandPsychol,*† and Harold Sexton, MD*
Abstract: The aim of the current study was to compare the 20-year outcome
in panic disorder with agoraphobia (PD with AG) and agoraphobia without
panic disorder (AG without PD) patients after inpatient psychological treatment.
Of 53 eligible patients having completed a medication-free integrated expo-
sure and psychodynamic treatment, 38 (71.7%)—25 PD with AG and 13 AG
without PD patients—attended 20-year follow-up. AG without PD patients im-
proved less than PD with AG patients did on primary outcome measures. In
the PD with AG group, there were large uncontrolled effect sizes (<−2.30).
More of the AG without PD patients had avoidant personality disorder at pre-
treatment, but the presence of this disorder did not predict outcome. The
follow-up results support that PD with AG and AG without PD are two different
disorders. The results also suggest that the very long-term outcome in PD with
AG patients is excellent for this integrated treatment.
Key Words: Panic disorder with agoraphobia,
agoraphobia without panic disorder, exposure, psychodynamic therapy,
long-term follow-up
(J Nerv Ment Dis 2016;204: 100–107)
T he validity of agoraphobia (AG) as an independent diagnostic
category has been a matter of controversy over decades. In both
the third-revised and the fourth editions of the Diagnostic Statistical
Manual (DSM-III-R, American Psychiatric Association [APA],
1987; DSM-IV, APA, 1994), AG is conceptualized as a subordinate,
residual form of panic disorder (PD). That is, AG is considered either
as a result of PD, leading to the diagnosis PD with AG, or as the
result of panic attack or panic-like features, leading to the diagnosis
AG without a history of PD (AG without PD). In the fifth edition
(DSM-5; APA, 2013), by contrast, AG and PD are considered inde-
pendent diagnoses and thus brought in line with the International
Classification of Diagnoses Tenth Revision (ICD-10, World Health
Organization, 1993). In a recent review, however, Wittchen et al.
(2010) conclude that evidence pertaining to these issues from basic
and clinical validation studies is incomplete and partly contradictory.
Studies of community samples suggest that PD with AG and AG
without PD are persistent disorders associated with frequent complica-
tions such as impairment, disability and comorbidity (e.g., Wittchen
et al., 2008). In the study of treatment response, a problem has been
that very few patients have received the DSM diagnosis AG without
PD. It is uncertain to what extent this is due to the secondary status
of AG in the diagnostic system or to less help seeking among agorapho-
bic persons who do not meet the criteria for PD. Subjects diagnosed
with PD with AG have been found to be more than twice as likely to
seek mental health treatment as those with AG without PD (Andrews
and Slade, 2002; Wittchen et al., 1998). In any event, studies of the
treatment response of agoraphobic patients have almost exclusively
*Research Institute, Modum Bad, Vikersund; †Department of Psychology, University
of Oslo, Oslo; and ‡Vestfold University College, Tønsberg, Norway.
Send reprint requests to Asle Hoffart, PhD, Research Institute, Modum Bad, N-3370
Vikersund, Norway. E-mail: asle.hoffart@modum-bad.no.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0022-3018/16/20402–0100
DOI: 10.1097/NMD.0000000000000419
100 www.jonmd.com The Journal of Nervous and Mental Disease • Volume 204, Number 2, February 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
been conducted on PD with AG patients. For PD with and without
AG, recent meta-analyses suggest that both cognitive therapy and ex-
posure therapy are efficacious (Norton and Price, 2007; Stewart and
Chambless, 2009). However, in making recommendations for treat-
ment, it is important also to know to what degree initial treatment
gains are maintained over a number of years. Only a few studies have
exceeded a 2-year follow-up. Fava et al. (1995, 2001) found promising
results for responders to standardized exposure therapy for PD with
AG patients at 2–9 and 2–14 years follow-up, respectively.
In the present study, we wished to examine and compare the
very-long-term outcome in PD with AG and AG without PD patients
by extending the observations of a previously studied sample (Hoffart
et al., 1995) to a 20-year follow-up. As avoidant personality disorder
was more frequent among the AG without PD than among the PD with
AG patients at pretreatment and has been found to affect treat-
ment outcome among PD with AG patients (Hoffart and Martinsen,
1992), we also examined whether the presence of avoidant personality
disorder was related to poorer 20-year outcome. These patients had
received an 11-week inpatient, standardized, and medication-free
treatment. The first 5-week phase consisted of exposure and the second
6-week phase of psychodynamic therapy, which addressed potential
vulnerabilities for developing AG and comorbid disorders and was
intended to protect against relapse. This study is part of a larger long-
term follow-up study of AG including also patients from two other
trials at our site (N = 96). A difference in long-term improvement and
end states would support that the two diagnostic groups represent two
different disorders.
