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This is to certify that the

dissertation entitled

PANIC DISORDER, AGORAPHOBIA
AND SEPARATION ANXIETY

presented by

Maxine S. Liberman

has been accepted towards fulfillment
of the requirements for

Ph - DA degree in Psychology

 

 

Majo/prcifessor
Charles Hanley

Dme 5/31/85

 

MS U is an Affirmative Action/Equal Opportunity Institution 0-12771

 

 

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RETURNING MATERIALS:
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PANIC DISORDER, AGORAPHOBIA
AND SEPARATION ANXIETY

By

Maxine S. Liberman

A DISSERTATION

Submitted to
Michigan State University
in partial fulfill of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Psychology

1985

ABSTRACT

PANIC DISORDER, AGORAPHOBIA
AND SEPARATION ANXIETY

By

Maxine S. Liberman

The present study explores a proposed developmental
link between separation anxiety and agoraphobia/panic
disorder. The etiological model views separation anxiety
as an evolved protest mechanism.with an innate biological
releaser, a mechanism believed to be dysfunctional in
agoraphobics (Klein, 1981). It is reasoned that agoraphobics'
early panic attacks lead to maladaptive styles of coping
with separations, styles that persist in adulthood even
when panic has been alleviated. This study also tests
Bowlby's observations that individuals react to separations
in characteristic ways.

Subjects were 10 females and 10 males in each of three
groups: 1) agoraphobics, 2) anxiety neurotics, 3) non-anxious
controls matched for age and education. A questionnaire
covered the subjects' developmental histories. Hansburg's
(1972) Separation Anxiety Test measured subject's
characteristic manner of coping with separation experiences.
The resulting data were treated by analyses of variance.

This study hypothesized that agoraphobics would exhibit

greater separation anxiety than would neurotic, non-phobic

subjects, who in turn would react more maladaptively than
non-anxious controls. These hypotheses were strongly
supported by the data analysis. Agoraphobics demonstrated
more attachment-seeking, less individuation, and more
reality avoidance, hostility and painful tension than did
neurotics and controls, even when faced with mild, temporary
separations. Agoraphobics with histories of childhood
separation anxiety however, did not show greater anxiety
than those without this history, but the information

testing this hypothesis proved unreliable.

The discussion considered the reasons for the
agoraphobics' strong responsiveness to the SAT as compared
with that of the other two groups. The relationships
between the various maladaptive responses and the development
of agoraphobia were explored. Directions for future research
were suggested, including studies that would measure
agoraphobics' reactions to stressful situations not
involving separation, which might distinguish their
separation anxiety from a general reactivity to any
emotionally—charged stimuli. Such studies could provide
further support for separation anxiety as a critical

variable in the development of agoraphobia.

To my mother and my father
with love and appreciation

ii

ACKNOWLEDGEMENTS

First and foremost, to Dr. Charles Hanley, whose rare
erudition, wit and practical wisdom guided me through the
completion of this dissertation. A true hero, he rescued
this uncertain project and graduate student with his
respect, support and very generous commitment of time. I
am ever grateful for having had this opportunity and
privilege to work with him.

To Dr. Gary Stollak, my association with whom began
at the outset of my graduate studies and seems, fittingly,
to have come full circle with his serving on my doctoral
committee. His humanity, his integrity, his teaching and
availability to his students remain lasting influences in
my work as a psychologist.

To Dr. Joseph Reyher for serving on my committee, for
encouraging me in this endeavor and for suggesting related
contexts in which to examine this thesis. His scholarship
and accomplishment, his enthusiastic interest in research,
and his intellectual challenges continue to inspire me.

To Dr. Raymond Frankmann, to whom I extend my
sincerest gratitude for his graciously consenting, at the
eleventh hour, to serve on my committee,and for his

invaluable contributions to the statistical analysis.

iii

To Dr. Dozier Thornton for his thoughtful reading and
support of this dissertation in its early stages, and for
agreeing to serve on my committee.

To Dr. Barbara Leviton for her insights regarding the
internal impediments to completing one's doctoral
dissertation, for her unwavering belief in my capabilities,
and for her enduring friendship.

To Dr. Les Forman, for encouraging me to pursue this
thesis from its inception, and for his generous assistance
in procuring subjects.

To Suzy Pavick, for preparing the final manuscript
and for her patient and helpful assistance with the various

administrative tasks associated with this project.

iv

TABLE OF CONTENTS

List of Tables.
Chapter 1
INTRODUCTION

Background and Statement of the Problem .
Panic Attacks. . . . . . . . . .
Agoraphobia.

Chapter 2
REVIEW OF THE LITERATURE.

Relationship Between Panic Disorder
and Agoraphobia . . .
The Development of Agoraphobia . .
Clinical Presentation of Agoraphobia .
Course of the Disorder . .
An Ethological Theory of Panic Disorder
and Agoraphobia . . . . . . . . . .
Development of the Theory. .
Psychoanalytic and Learning Theories
of Agoraphobia. . . .
Panic Attacks and Separation Anxiety .
Diagnostic and Treatment Problems in
Agoraphobia .

The Sex Difference in Incidence of Agoraphobia :

Bowlby' 8 Theory of the Separation Process.
Chapter 3
PURPOSE OF THE STUDY.
Chapter 4
PROCEDURE
Description of Instruments .
Subjects.

Hypotheses . . .
Exploratory Hypotheses .

Page

, vii

m\ll—' H

36

41

41
44
48
49

Page
Chapter 5
RESULTS. . . . . . . . . . . . . . . . . . . . . . 50
Chapter 6
DISCUSSION . . . . . . . . . . . . . . . . . . . . 58

Exploratory Questions . . . . . . . . . 67
Implications for Future Research. . . . . . . . 7O

APPENDICES

APPENDIX A . . . . . . . . . . . . . . . . . . . . 74
APPENDIX B . . . . . . . . . . . . . . . . . . . . 78
APPENDIX C . . . . . . . . . . . . . . . . . . . . 84
APPENDIX D . . . . . . . . . . . . . . . . . . . . 88
REFERENCES . . . . . . . . . . . . . . . . . . . . 105

vi

Table

LIST OF TABLES

Page

Total Responses to the SAT: Means,
F-ratios from ANOVA and Statistical
Significance. . . . . . . . . . . . . . . . 51

Means, F-ratios from ANOVAs and Significance
Levels of Attachment, Hostility, Reality
Avoidance, and Painful Tension Scores for
Agoraphobic (A), Neurotic (N), and

Control (C) Subjects. . . . . . . . . . . 54

Childhood Separation Symptoms and SAT
Scores. . . . . . . . . . . . . . . . . . 56

Mean Number of Losses and Separations

Experienced by Agoraphobics (A),

Neurotics (N), and Controls (C) as

Children and Adults . . . . . . . . . . . . 56

Number of Subjects reporting Family
Incidence of Agoraphobia and Other
Psychiatric Disorders . . . . . . . . . . . 57

vii

Chapter 1
INTRODUCTION

Background and Statement of the Problem
Panic disorder and its frequent concomitant, agoraphobia,
have been officially recognized by the authors of DSM III

1 rather than as

(1981) as discrete psychiatric entities,
neurotic symptoms; reflecting a shift in prevailing
theoretical and clinical views not only of phobic disorders,
but also of the meaning of anxiety. But despite this
categorization in DSM III (which is primarily descriptive and
not concerned with etiological theories), and despite
considerable overlap in clinical descriptions of agoraphobia,
there remains little agreement within the psychological
community about the origins, development, and nature of this
disabling and relatively commonly occurring disorder. This

lack of concurrence and the aroused controversy about how

panic disorder should be understood - if indeed some would

 

1A strong case can be made for agoraphobia's being a
secondary development of panic disorder, rather than as an
entity in and of itself; i.e., as a later and more visible
stage in the course of panic disorder. DSM III, however,
lists agoraphobia with and without panic attacks, and panic
disorder, as separate categories, reflecting the continuing
lack of a unified view of their origins and meaning. As will
be discussed in the text, agoraphobia will be viewed in this
study as a consequence rather than as a cause or predecessor
of panic attacks, although the causes of the spontaneous
panic attack remain questions for further research (Muskin
and Fyer, 1981).

2

view panic attacks as a "disorder" at all - has underscored
divisions in theoretical perspective regarding basic concepts
of anxiety, earliest development, and the role of biology in
psychological functioning.

There are at least three major theoretical models of
phobic disorders. The psychoanalytic perspectives, briefly
stated, (Deutsch, 1929; Weiss, 1964; Stamm, 1972) is that
panic attacks and phobic anxiety represent the displacement
of anxiety which results from the breakdown of defensive
operations for keeping internal conflict out of consciousness.
The explanation offered by learning theorists (who have
reported frequent success in treating certain phobias) is
that phobias are learned avoidance responses to conditioned
anxiety. Both of these latter theories place panic attacks
at the extreme end of an anxiety continuum; i.e., anxiety
surges to an overwhelming pitch and an "attack" occurs. A
third theoretical view, which might be called the ethological
perspective, conceptualizes panic disorder as resulting from
a dysregulation of basic biological systems which mediate
separation anxiety; and makes a qualitative, not a
quantitative, distinction between the panic attack and the
phobic anxiety and avoidance (Klein and Fink, 1962;

Liebowitz and Klein, 1981; Zitrin et al., 1981).

