Am J Psychiatry 1997; 154:27-38
Copyright © 1997 by American Psychiatric Association
The panic-agoraphobic spectrum: a descriptive approach to the assessment and treatment of subtle symptoms
GB Cassano, S Michelini, MK Shear, E Coli, JD Maser and E Frank
Institute of Psychiatry, School of Medicine, University of Pisa, Italy.
OBJECTIVE: Psychiatric classification is still a topic of considerable
discussion and debate in spite of major advances in the past two decades.
The debate involves categorical versus dimensional approaches, cutoff
numbers of symptoms to define a case, degree of impairment, objective
diagnostic criteria versus more theoretically based criteria, episodic
versus trait-like symptoms, and the role of atypical and subclinical
symptoms. All of these issues have been raised for the anxiety disorders
and depression. This article presents the conceptualization of a relatively
novel and testable approach to the diagnosis and classification of panic
and agoraphobia, the panic- agoraphobic spectrum, and pilot data on a new
questionnaire to assess it. METHOD: Pilot testing of the Panic-Agoraphobic
Spectrum Questionnaire was undertaken with 100 inpatients who had lifetime
diagnoses of panic disorder, unipolar depression, comorbid panic and
unipolar depressive disorders, or an eating disorder. The instrument
emphasizes impairment related to 144 behaviors and experiences in seven
panic-agoraphobic symptom domains. RESULTS: Patients with panic disorder
scored highest on the questionnaire, and those with comorbid depression
showed even greater severity of illness. The scores of the patients with
eating disorders and of the depressed patients differed from those of the
other groups but also differed from 0. CONCLUSIONS: The spectrum model of
panic and agoraphobia is a flexible and comprehensive means of describing
this clinical complex. The proposed model, complementary to the categorical
approach, presumably expresses a unitary pathophysiology. Its usefulness is
discussed in terms of its value for patient-therapist communication,
outcome measures, identification of subtle personality traits, and
subtyping of patients for research and treatment.