METHODS
Participants
Participants of the study were patients who had been treated
at a Norwegian inpatient clinic that has had a specialized treatment
program for AG since 1985. Because of the scattered settlement in
Norway, such residential adaptations of programs developed in an
outpatient setting assist in providing specialized and intensive treat-
ment opportunities for the entire Norwegian population. Thus, the
patients were referred because of lack of specialized local treatment
or because outpatient treatment attempts had failed. The participants
of the present study were admitted to treatment from January 1989 to
November 1990 in an open trial according to following inclusion
criteria: a) satisfied DSM-III-R criteria for PD with AG or AG with-
out PD, b) the patients considered the symptoms of AG as their main
problem, and c) were 20 to 65 years old.
As most participants had tried medication previously without
satisfactory effect and use of medication could interfere with cognitive
and behavioral learning, the use of psychotropic medication was pro-
hibited during the inpatient treatment period. Participants were informed
about this and a plan for the reduction or discontinuation of medication
before admission was agreed upon.
All those who completed treatment were included in the pre-
sent study of long-term outcome. Fifty-eight patients were admitted to
treatment and 5 (8.6%) of these dropped out, leaving 53 to be included
The Journal of Nervous and Mental Disease • Volume 204, Number 2, February 2016 Agoraphobia Treatment Follow-up

FIGURE 1. Flow of PD with AG and AG without PD patients through the study.

in the present study. Thirty-six of these met criteria for PD with AG
and 17 for AG without PD (see flowchart in Fig. 1). The reasons for
not attending long-term follow-up listed in Figure 1 show that
5 (9.4%) withdrew, whereas 10 (18.9%) did not attend for external
causes (death, sickness, unavailability).
The 38 patients who attended the long-term follow-up were
compared with the 15 nonattending patients for the pretreatment
values on the variables listed in Table 1 to determine the represen-
tativeness of the original sample. The two groups of patients proved
to be similar, with the exception that relatively more of the attending
patients had been working the previous year (42.1% vs. 13.3%),
χ2(1) = 4.22, p = 0.040, and had dysthymia (34.2% vs. 6.7%),
χ2(1) = 4.20, p = 0.040.
Of the 13 attending AG without PD patients, 6 had never
experienced unexpected panic attacks. Seven reported that they
had had unexpected attacks but failed to reach one or more of
the other DSM-III-R criteria for PD. Five of them failed to reach
the severity criterion (Criterion B: either four attacks in 4 weeks or
1 month with persistent fear of having a new attack), three had attacks
that turned out to be limited symptom attacks (Criterion C: fewer than
4 of the 13 listed symptoms during attacks), and four patients had
symptoms that did not reach maximum intensity within 10 minutes

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Hoffart et al. The Journal of Nervous and Mental Disease • Volume 204, Number 2, February 2016

session where the patients' training tasks for that day were specified
TABLE 1. Participant Characteristics at Pretreatment in detail, for example, travel alone by bus to the town nearby and buy
three articles in the supermarket. The patients could be accompanied
PD With AG AG Without PD
on the first one or two tasks. With reference to the principle of anxiety
Variable (n = 25) (n = 13)
decrease with time, they were encouraged to stay within the situation
Age at intake, mean (SD), yrs 35.9 (7.9) 38.3 (8.3) until the anxiety level subsided. Afterward, they wrote down their
Duration of AG, mean (SD) 9.8 (9.7) 11.3 (5.8) reactions during the exposure and rated their anxiety level (0–10)
Female 21 (84.0) 7 (53.9) over time. The patients were expected to continue their training until
Married/cohabiting 17 (68.0) 7 (53.9) they were gathered for a 1-hour session at the end of the day to dis-
cuss their experiences from the exposure tasks. In the fifth week, the
Lower occupational levela 18 (72.0) 11 (84.6)
patients returned home to test their newly acquired skills in their
In work last year (>50%) 10 (40.0) 6 (46.2) natural environments.
Previous psychiatric treatment 22 (88.0) 9 (69.2) In the second 6-week psychodynamic phase of the program, life
Use of BZ last month 18 (72.0) 10 (76.9) problems and inner conflicts that may cause or maintain anxiety were
Use of antidepressants last month 4 (16.0) 4 (30.8) addressed during group sessions and individual sessions according to
Axis I disorders psychodynamic principles (Chambless et al., 1986). Such life problems
Social phobia 13 (52.0) 6 (46.2) and conflicts included unresolved grief; fear and guilt about angry feel-
Generalized anxiety disorder 6 (24.0) 4 (30.8) ings toward close persons; anxiety about leaving the role of a “sick”
Obsessive compulsive disorder 5 (20.0) 0 (0.0) person and assuming normal, responsible functions; problems of self-
Simple phobia 5 (20.0) 2 (15.4) assertion related to the expectations of family and friends; and worries
about possible misfortune befalling loved ones. During the final
Hypochondriasis 1 (4.0) 0 (0.0)
2 weeks, feelings of separation were focused upon in the group setting.