In asserting their definition of panic disorder as a
discrete psychiatric entity, DSM III authors relied
principally on the accumulating evidence from recent

psychopharmacological research and treatment outcome studies

3
(e.g., Zitrin et al., 1980, 1981; Lipsedge et al., 1978;
Sheehan et al., 1980). Most of this research has evolved
from the discovery by Donald Klein more than twenty years ago
that the drug imiprimine, a tricyclic antidepressant
medication, successfully blocked the panic attacks of highly
anxious hospitalized patients (individuals who would now be
diagnosed as agoraphobic), subsequently allowing them to
overcome their phobic avoidance behavior with supportive
psychotherapy (Klein and Fink, 1962). The striking and
perplexing aspect of this finding was its challenge to the
notion of an anxiety continuum: the major antipsychotic
medications, the phenothiazines, considered to be antianxiety
drugs, had been totally ineffectual in treating these anxious
patients (as had been intensive inpatient and outpatient
psychotherapy). Although it has been argued that these
patients responded to antidepressants because they actually
were depressed and had simply been misdiagnosed originally,
these patients did not (and agoraphobic patients generally

do not) meet the criteria for depressive disorders; when not

 

2The relationships between depression, agoraphobia and panic
disorder have not yet been clarified, although the
neurobiological action of imiprimine on panic attacks does
not appear to be identical to its action on depressive
disorders (Jobson, et a1, 1978). The nature of these
relationships remain an important question, however. Several
studies have examined them in terms of the role of anxiety in
depression (Prusoff and Weissman, 1981; Gardos, 1981), and
others from the point of view that agoraphobia is actually a
form of depression (Bowen and Kohout, 1979). Klein (1981)
hypothesizes that depression may be controlled by a different
part of the same neurobiological regulatory mechanism that
controls panic attacks.

4

overwhelmed with anxiety, they are sociable, experience no
diminished pleasure in food and sex, and express no guilt or
suicidal ideation. Against the conventional psychiatric
wisdom of the time, then, Klein's discovery suggested that
the anxiety of nonpsychotic patients was not simply
quantitatively less than that of psychotic patients. This
finding stimulated a reexamination of extant theories of
anxiety.

Speculating that humans have a neurobiological mechanism
which regulates their response to separation from primary
attachment figures, as has been indirectly measured in

3 Klein proposes that in those individuals experiencing

primates,
spontaneous panic attacks, this mechanism is dysfunctional
(Klein, 1981). The notion that such a neurobiological
mechanism exists is based on an ethological perspective of
separation anxiety and of protest as evolved prosurvival
mechanisms. Although not yet identified biochemically, this
hypothesized mechanism is seen as the internal physiological
equivalent or releaser of the observable protest response to
separation.

Klein's speculation about the relationship between panic
disorder and separation anxiety is derived from several

sources which will be reviewed here. These are: Bowlby's

work on attachment behavior, particularly the delineation of

 

3(Harlow et al., 1959; Kaufman and Rosenblum, 1967; Suomi,
1977; Coe and Levine, 1981)

5

the stages of response to separation; evidence that many
adult agoraphobic patients experienced separation difficulties
in childhood, often manifested in school phobia; and the
frequently noted clinical impressions of researchers and
psychotherapists that agoraphobic individuals exhibit high
levels of dependency and problems with individualism, as
suggested in part by their underachievement. The most
significant factor in Klein's thesis, however, is the by now
well-established finding of the psychopharmacological studies
of the effects of imiprimine on panic attacks,4 which
demonstrates successful blocking of the panic attack (the
more severe anxiety) without alleviating the less intense
anticipatory anxiety that results in the phobic avoidance
behavior. This research evidence lends strong support to the
notion that panic attacks and anticipatory anxiety are
qualitatively different, though inextricably related,
phenomena.

It should be noted here that the traditional
psychoanalytic view, as well as the more recent theorizing of
Mahler (1975), for example, would concur that separation

anxiety underlies agoraphobia, but their position does not

 

4Other classes of drugs, including MAO inhibitors, have been
shown to be effective in treating panic attacks, although
there are greater risks and side-effects with many of these.
Sheehan (1982) has been experiencing with a relatively new
triazolo-benzodiazepine, alprozalam, which he believes works
on both the panic attack and the anticipatory anxiety, and
asserts is the most rapidly effective and least toxic of the
antipanic drugs available, but data to substantiate these
assertions have not yet been published.

6
postulate a biological mechanism which may trigger panic and
subsequently produce phobic anxiety and avoidance behavior.
Instead, the psychoanalytic view, as well as the learning
theory view, is that a panic attack is the result of a state
of increasing anxiety, rather than the first stage, if not the
cause, of the agoraphobia; these views do not readily
accommodate the physiological discontinuity between the panic
attack and the anticipatory anxiety.

In light of Klein's proposed ethological explanation of
the origins of panic disorder - a view which does not discount
the possible influence of more purely psychological variables,
but also does not explore the relationship between these and
the physiological mechanism - the present study will attempt
to look more closely at the psychological responses to
separation of panic disorder patients. Although the literature
on agoraphobia and panic disorder invariably describe such
individuals as dependent and passive, these observations are
usually incidental clinical impressions. There has been
almost no research which has been concerned primarily with
an empirical assessment of the psychological characteristics
of persons with panic disorder.

Before discussing the purpose of the proposed study in
greater detail, a clinical picture of panic disorder and
agoraphobia will be given to help acquaint the reader with

issues already presented.

7
Clinical Descriptions of Panic Disorder and Agoraphobia

Panic Attacks

 

The spontaneous panic attack is a terrifying and
traumatic experience. It occurs without warning and without
apparent provocation. Although it may last for only a
minute, the sensation of panic can subsequently render the
afflicted individual incapable of normal functioning for long
periods of time, if not permanently (without adequate
treatment). A seventeenth-century description of panic
attacks and of the anticipatory anxiety which develops in
their wake conveys the power of this phenomenon:

Many lamentable effects of this fear causeth
in men, as to be red, pale, tremble, sweat; it
makes sudden cold and heat to come all over the
body, palpitation of the heart, syncope...many men
are so amazed and astonished with fear, they know
not where they are, what they do; and that which
is worst, it tortures them many days before, with
continual frights and suspicion. It hinders most
honorable attempts, and makes their hearts ache,
sad and heavy. They that live in fear, are never
free, resolute, secure, never merry, but in
continual pain...no greater misery, no rack, no
torture, like unto it; ever suspicious, anxious
solicitous, they are childishly drooping without
reason, without judgment...

(Burton, 1621, p. 143)
Similarly, a contemporary description of a panic attack,
given by subjects experiencing sodium lactate infusion-induced
panic (Muskin and Fyer, 1981) reveals many of the elements
found in the earlier description:
I feel like I'm going to die...I just can't
explain it. I feel such a warm feeling and such
a terrible feeling, a devastating feeling and I

want to get up and run, and I feel very very
nauseous...

8
I'm not going to make it, I can't get help,

I can't get anyone to understand the feeling...

It's like a feeling that sweeps over from the

top of my head to the tip of my toes. I detest

the feeling. I'm very frightened.
These descriptions suggest the experience of an almost
primordial, engulfing feeling that threatens one's very
existence. Indeed, the individual experiencing a panic
attack behaves, internally and demonstrably, as though her
life were threatened, although there is no immediately
identifiable source of danger.

The psychoanalytic view would hold that a source of

danger does exist, although it is not objective, not out
there," but rather an unconscious, unacceptable impulse
coming perilously close to the panicky individual's conscious
awareness. Hence, so-called "spontaneous," out-of-the-blue
panic attacks are believed to be provoked by an identifiable
stimulus, an intrapsychic conflict, which is not outwardly
observable but discernible through analysis. Patients'
descriptions of panic attacks given as case illustration by
psychoanalysts do not usually resemble those given by panic
disorder patients, however, so that it is difficult to
ascertain whether the same phenomenon is being discussed

(Nemiah, 1981).

Agoraphobia

 

Agoraphobia, though literally translated as a "fear of
the marketplace," has generally been defined as a fear of
public places, particularly those which are either too

crowded or too empty. Snaith (1968) has offered a more

9
parsimonious definition of agoraphobia as a fear of being
away from a place or object representing safety. This
perceived lack of safety appears to be the feature common to
the multiple situations which agoraphobic patients avoid.
The question which arises in attempts to understand this
phenomenon is just how and why previously benign situations
in the experience of the agoraphobic suddenly become infused
with a sense of danger. Unlike agoraphobia, simple phobias
(those with a specific stimulus, such as snake phobia) do not
appear to have such an abrupt onset but rather are present
throughout an individual's lifetime.

Most people at some time in their lives experience fear,
even panic, usually caused by a sense of impending danger.
But phobias are a special type of fear, in that they are
persistent, excessive and attached to an object or a
situation which objectively is not a significant source of
danger (Marks, 1959). Phobias have been defined as "a
specific fear which the patient himself knows is ridiculous
but which he cannot overcome," (Ross, cf. Marks, 1959). As
Marks notes, most phobic individuals recognize that their
fears are excessive and unrealistic and that others would
not be similarly fearful of the same situation. When
confronted with their phobic situations, however, such
individuals are overwhelmed with anxiety and experience
uncomfortable physiological symptoms, such as sweating,
tremor, pallor, tachycardia, rapid breathing, nausea, vomiting,

and urinary frequency. Although these symptoms appear in

10

agoraphobia, this disorder is arguably different in
important respects from simple phobias. Unless confronted
with the phobic stimulus, individuals with phobias are not
usually distressed by the fear, nor are their abilities to
function in the world severely limited by the fear.
Individuals with simple phobias are anxious only and always
when the phobic stimulus is present. Moreover, they do not
respond to treatment with imiprimine, again suggesting that

the panic attack is a special event.

