Agoraphobia, panic disorder and generalized anxiety disorder: some implications of recent advances.

The nature of the relationship between 'panic disorder', agoraphobia and general anxiety disorder remains open. The aetiological theories which have tried to link them with the aid of biological and psychological concepts fail to take account of conflicting observations. 'Panic' attacks are not confined to agoraphobic and related disorders, being indistinguishable from the attacks of acute anxiety and phobic aversion manifest in a wide range of anxiety and affective disorders. There is continuity and discontinuity in the evolution of agoraphobia; those affected differ in respect of a range of premorbid features from patients with other disorders and control subjects. These variables include family history, life development, trait anxiety and other personality characteristics including introversion, neuroticism and probably emotional dependence on others. Not all the claims made on behalf of the efficacy of pharmacological treatment on the one hand and behavioural therapies on the other are substantiated. The success achieved by behavioural treatment appear to endure over some years. But the residual disabilities and defects that follow all forms of treatment and the problems posed by patient selection and high drop-out rates have received insufficient attention. Aetiological theories of agoraphobia and related conditions have been advanced along biomedical, psychological and psychodynamic lines. Some evidence supports each kind of theory. But none is wholly consistent with the findings regarding its phenomenology and evolution. Recent biological investigations have led to the formulation of hypotheses in relation to anticipatory and chronic anxiety in terms of changes in synaptic connections, enhancement of transmitter release as well as alterations in molecular configuration and regulation of gene expression. It would be premature to conclude that these findings can provide a unitary conceptual framework for the explanation of human anxiety disorders. The psychological, behavioural and psychodynamic aspects of this group of disorders should all continue to receive due attention both in clinical management and scientific investigation.