Somatoform pain disorder 3 (12.0) 1 (7.7)
Undifferentiated somatoform disorder 5 (4.0) 1 (0.0)
Therapists and Supervision
Major depression, current 7 (28.0) 1 (7.7)
Major depression, lifetime 10 (40.0) 5 (38.5) The staff consisted of a certified clinical psychologist (having
completed a 5-year specialization program in clinical psychology),
Dysthymia 9 (36.0) 4 (30.8)
two psychiatric nurses, an occupational therapist, and a consulting psy-
Alcohol dependence/abuse 3 (12.0) 1 (7.7) chiatrist. Most therapists had extensive experience in the program and
Non-alcohol dependence/abuse 4 (16.0) 0 (0.0) every one had participated in at least one pilot training treatment group.
Axis II disordersb The program had existed in the same form since 1985. The therapists
Paranoid 2 (8.0) 0 (0.0) had a written description of the treatment, but no formal adherence
Antisocial 1 (4.0) 0 (0.0) checks were made. A PhD psychologist (the first author) conducted
Borderline 2 (8.0) 0 (0.0) a 60-minute weekly supervision session of the therapists, addressing
Histronic 3 (12.0) 0 (0.0) immediate treatment problems and questions about adherence to the
Narcissistic 0 (0.0) 1 (7.7) treatment model.
Avoidant* 5 (20.0) 9 (69.2)
Dependent 4 (16.0) 1 (7.7) Measures
Obsessive compulsive 3 (12.0) 1 (7.7) All psychometrics are given for the three combined long-term
follow-up sample consisting of 96 patients. The self-report Mobility
Note: Data are presented as n (%), unless otherwise stated. Inventory for Agoraphobia (MI; Chambless et al., 1985) measures
a
Unemployed, skilled/unskilled worker, uneducated functionaries. agoraphobic avoidance of a range of situations, both when the patients
b
Schizoid and schizotypal axis II disorder not present. are alone (MI-AAL) and when they are accompanied (MI-ACC), on a
*Significantly (p < 0.05) higher frequency among AG without PD patients. 1-to-5 scale. As the MI-AAL subscale was deemed as most relevant,
only this subscale of the MI was analyzed. It was also selected as the
primary self-report outcome measure. The reliability and concurrent
(Criterion D). The principal AG-triggering symptom was dizziness for and construct validity of the MI have been supported (Chambless
six patients, depersonalization or derealization for four patients, short- et al., 1985). The self-report Body Sensations Questionnaire (BSQ;
ness of breath for two patients, and feeling paralyzed for one patient. Chambless et al., 1984) measures on a 1-to-5 scale how anxiety pro-
voking the subjects find various body sensations associated with high
arousal. The Agoraphobic Cognitions Questionnaire (ACQ; Chambless
Treatment et al., 1984) measures thoughts about the possible catastrophic physical
The effectiveness of the program has been indicated in a quasi- and loss of control consequences of panic attacks (e.g., heart attack,
experimental study (Hoffart and Martinsen, 1990). The patients were going crazy). The patients rated on a 1-to-5 scale how often each
admitted to closed treatment groups with eight members in each. Blood thought occurred during anxiety episodes. The reliability and discri-
sample tests of drug or alcohol use were collected routinely at intake minate and construct validity of the BSQ and the ACQ have been sup-
and upon suspicion throughout treatment. ported (Chambless et al., 1984). For the long-term follow-up scores
In the first 5-week exposure phase, the patients had no individual in the present study, the Cronbach's alpha of the MI-AAL, BSQ,
sessions except for the intake session. The first week consisted of and ACQ-control scales ranged from 0.86 to 0.97, whereas the alpha
education, where the patients were introduced to the principle that was somewhat lower (0.74) for the ACQ-physical scale. The self-
a high level of anxiety must decrease if an anxiety-provoking situa- report State-Trait Anxiety Inventory (STAI; Spielberger, 1983) pro-
tion is endured for a long enough time (Marks, 1987) and the patients vides scores for both state (STAI-Y1) and trait (STAI-Y2) anxiety.
setting specific goals for their treatment. Also, within this first Considerable evidence attests to the construct and concurrent validity
week, any remaining psychotropic medication was discontinued. In of the scale (Spielberger, 1983). The self-report Beck Depression
the second to fourth week, each day began with half an hour planning Inventory (BDI; Beck et al., 1988) measures degree of depressive

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The Journal of Nervous and Mental Disease • Volume 204, Number 2, February 2016
symptoms. The construct and concurrent validity with respect to a
variety of psychological measures has been established (Beck et al.,
1988). For the long-term follow-up scores, alpha ranged from 0.91 to
0.96 on these three scales.