Chapter 2
REVIEW OF THE LITERATURE

Relationship Between Panic Disorder and Agoraphobia

The Development of Agoraphobia

Klein (1981) describes the typical development of
agoraphobia in three stages, which he believes begins with
the occurrence of a panic attack, as follows: An individual
who is feeling normally well, in the course of doing
something innocuous such as walking down the street or dining
out, suddently is "struck by the worst experience of their
life: they become suffused with terror, with a pounding
heart and inability to catch their breath...they are convinced
that death from a stroke or heart attack is imminent,"
(p. 236). Terrified, this individual may blindly appeal for
help from passersby, and eventually get herself to a
physician. As the physician finds nothing physically wrong
with her, she is reassured that there is no reason for
concern and is sent home. The stricken individual usually
recovers quickly, and feels more or less normal again, until
within days or sometimes weeks, she is struck with another
panic attack. Usually, she seeks out medical help once more,
but when a thorough physical examination again detects no
physical cause for her symptoms, she is sent home with
further reassurances. These may suffice to relieve the
individual's fears for a time, until yet another panic attack

11

12

occurs. At this point, the individual becomes convinced
that something is dreadfully wrong with her (something
physical) and that the doctors have simply failed to
determine the proper diagnosis, although many such patients
also become convinced that they are in fact going crazy.

Usually, a series of panic attacks occur next, between
which the individual becomes increasingly apprehensive,
anxious and vigilant. Thus begins the second stage in the
development of agoraphobia: the individual grows
increasingly alert for any signs of an impending attack. The
third stage begins when the individual begins to avoid
certain situations, those where access to a helpful and
reassuring person (medical personnel, a relative, or close
friend) may not be readily available. Eventually, as
apprehension mounts, this individual may retreat to the
confines of her home, seldom venturing forth from familiar
surroundings, which provide for her a certain feeling of
reassurance that she will be near help in case of another
panic attack.

Thus, the typical clinical picture of the agoraphobic5
patient emerges; an individual suddenly begins to experience

severe panic attacks, becomes chronically anxious

 

5All panic disorder patients do not become agoraphobic, but
it is believed that all agoraphobics have experienced panic
attacks and that panic disorder underlies their phobic
avoidance behavior. For the purposes of this study, however,
the terms agoraphobic and panic disorder will be used
interchangeably except where a more limited meaning is
specified or evident from the context.

13
in anticipation of the next panic attack, and begins to stay
close to home, which provides a feeling of safety. She
thereby becomes housebound to some degree, fearful of being
alone, and often dependent upon others even to perform
everyday tasks for her.

Clinical Presentation of Agoraphobia

 

Perhaps the most disturbing aspect of agoraphobia for
the individual involved is that noted by the research subject
quoted earlier; the agoraphobic feels that she cannot make
anyone else understand how she feels. She therefore feels
isolated, as she knows that her fears are unfounded and that
others view her as being weak or undependable. Agoraphobics
report being extremely sensitive to this (however justifiable)
lack of understanding of their fearfulness, because they
feel ashamed of their inexplicable, groundless fears; and
often attempt to conceal them for as long as possible.
Marks (1969) notes: "The more common and familiar the phobic
objects are the greater is the incomprehension and lack of
compassion which the plight of the phobic arouses in normal
people. It surpasses the intuitive understanding of normal
people how anyone can be scared of...going outside her home.
It is often thought that the patient pretends or exaggerates
...should pull herself together or be forced to do so."
(p. 4). But, as Burton (1621) long ago observed, phobias
are not the result of insufficient willpower but are due to
causes outside the patient's control: "Take away the cause,

and otherwise counsel can do little good; you may as well bid

l4
him that sick of an ague, not to be adry, or him that is
wounded, not to feel pain," (p. 347). It is of interest that
current treatment approaches follow this advice exactly; that
is, they treat the panic attacks before or in conjunction
with treatment for the chronic anticipatory anxiety.

When agoraphobic patients finally do reveal their
symptoms, they often complain only of symptoms secondary to
their anxiety such as headaches and other physical distress.
While these complaints are at least comprehensible, their
frequency prompts others to regard the individual involved
as extremely hypochrondriacal, another common feature of
this disorder. Because of the distressing sensations
associated with the panic attack, agoraphobic patients do
tend to be highly alert to any slight physical changes or
bodily discomforts they may experience, which they believe
could signal the onset of another panic attack. Thus, they
often become obsessively concerned with their physical state,
although never actually ill (Goldstein and Chambliss, 1978).

Agoraphobic patients are aware that they feel "different"
from other people (and from the way they once felt about
themselves), but their sense of strangeness is only
compounded by their lack of awareness that anyone else could
possibly suffer from the same problem as they. The belief
that this condition is unique to them is reaffirmed
frequently by the misdiagnoses of their condition and by the

lack of public awareness of this disorder, at least until

15
relatively recently.6 Thus, the agony of the anxiety and
phobic behavior is suffered secretly, which makes it all the
more demoralizing for the individual so afflicted.

Course of the Disorder

 

It is evident, as noted earlier, that the course of this
disorder does not resemble that of other phobias. Panic
disorder and agoraphobia appear to be recurrent over the
lifetime, although there may be long periods where one is
free of panic attacks. In such cases, the disorder appears
to be phasic in nature; in other cases the panic and anxiety
are more chronic and unremitting. Also, some individuals
apparently have panic attacks which do not lead to
agoraphobia. Although the vast majority of cases first
experience panic attacks in late adolescence or early
adulthood, there appears to be a bimodal distribution of
onset, with another group experiencing this problem for the
first time in midlife. It is of considerable interest that
this distribution coincides with those periods of
developmental transition that involve major separations.

As mentioned earlier, panic attacks can be successfully
treated with the drug imiprimine. However, when only the

chronic, anticipatory anxiety is treated, usually with

 

6In recent years, various media programs focused on
agoraphobia have created public awareness of the existence
of this disorder and of its impact on individuals so
afflicted. Agoraphobia self-help groups have formed across
the country, and some clinicians now specialize in treating
this disorder.

l6

benzodiazapenes, the panic attacks can and often do recur,
setting off a renewed round of anticipatory anxiety and
phobic avoidance. Traditional methods of psychotherapy which
seek an underlying trauma responsible for causing the panic
attacks may never reveal one; and usually after only a short
time, the symptomology becomes so crippling that the
agoraphobic's life is in desperate straits. There is strong
evidence, however, that if the panic attacks are first
treated with imiprimine, then any psychotherapeutic modality
subsequently can be useful in alleviating the anticipatory
anxiety and in eliminating the phobic avoidance (Zitrin et
al., 1981).

Of relevance to this issue are several studies by
Gittelman-Klein (1971, 1973) that have found imiprimine to be
effective in treating school-phobic children. The usual
approach to treating such children is to effect their prompt
return to school, and then to treat their lingering
apprehensiveness and fearfulness in psychotherapy, where the
causes of their phobic behavior can be addressed. Few
therapists would allow a child to stay away from school
indefinitely while these causes were being unravelled. Yet,
adult agoraphobics are often treated as though their panic
attacks did not exist, and they may spend many years in
treatment for their anxiety, seeking its foundations to no

avail.

17

An Ethological Theory of Panic Disorder and Agoraphobia

Development of the Theory

 

Klein's discovery of the effectivness of imiprimine in
treating panic attacks evolved from careful observation of
the behavior of certain inpatients under his care at Hillside
Hospital in New York. These highly anxious and apprehensive
patients had proved intractable to any form of psychotherapy
and pharmacotherapy that previously had been offered,
including the phenothiazines. In large measure because there
was nothing left to try with these patients, Klein decided
to administer to them the new anti-depressant medication,
imiprimine, which was known to have tranquilizing properties.

After three weeks of treatment with this drug, these
patients still claimed to feel unimproved. However, the
ward staff believed that there had been some improvement,
despite their inability at first to specify this change.
Eventually it was recognized that a particular patient
behavior which had occurred daily during the ten months prior
to the imiprimine trial no longer happened. Previously these
patients had been rushing to the nursing station several
times a day, every day, proclaiming they were about to die
and requesting immediate attention; after being reassured
by the nurses, who would sit with them for about twenty
minutes, the patients would leave - their acute, overwhelming
distress somewhat relieved. Since the end of the second week
of treatment with imiprimine therapy, patients began

approaching situations on their own which they previously

18
had avoided, even venturing outside by themselves.
Furthermore, and perhaps more importantly, these patients'
moves toward independence could now be accelerated by staff
pressure and direction, efforts which had previously proved
futile. Thus, it appeared that the panic attacks, or the
acute distress, could now be effectively treated with a
medication that had a specific action only on them; panic
anxiety appeared to be a discrete, separate event from other
anxiety.

Results of studies with intravenous lactate infusions
provide further evidence that the panic attack is a special
event. Pitts et al. (1967) found that such an infusion
induces a panic attack in people who have spontaneous panic
attacks, but not in normal subjects. Although a conditioning
theory has been proposed as an explanation of this finding -
that any infusion which causes certain autonomic effects,
even in normal subjects, will serve as a conditioned stimulus
and will "precipitate” a panic attack - this hypothesis can
be rejected because infusion of EDTA, a chemical agent that:
actually throws patients into tetany, does not produce panic
attacks in persons with spontaneous panics or in normal
subjects. Also, it has been demonstrated that the induced
panics are successfully blocked in panic disorder patients
treated with MAO inhibitors (Kelly et al., 1971) and with
imiprimine (Appleby et al., 1981).

Psychoanalytic and Learning Theories of Agoraphobia

 

Klein asserts that several things could have been

surmised from his findings of the effectiveness of imiprimine

19
in treating panic attacks. As already mentioned, the
specificity of the action of this drug actually led to his
making the distinction between the panic attack and the
subsequent anxiety. It also led to a reconsideration of
existing theories of anxiety, since imiprimine prevented the
recurrence of the severe panic but did nothing for the less
severe chronic anxiety, challenging the notion of an anxiety
continuum. In his attempt to account for this finding from
an established theoretical perspective, Klein found both
learning theory and psychoanalytic theory to be deficient in
their ability to explain the development of panic disorder.
The reader is referred to his cogent assessment of the
problems in these theories (Klein, 1981), which will be
summarized here.

In essence, Klein views Freudian theory and learning
theory as markedly parallel in their emphasis on the
importance of contiguity conditioning, which leads to anxiety
as a signal of anticipated traumatic states. As noted
earlier, neither of these theories focuses on the distinction
between the panic attack and chronic anxiety, nor considers
the panic attack to be the antecedent of the developing
anxiety. Fenichel (1945) proposes that panic attacks are
actually signal anxiety gone amok: "The patient has such
tremendous internal tensions because of massive repressions
that signal anxiety acts much as a match in a gunpowder
factory," (Klein, 1981, p. 244). Although Weiss (1964) did

perceive that panic attacks precede the development of

20
anticipatory anxiety and that the patient suffers from
anxiety concerning his panic attacks, this explanation is
again an elaboration of the notion of the return of the
repressed (in his model, an early ego state rather than an
infantile libidinal drive).
Panic Attacks and Separation Anxiety

Because outstanding clinical features of the patient with
panic disorder are their clinging,dependent behavior and
their intolerance of being alone, Klein began to think that
perhaps an outbreak of separation anxiety was at the root of
agoraphobia. Among the evidence to support this notion were
histories of at least fifty percent of the patients studied
of having suffered separation anxiety in childhood, and that
the initial panic episode had often been preceded by
significant object loss (Klein, 1964). Thus, he thought this
indicated that these patients had a special early predilection
for separation anxiety which manifested itself as agoraphobia
later in life.

In attempting to account for this notion from a theoretical
perspective, Klein found that psychoanalytic theory was lacking
in explanatory power. Separation anxiety in that theoretical
framework is viewed as a form of classical conditioning: the
unconditioned stimulus is an increase in instructual tensions
that leads to the unconditioned response of traumatic and
painful excitation. The absence of the mother is the
antecedent conditioned stimulus; and it is the child's
association of the mother's absence with mounting tension

that leads to anxiety during her absence. Thus, separation

21
anxiety would require the recognition of the mother as a
distinct object, the ability to discriminate her presence
versus her absence, and the association of absence with
states of increasing tension. This conceptualization offers
no explanation for a specific drug effect on panic anxiety
and not on other types of anxiety.

Bowlby's work on the attachment process suggested that
attachment did not depend on the infant's learning that the
mother was a need gratifier, but antedated such learning,
resembling the ethological notion of imprinting. Separation
anxiety did not depend on the infant's learning that the
mother's absence was associated with distress, "but was an
evolved protest mechanism, instinctively released during the
appropriate developmental phase by separation," (p. 246).
Observation of animals' states of distress after separation
from their nests or from their mothers immediately after
birth supports Bowlby's speculation. Rather than learning
through experience that the presence of the mother is
associated with relief from instinctual tension, animals
appear to react with innately released protest.

The evolutionary purpose of the signals emitted by the
vulnerable infant is to elicit retrieval by the mother.
Klein points out that the helplessly dependent infant that
has wandered away from its mother is a target for predators
(evolutionary speaking); and that in the absence of predators,
a lost child is vulnerable to dehydration and becoming

weakened. If the infant actually waited for the pains of

22

hunger before emitting distress vocalizations, then it is
likely the infant would be lost or hurt. Thus, the innately
released protest mechanism (released under conditions of
naive separation) serves to insure contact with the mother
before such pain or damage occurs.
Any biological control mechanism has a wide
range of variations in strength and threshold, and
perhaps some children have constitutional or
familial vulnerabilities in this area. The existence
of such an innate alarm.mechanism may explain the
specificity of the antidepressants: if
antidepressants specifically raise the threshold of
this mechanism, they would prevent panic but have no
effect on anticipatory anxiety...the pathophysiologies
of separation anxiety and depression seem intricately
related as shown by their drug receptivity and by the
higher incidence of phasic depressions in people
with agoraphobia,"
(Klein, 1981, p. 247).
Bowlby has delineated three stages of response to
separation: protest, despair, and detachment. Protest
appears to be similar in nature and behavioral manifestation
to the panic attack: both are characterized by pleading,
clinging, and demanding. Klein speculates that the despair
stage may also serve an evolutionary purpose, in that it
serves to inhibit protest when the mother is unavailable to
respond. If protest were to continue indefinitely, then the
infant would be calling attention to itself and be vulnerable
to predators. Endless protest would also exhaust the infant
physically. In this case, the protest of the infant would
serve an antisurvival function. Therefore, despair may serve

as a built-in conservation mechanism and prosurvival function.

(Klein further reasons that one way in which evolution could

23
radically reduce an organism's interactions with the
environment while maintaining consciousness would be to
inhibit the brain's pleasure centers, which would account for
certain depressive symptomology.)

The relationship between depression and panic disorder,
as suggested by their mutual responsiveness to antidepressants,
may be that the protest-despair mechanisms have co-evolved
over human history to maintain the survival of the vulnerable
or lost infant. Klein states,

The appearance of apparently spontaneous panic attacks

or apparently spontaneous depressive episodes are

the results of a pathologically lowered threshold

for release of these distressing affective regulatory

states. If the threshold is lowered in that portion

of the...mechanism that controls protest, then

spontaneous panic attacks occur, whereas if the

lowered threshold occurs in the segment that

regulates despair, then a phasic depressive episode

results. I make the parsimonious hypothesis that

the sole function of all antidepressants is simply

to raise thresholds throughout this apparatus...and

that their beneficial effects on anxiety attacks

and/or depression result from this normalization

of function,"

(Klein, 1981, p. 248).

Diagnostic and Treatment Problems in Agoraphobia

What Klein noticed in his original patients, and what
often occurs in attempts to diagnose and treat panic disorder,
is that these patients have great difficulty making the
distinction between the panic attack and the anticipatory
anxiety; because the latter is so disturbing, it becomes
nearly indistinguishable from the panic. Also, the panic

attacks may have occurred only a few times, and may have even

24
remitted altogether, while the sense of dread that the
experience will be repeated has not abated. (In learning
theory terms, the unpredictable panic attack reinforces the
anticipatory anxiety - the conditioned response - on an
intermittent, random schedule, which makes the response
extremely difficult to extinguish.

Despite DSM III acknowledgement of panic disorder and
agoraphobia as discrete entities and despite the established
efficacy of imiprimine treatment, panic disorder and
agoraphobia have long been, and frequently still are,
misdiagnosed. Panic disorder patients are often seen as
having obsessional neuroses (because of their obsessive
concern with their bodies and feelings), as being
hypochondriacal, as delusional (thus psychotic), as suffering
with a major depressive disorder (usually bipolar depressive
illness), as hysterical personalities, as dependent
personalities, and even as schizophrenic because of their
marked social impairment and severity of symptoms. Even when
accurately diagnosed, it is not uncommon for panic disorder
patients to have been treated for many years only with
psychodynamic therapies without any relief of their presenting
complaints.

Because spontaneous panic attacks and agoraphobia so
frustrate and mystify psychotherapists trying to understand
them from their own particular frame of reference, it is not
surprising that the patient experiencing this disorder is seen

as difficult, intractable, and uncooperative. It is also

25
understandable that such an attitude on the part of therapist
may serve only to perpetuate the patient's deep sense of
shame about the disorder and to increase the patient's
anxiety that she is insane (Muskin and Fyer, 1981). The lack
of credibility accorded the spontaneity of the panic attacks
probably contributes to the ineffectiveness of treatment.
Traditional therapies situate the disorder within the
individual, and rightly so, but whether it is under the
control (conscious or unconscious) of the patient is still
unknown.

The fact that the panic attacks may have remitted by the
time a patient reaches a psychotherapist often makes the
problem of diagnosis more difficult, because chronic anxiety
and even phobic behavior can be symptoms of a variety of
diagnoses. The resistance of psychotherapists to accepting
research findings about agoraphobia, however, (particularly
regarding the usefulness of imiprimine in treating this
disorder) may be seen as just that: resistance, or a
countertransferential response to patients who simply are not
amenable to the offered mode of treatment. It also reflects
a strong prejudice within the psychological community against
medical interventions for disorders that are viewed as
primarily psychological in nature.

The Sex Difference in Incidence of Agoraphobia

It is little wonder that agoraphobia is often viewed as

being a woman's problem, or the "housewife's syndrome."

Stereotypic notions of women as dependent, helpless, fearful,

26
and hysterical are embodied in the very essence of this

disorder: the panic and phobic behavior are not rational.

 

Estimates of the sex ratio for incidence, however, based on
frequency of diagnosis, vary from 50/50 to 95/5 (females/
males). Accurate diagnoses have often been clouded by
clinicians attending only to the histrionic, hypochrondriacal
complaints of women who are often secretly terrified that
they have "gone crazy." Such patients are most commonly
given sedatives, such as benzodiazapenes, in order to lower
their anxiety and calm them. As noted earlier, however,
these drugs do nothing to block the panic attacks; thus,
they perpetuate the disorder while potentially fostering
another type of dependency.