The interview-based Phobic Avoidance Rating Scale–Separation
(PARS-Sep; Hoffart et al., 1989) subscale was administered at long-
term follow-up. The PARS-Sep has proved to have satisfactory
interrater reliability, internal consistency, concurrent validity, ability
to discriminate between diagnostic groups, and sensitivity to change
after treatment (Hoffart et al., 1989). The two interviewers indepen-
dently rated tapes of 10 of each others' randomly selected PARS
interviews. The intraclass correlation (3,1; Shrout and Fleiss, 1979)
was 0.97. Cronbach's alpha was 0.90. The PARS-Sep was used as the
primary interview-based measure.
At the follow-ups, the distributions on most of the outcome
measures exhibited positive skewness and kurtosis. That is, an over-
abundance of scores approached minimum scores and the distribu-
tions were narrower and higher than the normal curve.
Diagnostics
The Structural Clinical Interview for DSM-III-R (SCID-I and II;
Spitzer et al., 1988) was used for the assessment of axis I and II dis-
orders. A satisfactory interrater reliability for the pretreatment and
2-year follow-up interviews has been evidenced (Hoffart et al.,
1995). However, because the AG without PD diagnosis is controversial
and the present sample, compared with other clinical samples, com-
prised an unusually high proportion of patients with this diagnosis,
the credibility of the original classifications could be questioned. There-
fore, the written SCID reports and treatment files of the 20 AG without
PD patients were inspected by the first author, who had not been in-
volved in the pretreatment diagnostics. He detected a probable misap-
plication in three cases of the E criterion for PD, saying that
“It cannot be established that an organic factor initiated and main-
tained the disturbance, e.g., …caffeine intoxication…” Although the
written material indicated that excessive coffee drinking was in-
volved in the first panic attack for the three cases, it also showed
that later and influential attacks occurred without being precipitated
by coffee intake. Thus, the organic factor of caffeine could not be
said to maintain the disturbance. As these three patients had been
judged to meet all the other criteria for PD, they were reclassi-
fied as PD with AG patients.
The diagnostic interviews at long-term follow-up covered the
period since the 2-year follow-up and were conducted by the sec-
ond and third authors. Twenty videotaped interviews—10 from each
interviewer—were randomly drawn from the interviews performed on
the 96 patients of the overall study and rated by the other interviewer
for a reliability check. The kappa values were 0.98 for PD with AG,
social phobia, and specific phobia and 0.75 for AG without PD. As
there were very few other diagnoses (two participants were diagnosed
with depressive disorders and only one other diagnosis was noted),
the kappa values were not calculated for these.
Procedure
Patients completed self-report measures at admission to hospital/
treatment start (pretreatment), after the exposure phase (midtreatment,
5 weeks, 0.1 year), and after the psychodynamic phase (posttreatment,
11 weeks, 0.2 year). The patients were invited as a group to short
(2–4 days) follow-up stays at the hospital and completed the self-
report measures also 1 and 2 years after end of treatment. The PARS-
Sep was administered at pretreatment, posttreatment and at 1- and
2-year follow-up and the SCID-I and -II at pretreatment and 2-year
follow-up. At long-term follow-up, the patients were approached
initially by letter, inviting them to contact the researcher for an
appointment. If no response occurred within 2 weeks, the patients were
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Agoraphobia Treatment Follow-up
contacted by telephone. The participants could come to the clinic or
meet at a place of their choice. Two participants preferred to be
interviewed in their own home. Travel expenses were refunded, as
well as any loss of income incurred as a result of their participation
in the research project. Other than refunding direct expenses, no
incitements were given for participation. If, during the interview,
it became apparent that the participant had a current need for treat-
ment, the interviewer assisted with a referral. The long-term follow-
up interviews occurred on average 20.5 years (SD, 0.6 years) after
start of treatment (pretreatment) and were conducted individually
and videotaped. In addition to the administration of the self-report mea-
sures described above, a comprehensive interview was conducted.
This interview included the SCID-I and -II, the PARS-Sep, and assess-
ment of the frequency of panic attacks for the last 2 weeks and for
the last month. As at the 1- and 2-year follow-up, employment status
and psychosocial treatments in the previous year and use of medi-
cation the previous month were tracked. The first interviewer (the
second author) is a PhD psychologist experienced in performing diag-
nostic interviews and follow-investigations. She was blind to the
results of the diagnostic assessments at pretreatment but had par-
ticipated in the treatment and supervision related to some of the
patients of the last two treatment groups. The second interviewer
(the third author) is a clinical social worker (Master of Social Work),
who has been trained in conducting DSM diagnostic interviews in
previous studies at another site. She was blind to all previous results
of this study and has never been involved in the treatments. The first in-
terviewer examined 27, and the second one, 11 patients.
Statistical Analysis
Our data are multilevel, in which the repeated measurements
are lower-level units nested within patients, who are upper-level units.
Therefore, we used linear mixed effects models, which can take ac-
count of, and adjust for, the interdependence of the repeated obser-
vations within individuals that is typical in multilevel longitudinal
data (Fitzmaurice et al., 2004). This dependency is accounted for
by introducing individual-specific random effects and by modeling
the covariance structure of the residuals. In each analysis, the com-
bination of random effects and covariance structure of the residuals that
gave the best fit was chosen. Maximum likelihood was used as esti-
mation method as this method allows a comparison of nested models.
Akaike's Information Criterion was used to compare the fit of different
models (Akaike, 1974).
Different degrees of change could be expected within the
differing time periods, that is, more change during active treatment than
afterward. Time was therefore modeled with two terms: elapsed time
since pretreatment in years (coded: 0, 0.1, 0.2, 1.2, and 2.2, [long-term
value]) and a two-value (period A: pretreatment, midtreatment, post-
treatment = 1, period B: the three follow-ups = 0) period variable. This
model fitted better than a curvilinear model (centered elapsed time
plus quadratic centered elapsed time) for all outcome measures.
The outcome measures—MI-AAL, PARS-Sep, BSQ, ACQ-
physical, ACQ-control, STAI-Y1, STAI-Y2, and BDI—were used as
dependent variables in the analyses. In the first step, time and period
were included as independent variables to examine whether the
scores on the outcome measures changed with time and whether
the scores had a different level in the periods. In the second step, a
time-by-period interaction term was included to examine whether
the scores changed at different rates between periods. In the third
step, an AG diagnosis (0 = PD with AG, 1 = AG without PD) term
was added to examine whether the scores had different levels in
the two diagnostic groups. Finally, we included a time-by-diagnosis
term to examine whether linear change was different in the two
groups when the difference in changes between periods was modeled
and thus controlled for. Because of small sample size and skewness
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and kurtosis of the variables at the follow-ups, we repeated the
final models using restricted maximum likelihood (REML) esti-
mation because this method is more accurate for small samples
(Fitzmaurice et al., 2004) and less affected by nonnormality of the
variables (Jiang, 1996). To examine the potential influence of avoid-
ant PD on outcome, we added an avoidant personality disorder term
and an avoidant personality disorder by time interaction term to final
mixed models for the MI-AAL and the PARS-Sep.
Diagnostic groups were compared at baseline using independent
t-tests for continuous data and chi-square (Fisher's exact test when
an expected cell number was below 5) for categorical data. McNemar's
test was used for dependent (longitudinal) categorical data. A sig-
nificance level of 0.05, two tailed, was selected. Effect sizes (ESs)
were computed as Hedges' g for dependent samples (Borenstein et al.,
2009). The criteria of Jacobson and Truax (1991) were used to cal-
culate clinically significant change at long-term follow-up. Using the
results in the agoraphobic and nonclinical samples of Chambless
et al. (1985) as normative data, a cutoff of 1.65 and a reliable change
index of 0.67 were used on the MI-AAL. To compare with Durham
et al. (2012), we also calculated clinical significance on the STAI-Y2.
We used the same cutoff as these authors, lower than 47, but because
of greater variance in our pretreatment scores, we computed reliable
change as greater than 11, whereas Durham et al. used greater than 7.
We used the program SPSS 19.0.
RESULTS
Comparing Diagnostic Groups at Pretreatment
The characteristics at pretreatment of the 25 PD with AG patients
and the 13 AG without PD patients are provided in Table 1. t-Tests or
chi-square/Fisher's exact test comparing the two diagnostic groups re-
vealed no significant ( p < 0.05) differences except that relatively more
of the AG without PD patients than of the PD with AG patients had
avoidant personality disorder, 5 of 25 (20.0%) vs. 9 of 13 (69.2%), χ2
(1) = 8.91, p < 0.01.
Comparing Outcome on Dimensional Measures
The descriptive statistics for the outcome measures across
diagnoses and assessments are provided in Table 2. On the PARS-
Sep, the ES was −2.32 (95% confidence interval, −3.19 to −1.46) for
the PD with AG patients and −1.08 (95% confidence interval, −1.85
to −0.30) for the AG without PD patients. On the MI-AAL, the
ES was −3.33 (95% confidence interval, −4.67 to −1.99) for the PD
with AG patients and −0.97 (95% confidence interval, −1.67 to
−0.26) for the AG without PD patients.
We used mixed-model analyses to determine if there were differ-
ences in long-term efficacy for the two diagnoses. For the interview-
based PARS-Sep, a first-order autoregressive moving average (ARMA
(1,1)) covariance structure for the residuals gave the best fit. A first-
order autoregressive (AR(1)) covariance structure gave the best fit for
all the analysed self-report measures. Random effects did not improve
the fit of any of the models.