Many studies describe agoraphobic patients as "very
dependent...and they tend to be women..." (Zitrin et al.,
1978). However, why this is so, or what the relevance of
this observation is for the development of panic disorder is
riot elucidated. Psychoanalytic case studies (Nemiah, 1981)
r>ropose that dependency conflicts and an inability to
sseparate from significant attachment objects form the basis
<>f agoraphobia, emphasizing the frequency of occurrence of
these problems in women.

Although the less frequent diagnosis of panic disorder
.mnd.agoraphobia in males may reflect the true incidence of
tile disorder among them, it is also likely that males report
agoraphobic symptoms less frequently than do females. This

ma5r be attributable to males' greater socializations for

27
independence, which would make it more difficult for them to
stay at home or to stop working at their jobs, even in the
face of severe panic and anxiety. Men tend to feel compelled
to carry on despite the presence of these symptoms, and they
often conceal their distress for longer periods of time than
do women, by self-medicating with alcohol and other substances.
Since men are encouraged throughout their lives to confront
danger and to be physically active, while women more often
are allowed, if not encouraged, to remain dependent and to
acknowledge dependency wishes, it follows that agoraphobia
would be more frequently seen and disgnosed in women. It is
of interest that Childhood Separation Anxiety Disorder,
experienced by many agoraphobics, occurs in equal numbers
among males and females. It may be that such (phobic)
behavior is simply more tolerable or acceptable for males
when they are children than when adults.

It has been observed that male infants as a group are
more aggressive and explore their environment more actively
than female infants do (Maccoby and Jacklin, 1974). From an
evolutionary position, one could speculate that because males
originally were hunters and were required to roam far from
their "home" bases, the mechanism for separation anxiety in
males evolved differently from that in females, at least in
terms of its range of reactivity. Were separation anxiety
too intense in males, it might hamper their ability to
effectively search for food. It could further be speculated

that because attachment involves an interaction between

28
mother and infant, females are constitutionally endowed with
a more reactive separation anxiety mechanism and a lower
threshold for separation anxiety in order to ensure their
responsivity to (and thus the survival of) their offspring.
It follows, then, that females are more vulnerable to
dysregulation of this hypothesized separation anxiety
mechanism, and consequently to more frequently experienced
panic disorder.

Despite the comparatively more frequent diagnosis of
agoraphobia in women than men, even among women the disorder
apparently often remains undetected for years by relatives
and friends. For example, many new cases of agoraphobia
revealed themselves in the course of a rehousing scheme in
New York City, where families that had been living in single
rooms were moved to larger housing in a new neighborhood
(Perman, 1966). Phobic symptoms became immediately apparent
in many of the women, who could not sleep alone, were fearful
of going out alone, and would not travel beyond their
neighborhoods. This outcome could be compared to the reactions
of other animal species who become extremely disoriented by
the destruction of their homes or nests and often do not
survive this trauma.

When it is considered that the avoidance behavior of
agoraphobics is nearly identical from individual to individual
(and not individually "conditioned" by a specific trauma)
and that it involves the fear of leaving a home base, it

seems quite likely that a phylogenetic response is involved.

29
Evidence from research on the causes of simple phobias
suggests a predisposition to react fearfully to certain
classes of stimuli. In agoraphobia, the feared situations
are often places where one could be "trapped" such as in
tunnels, or out of view of help (of the mother?), as in a
crowd or vast open space. Marks (1959) observes: "Certain
classes of stimuli are more likely than others to trigger
off phobias, given that these different stimuli are all
encountered quite frequently. It is reasonable to expect
that phylogenetic mechanisms are at least partly responsible
for this potency of certain stimuli to produce fear in man,
just as they do in other species," (p. 116).

In a study of field dependence and agoraphobia, a
slightly different perspective is proposed. Rock and
Goldberger (1978) found significantly greater field
dependence in agoraphobic versus simple phobic females (though
not for males). Although Witkin (1972) theorized that
adequate adjustment is to be found at any level of
differentiation, when there are failures of personality
integration, the disturbances that emerge are more likely to
be consistent with the person's level of differentiation.

In the case of females who become agoraphobic,

the fact that they tend to be highly field dependent

may make them more likely than other persons to

react to stress with overwhelming, diffuse anxiety

and undifferentiated symptoms that tend easily to

generalize and emerge when external supports are

withdrawn...Also, partly based on their field

dependent, they may...move more readily into a

position of dependence upon others rather than
relying upon their own internal cues and emotional

30

resources to understand and cope with their
environment.

(Rock and Goldberger, 1978, p. 784).

While the above interpretation of the findings appears
to follow logically from the results of this study, a problem
inherent in the research is that the subjects of the study
were actively agoraphobic. It may be that agoraphobics shift
their self-other orientation when anxiety is chronically
high, and become so occupied with cues from their internal
state that they are incapable of using external cues from the
field to help them or to utilize support from others in
order to feel better. Also, the generalization of symptoms
of these subjects cannot be explained in terms of their
having identical experiences; rather, the generalization of
symptoms is to specific "classes" of stimuli. However, the
finding of a difference between the field dependence of
agoraphobic women and those with simple phobias is of
significance in that it once again suggests the uniqueness
of agoraphobia and implicates certain cognitive and perceptual
processes in the development of the disorder.

Bowlby's Theory of the Separation Process.

Through his naturalistic studies, Bowlby (1973) has
described a three-stage process experienced by the individual
following a separation. The process begins with separation
from an attachment figure, upon which the child first becomes
distressed and protests the separation through its cries and
other behavioral signs, in order to retrieve the lost object.

As noted earlier, this protest response seems to be an

3l

innately released behavior, rather than a learned response,
at least when the child is an infant. If the infant's
response is not soon attended to, the infant begins to
despair, becoming preoccupied with and vigilant for the
return of the lost object. Eventually, with reunion with
the attachment figure not forthcoming, the child may become
emotionally detached from her. This detachment phase will
end with the return of the attachment figure, when the child
again attaches to her; although now the attachment may be
anxious, and the child will insist on remaining in close
contact with her for some time after their reunion. Children
who have experienced many such separations may respond with
anticipatory dread (like that of the agoraphobic) to any
situation that might involve separation. On the other hand,
if separations are prolonged or repeated over the first few
years of life, the child may become persistently detached.

There are various affective responses to separation as
well. One of these is hostility or anger, which functionally
appears to express reproach toward the abandoning attachment
figure and to discourage further separation. This anger,
which retrieves the lost object, can become dysfunctional
when it persists and is excessive, thereby alienating the
attachment figure. According to Hansburg (1972), an overly
intense hostile reaction can become pathological when it is
unaccompanied by a desire for attachment.

When the child's ego cannot tolerate the expression of

hostility, the reality of the separation may be avoided

32
through withdrawal, fantasy, or evasion of one's real
feelings. Although, as Rochlin (1965) points out, escaping
the reality of a loss is necessary for every individual at
some time, so that the trauma can be mastered gradually,
excessive withdrawal and fantasy can become pathological
when they dominate the individual's response to separation.
An individual who entirely evades his true feelings about a
loss may unconsciously recreate a loss situation which he
has been attempting to deny.

The need for a balance in being adequately attached to an
object and able to withstand some separation without distress
is the basis for an individual being able to develop as a
mature and separate being. Exaggerations of either the
attachment need or excessive individuation (detachment) make
up pathological coping mechanisms. The anxiously attached
individual exhibits excessive help-seeking and dependency,
resulting from the belief that separation from an attachment
figure will be repeated, and from a lack of confidence that
these figures will be available and responsive when needed.
Thus, such individuals avoid any separations by clinging
excessively to their attachment figures. Although remaining
in close proximity to attachment figures may provide a sense
of security for the individual, it is gained at the expense
of a loss of autonomy and independence. On the other extreme
of the drive toward individuation is the excessively
self-sufficient individual. This person is detached from

dependence on another person. Bowlby describes this detachment

33
as resulting from the intensity of the protest stage and the
child's inability to withstand the despair stage which would
stave off the detachment. In excessive protest, the child's
anger may alienate the attachment figure so that the bond
between them is weakened, with the attachment object less
responsive. The child then defensively withdraws into
excessive self-sufficiency, which increases the child's sense
of loneliness and deprivation and his belief that no
relationships can be relied upon.

Hansburg points out that healthy personalities respond to
mild separations (those which are temporary and in which
reunion is assured) with little anxiety, and may even welcome
these separations as opportunities for expressing autonomy.
Individuals who are excessively self-sufficient, however, will
meet mild separations with an intense drive to individuate,
so that they are unable to connect with other people during
times of separation or less. The anxiously attached
individual, on the other hand, will react with intense
anxiety to even mild separations and will attempt to remain
in contact with the lost attachment figure, often relying
excessively on others and being unable to be alone and rely
on themselves.

This outline of the separation process for the anxiously
attached individual as described by Bowlby and Hansburg seems
to parallel the behavior of agoraphobics. Although there is
usually no precipitating or imminent separation experience

coinciding exactly with the first panic attacks of such

34

individuals (although some report the onset of symptoms
sometime after experiencing a major loss), they react as
though this is the case. If indeed the protest phase of the
response to separation has gone awry in such individuals
(because of a dysfunctional physiological mechanism), they
may constantly be anxious and seeking attachment and security
‘without cause, which are the symptoms of agoraphobia; and
rather than being able to experience a separation which sets
off the normal separation stages, avoids separation altogether
by remaining tied to the attachment figure; i.e., in this
case, home.