To illustrate the steps in our mixed model analyses, the results for
our primary self-report outcome measure—the MI-AAL–are reported
in Table 3. There was an effect of elapsed time and period and, in the
next model, a time-by-period interaction, indicating that the scores
changed differently in the two periods. The third model indicated that
there was no effect of diagnosis; that is, the levels across assess-
ments were not different in two diagnostic groups. In the final model,
the time-by-diagnosis interaction was significant. As the AG with-
out PD patients was used as baseline, the negative sign of the t-value,

TABLE 2. Mean (SD) for the Outcome Measures Across Diagnostic Groups and Assessments

Pretreatment Midtreatment Posttreatment 1-yr Follow-up 2-yr Follow-up 20-yr Follow-up

PARS-Sep
PD w AG 2.77 (0.94) — 1.23 (0.97) 1.19 (1.07) 1.05 (1.08) 0.65 (0.82)
AG wo PD 2.52 (0.89) — 0.82 (0.54) 1.14 (0.95) 0.94 (1.01) 1.22 (1.30)
MI-AAL
PD w AG 3.88 (0.78) 2.74 (0.80) 2.31 (0.80) 2.11 (0.80) 2.15 (0.99) 1.64 (0.48)
AG wo PD 3.44 (0.79) 2.39 (0.74) 1.95 (0.63) 1.97 (0.97) 1.87 (0.97) 2.28 (1.32)
BSQ
PD w AG 3.08 (0.68) 2.51 (0.65) 1.99 (0.55) 1.81 (0.43) 1.87 (0.66) 1.60 (0.51)
AG wo PD 2.91 (0.62) 2.16 (0.74) 1.89 (0.88) 1.87 (0.78) 1.77 (0.85) 1.84 (0.53)
ACQ-Physical
PD w AG 2.39 (0.58) 2.00 (0.44) 1.75 (0.37) 1.58 (0.34) 1.61 (0.46) 1.50 (0.42)
AG wo PD 2.15 (0.78) 1.77 (0.97) 1.44 (0.49) 1.38 (0.52) 1.32 (0.33) 1.36 (0.41)
ACQ-control
PD w AG 3.35 (0.75) 2.66 (0.77) 2.13 (0.74) 1.90 (0.56) 1.82 (0.73) 1.35 (0.37)
AG wo PD 2.77 (0.71) 2.11 (0.59) 1.87 (0.63) 1.76 (0.73) 1.76 (0.69) 1.44 (0.51)
STAI-Y1
PD w AG 50.8 (14.5) 46.0 (11.3) 45.0 (13.4) 39.1 (11.4) 35.0 (11.5) 31.9 (9.1)
AG wo PD 51.5 (12.4) 39.4 (12.4) 36.3 (11.6) 35.5 (13.0) 35.7 (15.5) 37.6 (16.7)
STAI-Y2
PD w AG 58.6 (10.9) 54.6 (11.1) 50.6 (12.2) 44.3 (10.3) 41.8 (11.9) 36.7 (9.6)
AG wo PD 56.7 (7.3) 45.6 (9.3) 43.3 (10.0) 39.2 (9.4) 38.3 (11.9) 40.5 (16.0)
BDI
PD w AG 19.0 (10.1) 13.4 (8.1) 13.0 (8.9) 9.2 (6.7) 8.2 (6.9) 6.7 (5.6)
AG wo PD 15.2 (8.9) 9.8 (7.1) 5.3 (5.5) 5.2 (4.9) 6.6 (6.2) 7.5 (8.1)
PD w AG indicates PD with AG; AG wo PD, AG without a history of PD.

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The Journal of Nervous and Mental Disease • Volume 204, Number 2, February 2016 Agoraphobia Treatment Follow-up

TABLE 3. Fixed Effects Estimates (Top) and Variance Estimates (Bottom) for Models of the MI-AAL

Parameters Model 1 Model 2 Model 3 Model 4

Fixed effects
Intercept 2.36* (0.14) 2.05* (0.13) 1.99* (0.17) 1.80* (0.18)
Timea −0.02* (0.01) −0.01 (0.01) −0.01 (0.01) −0.03* (0.01)
Period A 0.51* (0.15) 1.62* (0.17) 1.62* (0.17) 1.62* (0.17)
Period B 0 0 0 0
Time  period A — −7.70* (0.66) −7.70* (0.82) −7.70* (0.80)
Time  period B — 0 0 0
PD w AG — — 0.09 (0.13) 0.37 (0.19)
AG wo PD — — 0 0
Time  (PD w AG) — — — −0.05* (0.01)
Time  (AG wo PD) — — — 0
Random parameters
Residual 0.96* (0.11) 0.72* (0.08) 0.72* (0.08) 0.68* (0.08)
Rhob 0.49* (0.07) 0.52* (0.06) 0.52* (0.06) 0.53* (0.06)
AIC 595.3 523.2 524.9 513.6
Note: Standard errors are in parentheses. Period A: pretreatment, midtreatment, posttreatment; period B: 1-, 2-, 20-year follow-up.
PD w AG indicates PD with AG; AG wo PD, AG without a history of PD; AIC, Akaike's Information Criterion.
a
Time = elapsed time since pretreatment.
b
Correlation between adjacent observations.
*p < 0.05.

t(223.7) = −3.71, p < 0.001, shows that the scores decreased more treatment to all the follow-ups ( p < 0.05, McNemar's test). At long-term
among the PD with AG patients. follow-up, relatively more of the AG without PD than of the PD with
The same analytic steps revealed a negative time-by-diagnosis AG patients used BZs, χ2(1) = 4.03, p < 0.05. There was a trend that
interaction effect also for the PARS-Sep, t(152.2) = −2.22, p < 0.05; the use of antidepressants increased from pretreatment to long-term
the BSQ, t(221.5) = −1.97, p = 0.05 (borderline); and for the STAI- follow-up ( p = 0.06, McNemar's test). At this follow-up, 16 of the
Y2, t(215.6) = −2.68, p < 0.01. A trend toward a time-by-diagnosis 38 patients (42.1%) used antidepressants. Except for BZ use, there
effect was noted for the STAI-Y1, t(222.9) = −1.72, p = 0.086. were no between-diagnostic differences at long-term follow-up on the
No time-by-diagnosis effect was revealed for the ACQ-physical categorical variables referred to above.
subscale, t(220.9) = 0.89, ns; for the ACQ-control subscale, t
(208.0) = −1.44, p = 0.153; and for the BDI, t(218.7) = −1.55,
p = 0.122. Repeating this final model with REML gave exactly
the same pattern of significant results.
TABLE 4. Descriptive Characteristics for the 25 PD w AG Patients and
13 AG wo PD Patients Across Assessments
Comparing Outcome on Categorical Measures 1-yr 2-yr 20-yr
Sixteen (64.0%) of the 25 PD with AG patients and 8 (61.5%) Pretreatment Follow-up Follow-up Follow-up
of the 13 AG without PD patients had no PD and/or AG diagnosis
at long-term follow-up. Of the 25 PD with AG patients, 1 had PD, 4 Employed last year
had PD with AG, and 4 had AG without PD at long-term follow-up. (>50%)
Of the 13 AG without PD patients, 3 had PD with AG and 2 had PD w AG 10 (40.0) 17 (68.0) 19 (76.0) 13 (52.0)
AG without PD. On the MI-AAL, 14 (56.0%) of the 25 PD with AG wo PD 6 (46.2) 10 (76.9) 11 (84.6) 7 (53.9)
AG patients attained recovery (reliable pretreatment to long-term Psychosocial treatment
follow-up change and below cutoff at follow-up), 10 (40.0%) were last year
improved (reliable change, but not below cutoff ), and 1 (4.0%) was PD w AG 22 (88.0) 14 (56.0) 13 (52.0) 1 (4.0)
unchanged. Of the 13 AG without PD patients, the rates were AG wo PD 9 (69.2) 10 (76.9) 8 (61.5) 1 (7.7)
6 (46.2%) recovered, 4 (30.8%) improved, 1 (7.7%) unchanged, and BZ use last month
1 (7.7%) deteriorated. On the STAI-Y2, 19 (76.0%) of 25 PD with PD w AG 18 (72.0) 6 (24.0) 4 (16.0) 7 (28.0)
AG patients and 7 (53.9%) of AG without PD patients attained recovery AG wo PD 10 (76.9) 5 (38.5) 6 (46.2) 8 (61.5)
status at long-term follow-up. There were no differences between
Antidepressant use
the two diagnostic groups on any of these categorical variables. last month
Compared with pretreatment, the number of patients at least
PD w AG 4 (16.0) 4 (16.0) 4 (16.0) 12 (48.0)
50% actively employed the previous year increased at 1- and 2-year
follow-up ( p < 0.05, McNemar's test) but was no longer different at AG wo PD 4 (30.8) 2 (15.4) 3 (23.1) 4 (30.8)
long-term follow-up (see Table 4). There was less use of psychosocial Note: Data are presented as n (%).
treatments at the follow-ups than before intake ( p < 0.01, McNemar's PD w AG indicates PD with AG; AG wo PD, AG without a history of PD.
test). Also, the use of benzodiazepines (BZs) was reduced from before

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Hoffart et al. The Journal of Nervous and Mental Disease • Volume 204, Number 2, February 2016
Avoidant Personality Disorder as a Predictor of
Long-Term Outcome
The additional avoidant personality disorder-by-time interac-
tion term did not contribute to MI-AAL scores, t(223.7) = 0.50, ns,
whereas the PD with AG patients still decreased more than the AG
without PD patients, t(223.7) = −3.02, p < 0.01, neither did the avoid-
ant personality disorder-by-time interaction term contribute to PARS-
Sep scores, t(153.7) = 1.28, ns, whereas the PD with AG patients
still tended to decrease more than the AG without PD patients,
t(153.7) = −1.69, p = 0.09.