The histories of Childhood Separation Anxiety Disorder
of many agoraphobics suggests that such individuals have been
dealing with a hightened sensitivity to separation all of
their lives and have developed characteristic ways of coping
with stress, separation, and loss. It may be that the proposed
'physiological mechanism regulating separation anxiety in
adults with agoraphobia plays a role in early separation
difficulities as well. It so, the personality characteristics
which develop in response to excessive anxiety in childhood
may influence the occurrence of panic disorder in adulthood.

Klein asserts that if separation anxiety is learned, it
learned on a biological substrate. Thus, it can be
speculated further that agoraphobics are passive, dependent
and unassertive because their high levels of anxiety in
response to separation situations as children do not allow

them throughout their lifetimes to adequately resolve

35
feelings of anger and hostility. If separation, which
normally temporarily evokes anger in the individual, arouses
anger so often and intensely in the child that the threat of
its expression becomes too dangerous (rejection or separation
will be experienced), it would be expected that as adults,
such persons would be passive, attempt to please others and
be fearful of their own hostility. Of course, a similar
hypothesis has been invoked to explain certain depressions;
i.e., anger experienced by the child is turned against the
self rather than expressed toward the attachment object for
fear of losing that object, which is the ultimate threat to
the infant's survival. If Klein is correct in his speculation
that the same physiological mechanism plays a role in the
development of both depression and panic disorder, then the
role of suppressed rage in producing neuroses may vary with

certain biological predispositions.

Chapter 3
PURPOSE OF THE STUDY

The present study attempts to investigate Klein's
(1981) of a link between panic disorder and separation
anxiety, by examining the responses of panic disorder
patients to situations involving separation and loss. The
central question is whether successfully treated
agoraphobic individuals are more vulnerable to separation
experiences than are other neurotic or normal individuals.
The underlying question is whether it is the response to
separation experiences which elicits panic attacks and
engenders the anxiety of the agoraphobic. And is this
response part of the personality structure or instead
induced by the nature of the disorder? That is, once the
panic attacks and anxiety are alleviated with treatment,
is it to be expected that an agoraphobic "personality"
remains intact?

The study is indirectly concerned with whether certain
psychological characteristics of an individual, in this
case, dependency, passivity, underachievement (pathological
responses to separation anxiety), predispose that individual
to develop panic disorder, or whether a predisposition for
panic disorder is the cause of dependent behavior. While
the apparent direction of causality may appear to be a

36

37

moot point, especially in light of the apparent efficacy

of current treatment procedures, it is a critical
distinction for matters of determining risk for the
development of the disorder, of prevention, and of improved
diagnosis and treatment.

If panic attacks are purely physiological events,
then the premorbid personality characteristics of the
agoraphobic patient would be irrelevant to the development
of this disorder. Klein has suggested that the traits so
often observed in agoraphobics are caused by the enormous
anxiety they experience, and that their dependency on
others is understandable: "Individuals who suffer panic
attacks are more comfortable entering feared situations
in the company of people they know and trust. While this
has been related to separation anxiety it seems...that it
may simply involve the comfort of knowing that if they
do have a panic attack there will be immediately
(available someone whom they trust to help" (Klein, 1981,
1:. 55). Once successfully treated, such persons would no
Longer be expected to display dependent behavior because
:it.is only an artifact of the disorder. But this does not
:seem.to be the case. MOSt studies of the effectiveness of
Vairious treatments assert that supportive or behavioral
pssychotherapy is required to deal with the dependency

euren after medication has alleviated the panic attacks and

38

anticipatory anxiety.7 So while the help-seeking of the
actively phobic individual may be an outcome of the stress
of the disorder, it does not preclude the possibility that
dependency is typical premorbid behavior of the agoraphobic.
The description in DSM III of Childhood Separation
Anxiety Disorder closely resembles the description of
panic disorder and agoraphobia. A predisposing factor
listed for Separation Anxiety Disorder is that such
children tend to come from families that are highly
close-knit and caring (or perhaps, from a family systems
point of view, would be seen as overly involved, enmeshed,
nondifferentiated). The psychoanalytic perspective might
assert that close-knit families evoke more intense Oedipal
anxiety and greater guilt, resulting in overidentification
with the same-sexed parent and an inability to individuate.
From this point of view, such excessive closeness would
also exacerbate conflicts in earlier psychological stages,
.again resulting in problems of attachment (Bowlby's
"anxious attachment"). Like the ethological view,
p>sychoanalytic theory emphasizes the child's interaction
writh parents. Apparently, according to the DSM III
ciescription of Childhood Separation Disorder, "neglected

‘

7Sheehan (1982) and his colleagues argue that agoraphobia

arid panic attacks can be treated entirely with medication,
arid that psychotherapeutic interventions should not be
tmecessary if medication is properly administered. This

is :not to suggest that they believe there are no psychological
coznponents to this disorder, but suggests that removal of
obvious symptoms is the only goal.

39

children are underrepresented in this disorder," although
reasons for this finding are not offered. Neglected children
could be said to suffer from excessive detachment, an

overly developed sense of autonomy in response to an
unresponsive environment. It could also be argued that
separation anxiety simply may manifest itself or be
interpreted differently in different families, e.g., perhaps
neglected children's absences from school are viewed not as
phobic behavior, but as either a lack of interest or
delinquency.

Reported results of treatment for panic disorder
suggests that clinicians should take a balanced view of the
causes and the symptoms of this problem. Muskin and Fyer
(1981) have found that, for some people, panic attacks do
not seem to serve as a resolution of unconscious conflict.
For such patients, treatment response is usually rapid,
and nothing beyond medication and encouragement to enter
jphobic situations is required for recovery. On the less
Itesponsive end of the range of treatment responses are a
group of patients in which the symptom complex also serves
.as a resolution of conflicts in areas of work, familial and
social relationships. In these cases, psychotherapy is
ruecessary before any change in symptom pattern occurs,
Galen when panic attacks are first blocked with imiprimine.
If? the patients who are more difficult to treat represent
thxase for whom the biological substrate has been more

rezactive and dysfunctional at an earlier age, then their

4O

agOraphobic symptoms may have developed as a learned
coping response to this biological predisposition. Since
separation anxiety will be considered both a psychological
and a neurobiological (instinctive) event for the purposes
of the present study, it is predicted that agoraphobic
patients will exhibit heightened responsiveness to

separation situations.

Chapter 4

PROCEDURE

Description of Instruments

 

The Separation Anxiety Test (SAT) is a semi-projective

 

instrument developed by Hansburg (1972) to measure the
responses of children and young adolescents to separation
experiences.' Although the instrument was designed for use
with adolescents, more recent studies have demonstrated
its usefulness with young adults as well (Hansburg, 1976;
DeLozier, 1979; Sherry, 1980; Cohen, 1984). Similarly to
the Thematic Apperception Test, the SAT consists of a
series of twelve pictures in which children are seen
separating from adults in a variety of situations
(Appendix D). Six of the pictures depict mild or tenporary
separations, such as a child leaving home in the morning
to attend school; six depict strong or permanent separations
such as the death of a parent. There are two editions of
the test, one for females and one for males, in which only
the gender of the child in the illustrations differs while
the situations and the statements remain identical.

Each of the SAT pictures has a title describing
the scene and a series of 17 statements describing the
possible feelings and reactions of the child protagonist.
The 17 statements have been classified according to eight

41

42

response themes: 1) attachment, 2) individuation, 3)
hostility, 4) painful tension, 5) reality avoidance, 6)
concentration impairment, 7) self-love loss, and 8)
identity stress. Only the first five of these themes are
relevant for the present study.

Each of the response themes is represented by three
items. The attachment theme contains items reflecting a
feeling of loneliness, a feeling of rejection, and a
feeling of empathy. The individuation theme taps feelings
of well-being, adaptation, and sublimation. The hostility
theme include an item reflecting a feeling of anger, plus
projective and intrapunitive items. The painful tension
theme consists of items describing phobic, anxious, and
somatic reactions. The reality avoidance theme has items
for withdrawal, evasion, and fantasy. A sample of these
statements from the SAT, the feelings the statements
represent, and their classification into one of the five
response themes can be found in Appendix D.8

Female subjects and male subjects received their
respective editions of the SAT. Each of the pictures has
an answer sheet containing 17 response statements. Subjects
were asked to empathize with the protagonist in each of
the 12 separation experiences and select those responses

that would most nearly describe their own feelings were

 

8Because three of the eight response themes (concentration
impairment, self-love loss, and identity stress) are repre-
sented either by only one item or by items which represent
more than one theme, there are only 17, rather than 24
statements .

43

they the child in the picture. Subjects could select as
many or as few of these statements as they wished.

Each subject's selections were then scored
individually and recorded in the Chart for Controlled
Associations (Appendix D). Then the total number of
attachment, individuation, hostility, painful tension,
and reality avoidance choices was determined by tabulating
the number of items corresponding to each response theme,
thereby producing five scores for each subject, which were
recorded in the Pattern Summary Chart (Appendix D). The
individuation score, for example, was calculated by
adding the number of adaptation, well-being, and sublimation
responses. Each of the five scores was also tabulated
separately for the mild pictures and the strong pictures.

These calculations produce a pattern of response to
separation that indicates the adaptive strategies of the
individual respondent. In his validity studies with this
instrument, Hansburg (1972, 1976) found, for example, a
number of differences in the way young adolescents separated
from their families respond to the SAT situations as
compared with the responses of adolescents from intact,
stable homes. These differences, such as excessively
self-sufficient responses on the part of the separated
adolescents, suggest difficulties in the attachment process
for such youngsters. Adolescents from secure homes
responded with a greater proportion of attachment than

individuation responses, although there was generally more

44

of a balance between these two types of response to
separation amongst this group. Thus, the patterning of
the responses to separation situations was the significant
factor in determining the individual's characteristic
reaction to such situations.

A Background Information Questionnaire, consisting of
24 questions, was developed specifically for this study
and was used to provide demographic data and information
about the subjects' histories of real separations and
losses, their general perceptions of the degree of closeness
within their families of origin, their families' incidence
of panic disorder and agoraphobia or other psychiatric
disorders, their birth order within their families of origin,
and other issues of relevance to the study (see Appendix C).

Subjects. gs were 10 males and 10 females in each of
three groups. The first of these, the agoraphobic group,
of central interest to this study, consisted of subjects who
had been diagnosed as having agoraphobia and who had been
successfully treated both with medication and psychotherapy,
successful treatment being defined as cessation of panic
attacks, relief of anticipatory anxiety, and absence of
phobic avoidance behaviors. Persons actively experiencing
panic attacks and symptoms of agoraphobia were not included
in this study, as it would have been impossible to
differentiate their responses to the research instruments
from their responses to their active phobic anxiety and

panic. Also in this regard, the question of whether an

45

"agoraphobic personality" underlies the symptomology, or
remains intact once symptoms are relieved, would have
been obscured by the inclusion of actively symptomatic
subjects.

The second group of subjects were "neurotic" individuals,
who had been treated for anxiety but not diagnosed as having
panic disorder or agoraphobia, and who were not currently
involved in psychotherapy. This group was of interest in
terms of the study's central thesis concerning the role of
separation anxiety in the evolution of panic disorder.

While separation anxiety has been proposed as a universal
and instinctive response to separation situations that
threaten an individual's survival, and thus as an important
element in the development of various defense mechanisms,
its special significance for agoraphobic individuals has
not been examined. The question is whether responses to
separation situations distinguish agoraphobics from other
anxious individuals.

The third comparison group was the "control" subjects.
These individuals had not been involved in any psychotherapy
and by self-report had not suffered from any serious anxiety
or depression. This group was included in part to provide
some normative data regarding the Separation Anxiety Test,
and also to determine whether this test could differentiate
between "normal" separation anxiety and more extreme anxiety.

The groups were matched for age, gender, educational

background, and marital status. Age was controlled, because

46

there appears to be a bimodal distribution of age of onset
for agoraphobia. Marital status was controlled in order to
reduce the possible influence of "dependency" factors;

if in contrast to agoraphobic subjects, all control subjects
were single and lived alone, that in itself could represent
differences in attachment and individuation needs between
them and the agoraphobic group. Subjects were matched in
educational attainment to provide a control for socio-
economic status.

The agoraphobic subjects for this study were obtained
through several of the author's colleagues in the
metropolitan Boston and New York areas, who agreed to contact
their former patients to inquire about their interest in
participating in a research study. In order to mitigate
the potential biasing influence of the therapist-patient
relationship on the patient's decision to participate in
the study, and because several therapists were involved in
procuring subjects, a standard script for contacting
potential subjects was developed (see Appendix A). This
procedure was followed closely.

Potential subjects were informed that the author was
planning to conduct a study for which subjects were
Iieeded who were both symptom-free and not presently in
tireatment. They were told nothing else about the study

aitzthat time, except that it was hoped its results would
<2<3ntribute to a better understanding of anxiety disorders.

13311 30 agoraphobic individuals who agreed to participate

47

in the study were then mailed a packet containing the
research instruments, instructions, and a statement of
informed consent to read and sign. Having been informed
that the tests would take an hour or less of their time,
subjects were instructed to complete these instruments in
a quiet place at home where they would not be distracted,
then return them by mail to the author.

Exactly ten agoraphobic males and twelve agoraphobic
females returned the completed forms. In order to maintain
even numbers of subjects for each gender, two female
subjects were dropped from the study: one who did not
complete the research instruments fully, and another at
random.

After information regarding the age, marital status,
and educational attainment of each agoraphobic subject was
ascertained, the twenty subjects for the "neurotic" group
matched with the agoraphobic subjects on these variables,
were then obtained in the same manner by the author's
colleagues. Twenty control subjects were sought from among
these same sources, as well as through acquaintance of the
author, and were again matched on these same variables.

All subjects were sent the same instructions, and
returned their completed forms to the author by mail. None
of the subjects in any of the groups knew the author, and
all were reassured of the confidentiality of their

participation.

48

Appendix A presents the age, marital status and
educational attainment for each of the three groups.

Hypotheses

 

In general, it is expected that agoraphobic subjects
will exhibit greater separation anxiety than neurotic and
control subjects, and neurotic subjects will exhibit greater
separation anxiety than control subjects. That is, there
is a continuum of maladaptive responses to separation
situations, from agoraphobic to neurotic to normal subjects.
Operationally defined the hypotheses are:

I. Agoraphobic subjects will have a higher percentage
of attachment responses on the SAT than the neurotic and
control subjects.

II. Agoraphobic subjects will have a higher percentage
of individuation than the neurotic and control subjects.

III. Agoraphobic subjects will have a higher percentage
of hostility responseS'than the neurotic and control subjects.
IV. Agoraphobic subjects will have a higher number of
reality avoidance responses, or denial, than the neurotic

and control subjects.

V. Agoraphobic subjects will respond with fewer
adequate coping responses, or more painful tension responses,
to separations than the neurotic and control subjects.

VI. Agoraphobic subjects who experienced separation
problems earlier in their lives, before the onset of adult

agoraphobia will have a higher percentage of attachment,

hostility, painful tension and reality avoidant responses

49

and a lower percentage of individuation responses, than
agoraphobic subjects for whom the onset of the disorder
was not preceded by early separation problems.

Exploratory Hypotheses

 

Predictions concerning the data gathered from the
Background Information Questionnaire will be primarily
exploratory, as there are few previous studies which have
addressed these questions.

Exploratory Hypothesis 1: There will be no difference

 

between agoraphobic and neurotic and control subjects in the
number of actual separations and losses they have
experienced.

Exploratory Hypothesis II: Reported separations and

 

losses will coincide in time with the onset of panic attacks
in agoraphobic subjects.

Exploratory Hypothesis III: Agoraphobic subjects will

 

report greater family closeness than will either of the other
subject groups. This prediction is based on the notion of

an interaction between the heightened anxiety of a child

and the protective response of attachment figures.

Exploratory Hypothesis IV: Given recent studies'

 

findings of high incidences of affective disorders,
alcoholism and panic disorder in the families of agoraphobic
parents, it is predicted that family incidence of
psychiatric disorders will be higher in this group than the

neurotic and control groups.

Chapter 5

RESULTS

The data were statistically treated by analyses of
variance for each variable considered. The mean scores of
the three subject groups were compared utilizing a split-
block randomized design to determine differences amongst
the three groups. The same design was used to determine
differences between the neurotic and control groups.

The SAT protocols have been scored by Hansburg (1972)
by determining each response theme's percentage of the total
number of responses to the SAT and then examining the
relations among these percentage scores to obtain patterns
associated with various personality characteristics.
Hansburg uses percentage scores because scales like his
permit subjects to make different total numbers of choices.
This response set (Cronbach, 1950) must be investigated
before further analyses of data. Dividing choices on a
given dimension by total choices makes a part-whole
correlation possible and further consolidates maladaptive
categories with adaptative categories. Table 1 shows the
results of an analysis of variance of the total number of
choices made to the 12 pictures in the test. (Tables for
this and following ANOVAs are in Appendix B.)

50

51

Table 1. Total Responses to the SAT: Means, F-ratios
from ANOVA and Statistical Significance

 

 

Mean Group

 

 

A ’N C F-ratio P
N: 20 20 20
Mild pictures 15.9 9.7 8.9 4.73 .05
Strong pictures 24.5 17.8 15.7 11.02 .01
All pictures . 40.4 27.4 24.6 14.2 .01

 

It is clear that the agoraphobic group makes more
choices than the others. To control for this group
difference in total choices, individual scores on each
maladaptive dimension were contrasted with scores on the
individuation dimension, the measure of adaptative tendencies.

The formula for each conversion was:

Maladaptive frequency (Maladaptive frequency +

individuation frequency)

Hypothesis I stated that agoraphobic subjects would

 

have a higher percentage of attachment responses on the SAT
than would neurotic and control subjects. Hypothesis II
stated that agoraphobic subjects would have a lower
percentage of individuation responses on the SAT than
neurotic and control subjects. Using the preceding ratio

of attachment and individuation scores, Hypothesis I and
Hypothesis II could be examined in one analysis. An analysis

of variance was used to determine the significance of the

52

differences between the means for the three groups, and
another analysis to determine the significance of the
difference between the neurotic and control groups. As
summarized in Table 2, the first analysis produced a highly
significant F—ratio of 23.2. The corresponding analysis
for the agoraphobic and control groups produced and F-ratio
of 8.08, significant at the .01 level. These results show,
as predicted, that agoraphobic subjects chose both a
significantly higher percentage of attachment responses

and a significantly lower percentage of individuation
responses than both the neurotic and control subjects;
neurotic subjects chose correspondingly higher and lower
percentages than the control subjects. Both Hypotheses I
and II are supported by the data.

Hypotheses IV, V, and VI were concerned with reactions

 

to separation other than attachment, namely hostility,
reality avoidance (denial) and painful tension (poor coping
responses). Each of these dimensions was measured by
comparing the total frequency of each of these categories
of response with the frequency of individuation responses,
again reflecting the balance between the number of
maladaptive and adaptive reactions to separation. The
results from the analyses of variance are reported in
Table 2.