DISCUSSION
In the present study, we compared the 20-year long-term out-
come in PD with AG patients and AG without PD patients after inte-
grated exposure and psychodynamic therapy. AG without PD patients
improved less than PD with AG patients on both the interview-based
and self-report primary outcome measure. The same differences were
evident on the secondary measures of fear of body sensations and trait
anxiety, but not of cognitions. Thus, although no differences were
observed at 2-year follow-up (Hoffart et al., 1995), these two diagnostic
groups differed in the long run. These results are consistent with those
of a longitudinal study of a community sample, where it was found that
AG without panic symptoms ranks among the most persistent disorders
over a period of 10 years with a stability exceeding the one of PD
(Emmelkamp and Wittchen, 2009).
Our results support that PD with AG and AG without PD are
two different disorders, which is reflected both in the current DSM-5
and ICD-10. Whereas agoraphobic avoidance in PD with AG
appears to be related to the stressful experience of panic attacks,
avoidance in AG without PD may be more related to a dispositional
analogue of panic, namely anxiety sensitivity. The anticipated con-
sequences (e.g. mental incapacitation) of anxiety symptoms may
inhibit approach to feared situations. Preliminary evidence for this
proposition has been provided (Hayward and Wilson, 2007). More-
over, an avoidant personality style/disorder may accentuate the risk
for developing agoraphobic avoidance despite the absence of frank
panic attacks. Consistent with this contention, avoidant personality
disorder was more frequent among the studied AG without PD patients
than among the PD with AG patients.
The presence of avoidant personality disorder was unrelated to
outcome, and the outcome remained different in the two diagnostic
groups even when the potential influence of avoidant personality dis-
order was controlled. Thus, it seems that the higher frequency of
avoidant personality disorder among the AG without PD patients could
not explain the poorer outcome in this group. However, the failure
to find such a relationship may be a result of the low statistical power
in the present study.
Exposure is the best documented treatment for PD with AG
and consistent with Fava et al. (1995, and 2001); the long-term results
appeared to be excellent for these patients. It should be noted, how-
ever, that nearly half (48.0%) of the PD with AG patients had used
antidepressants the month before long-term follow-up, and this use
may have contributed to outcome. Compared with the only existing
very long-term (2–14 years) follow-up study of CBT for anxiety dis-
orders (Durham et al., 2012), the present proportion recovered of
19 (76.0%) of 25 on the STAI-Y2 in the PD with AG group exceeded
the proportion obtained in that study, 66 (44.0%) of 151, χ2
(1) = 8.96, p < 0.01. However, only one third of the patients in that
study had a primary diagnosis of PD. Two thirds had a primary diag-
nosis of generalized anxiety disorder, making comparisons with the
present sample difficult. Also, the present AG without PD patients did
well on the categorical outcome measures.
The utilization of psychosocial treatments during the previous
year was almost nonexistent at long-term follow-up. The proportion
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of patients working increased from pretreatment to 1- and 2-year
follow-up but was no longer different at long-term follow-up. The
proportion of patients using BZs was reduced from before treatment
to all the follow-ups, whereas the use of antidepressants tended to
increase from pretreatment (21.1%) to long-term follow-up (42.1%).
Relatively more of the AG without PD than of the PD with AG
patients used BZs at long-term follow-up. As many as 8 (61.9%) of
the 13 AG without patients used BZs. Half of these patients used BZs
on an intermittent as-per-needed basis, suggesting that they were
used as a safety measure to protect against feared bodily and/or men-
tal symptoms.
Several limitations of this study should be noted. One was that
28.3% of the included patients did not attend long-term follow-up.
Only 9.4% actually withdrew from the study, whereas 18.9% did
not complete because they were dead or physically ill or could not
be reached. There were few differences in pretreatment characteris-
tics between attendants and nonattendants and they did not have a
different outcome at 2-year follow-up, indicating that they were not
different. Still, we do not know the nonattendants' end status. We also
do not know what the patients' course would have been without treat-
ment. However, the use of a no-treatment control group in such a very
long-term follow-up study would be both unethical and practically in-
feasible. Finally, the sample size for AG without PD was small, limiting
statistical power.
In conclusion, the present results support that PD with AG and
AG without PD are two different disorders. They are also consistent
with other evidence of the enduring efficacy of exposure therapy for
PD with AG and should stimulate clinicians to apply exposure for
this disorder. Whether psychodynamic therapy contributes to long-
term outcome is more uncertain. If future research supports that the
enduring effect of exposure on AG without PD is limited, this would
suggest that this disorder is in need of additional or alternative treat-
ment. Adding cognitive therapy to exposure to better address anxiety
sensitivity could enhance outcome in AG without PD patients. Schema
therapy could be a promising alternative for addressing the avoidant
personality disorder frequently associated with AG without PD as this
treatment has turned out to be highly effective for personality disorders
(Bamelis et al., 2014).
ACKNOWLEDGMENTS
The authors thank Professor Knut Hagtvet for a statistical expert
review of this article.
DISCLOSURE
This research was funded by the South-Eastern Norway Regional
Health Authority (grant no. 2009045).
The authors declare no conflict of interest.
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