Hypothesis IV stated that agoraphobic subjects would

 

have a higher percentage of hostility responses than both

the neurotic and normal subjects. The analysis of variance

53

for these three groups produced a highly significant F-ratio
of 17.07. The corresponding analysis of variance, comparing
scores for the neurotic and control subjects, yielded an
F-ratio of 5.8, significant at less than the .05 level.
These results confirm Hypothesis IV; agoraphobic subjects
react with a significantly higher percentage of hostile
responses to the SAT than neurotic and control groups, and
neurotic subjects select significantly more hostile
responses than controls.

Hypothesis V predicted that agoraphobics would have

 

a higher percentage of hostility avoidant responses on the
SAT than would the neurotic and control subjects. As seen
in Table 2, the analysis of variance of these scores of
the three groups produced an F-ratio of 9.7, significant
at less than the .01 level. The companion analysis of
variance comparing reality avoidance scores of neurotic
and control subjects produced an F-ratio of 6.7, significant
at less than the .05 level. Again, the data support the
hypothesis: agoraphobics are more likely than the others
to select reality avoidance responses, and the neurotic
subjects more likely to choose such responses than the
controls.

Hypothesis VI stated that agoraphobic subjects would

 

respond with fewer adequate coping responses, or greater
frequencies of painful tension responses, than would
neurotic and control subjects. As seen in Table 2, the

analysis of variance for the three subject groups gave a

54

highly significant ratio of 15.95. The parallel analysis

for the neurotic and control groups yielded an F-ratio

of 14.26, significant at the .01 level. These results

show that agoraphobic subjects tended to react to separation

with fewer adequate coping responses, or a greater number

of anxious, phobic and somatic responses, than both the

neurotic and control subjects; and that neurotic subjects

gave fewer adaptive responses than controls.

Table 2. Means, F-ratios from ANOVAs and Significance
Levels of Attachment, Hostility, Reality Avoidance,

and Painful Tension Scores for Agoraphobic (A),
Neurotic (N), and Control (C) Subjects.

 

 

 

A N C F P
Attachment 67.9 43.2 36.2 23.2 .01
Hostility 52.05 29.3 22.1 17.09 .01
Reality 40.75 12.0 5.4 17.0 .01
Avoidance
Painful 69.6 34.4 22.5 17.9 .001
Tension

 

Hypothesis VI stated that agoraphobics who experienced
more separation difficulties as children would have a
higher percentage of attachment, hostility, painful tension,
and reality avoidant responses, (more maladaptive responses)
and a lower percentage of individuation responses than
agoraphobics for whom onset of the disorder was not preceded

by earlier separation problems. In order to test this

55

hypothesis, mean scores on the attachment, hostility,
painful tension, and reality avoidance and individuation
variables for agoraphobic subjects who had early symptoms
of agoraphobia (as reported on the questionnaire) were
compared with those of agoraphobic subjects who did not
report early difficulties. Only four of the 20 agoraphobic
subjects reported childhood symptoms as precursors to their
adult onset agoraphobia. As can be seen in Table 3, mean
scores on these variables for these four subjects are
higher than those of the other agoraphobic subjects. Thus,
Hypothesis VI was not upheld by the data.

Exploratory Hypothesis 1. The prediction that there

 

would be no differencesbetween the agoraphobic, neurotic
and control subjects in the numbers of serious separations
and losses they have experienced was supported by data from
the questionnaire. Table 4 shows the mean number of

losses reported by each group.

Exploratory Hypothesis II. The data did not support

 

the prediction that reported losses among agoraphobic
subjects were likely to coincide with the onset of their
panic attacks. Only three female subjects and one male
subject reported major separations and a death as preceding
the onset of their symptoms. Of the other separations and
losses experienced by these subjects, none were temporally
associated by them with the onset of the disorder.

Exploratory Hypothesis III. The expectation that

 

agoraphobic subjects would report greater family closeness

56

 

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57

than would the neurotic and control subjects was not borne
out by the data. In response to the questionnaire,
subjects described the degree of closeness within their
families on a scale from 1 to 5, with 5 representing
extreme closeness. All of the group means were higher than
3.0, ranging from 3.3 to 3.6, indicating that all subjects
tended to perceive a slightly more than average degree of
closeness within their families.

Exploratorngypothesis IV. The prediction that family

 

incidence of psychiatric disorders would be higher in the
agoraphobic group than the neurotic and control groups

was partially substantiated by the results. As summarized
in Table 5, agoraphobics were the only group to report a
high rate of agoraphobia within their immediate and
extended families. The incidences of other psychiatric
disorders reported by each of the three groups were small.

Table 5. Number of Subjects Reporting Family Incidence
of Agoraphobia and Other Psychiatric Disorders

 

 

 

 

Group
A N’ C
Agoraphobia 12 l 1

Other psychiatric
disorders 9 6 5

 

Chapter 6

DISCUSSION

The present study investigated a proposed but
previously untested link between agoraphobia and separation
anxiety by examining the responses of agoraphobic
individuals to drawings depicting separation and loss. The
hypothesis was that agoraphobic subjects would display
greater vulnerability to separation experiences, responding
more frequently with maladaptive responses than would
neurotic and control subjects. Of the seven major hypotheses,
the six that concern differences in separation anxiety
between these three groups were strongly supported by the
data. Agoraphobics selected significantly greater
percentages of responses related to attachment, hostility,
reality avoidance, and painful tension, and a smaller
percentage of individuation responses. Neurotic subjects
similarly chose more maladaptive and fewer adaptive responses
than controls. A hypothesis involving comparison of
agoraphobics with early separation difficulties to those
without such problems was not supported by the data.

Clearly, the SAT evokes powerful reactions to separation
in agoraphobics. Even the total number of responses
selected by such subjects was significantly greater than

that chosen by neurotic and control subjects, with the mean

58

59

frequency for agoraphobics nearly twice that of the others.
Since subjects were asked to imagine that they were the
child in the scenes shown on the SAT, the greater
responsiveness of the agoraphobics may be related to their
having experienced greater anxiety about separation when
they were children. Although these agoraphobics did not
report greater separation anxiety as children, previous
studies (Klein, 1964, 1981) have found that as many as 50%
of agoraphobics experience school phobia as children. It
is of interest that on the pictures showing a child going
to school in the morning, a mild separation, many of the
agoraphobic group chose attachment and phobic responses,
suggesting unhappy childhood experiences for them.

Although there were significant differences in the
frequency of total responses between each of the three
groups of subjects, the difference between agoraphobics
and neurotics was surprisingly large. While significant
as predicted, differences between neurotics and controls
were much smaller. An examination of the protocols indicates
that agoraphobics selected many responses to each
separation situation, even the mild, temporary separations.
This responsiveness to the mild separations is noteworthy,
as these pictures would appear to generate independence
striving in most individuals, suggesting that even the
most minor separation is felt by an agoraphobic as
catastrophic. Further, since the agoraphobics participating

in this study were not actively phobic--they were "healthy"

60
compared to those seeking treatment--their high degree of
responsivity to the SAT must reflect underlying personality
patterns and unconscious responses to separation. Given the
results of this study, agoraphobics must be viewed as a
distinct group among other kinds of anxious persons.

The hypotheses concerning the balance of attachment to
individuation responses were strongly confirmed by the
analysis. Agoraphobics chose a significantly greater number
of attachment compared to individuation responses than did
neurotics and controls, with an average of 67% attachment
and 33% individuation scores. On the SAT, such scores of
50% or greater indicate a balance dominated by the attachment
,theme. The neurotics' mean of 43% and the controls' mean of
36% represent ratios dominated by individuation responses.

According to Hansburg (1972), the mild separation scenes
are expected to produce a low number of attachment responses:
conversely, the strong separation scenes should produce a
greater number of attachment responses. He points out that
any shift in this pattern toward equalization on the mild
and strong scenes is a likely "symbiotic" indicator.
Furthermore, when attachment responses to mild separation
scenes exceed the number of individuation responses to

these separations, a very strong symbiotic indicator is

61

present.9 In Hansburg's validity studies, adolescents from

intact, secure homes, as opposed to those separated from
their families, tended to select a slightly higher total
frequency of attachment responses than individuation responses.
In the present study, the neurotic and control subjects had
a higher frequency of individuation responses, which Hansburg
might interpret as excessive self-sufficiency. This
discrepancy can best be accounted for by the fact that the
subjects in the present study were adults, not adolescents.
It is likely that having resolved the issues of adolescence,
including issues of autonomy and dependency, healthy adults
may actually be slightly more self-sufficient than they are
affiliative. Another explanation for the difference in the
findings between this and Hansburg's study is the scoring
method he employs, the problems of which were mentioned in
the preceding section.

Hansburg (1980) asserts that attachment is a primary
response related to the basic instinctive need for protection
and care. In the attachment system, an individual seeks

proximity to another for the instinctual purpose of

 

9Hansburg (1972, 1976) describes severe anxious attachment
as an unconscious symbiotic need, a desire for a relationship
in which the individual feels fully and completely attached
to another. Unlike the term's usage in biology, which refers
to an adaptive partnership where both parties are dependent
upon each other for survival, the attachment figure in
Hansburg's usage does not necessarily share in the attachment
need. That is, symbiotic attachment refers to "an unconscious
feeling (about) unassuaged experiences during early childhood
when the attachment figure's need to separate from the
infant...was never adequately accepted by the child."
Hansburg, 1980, p. 16

 

62
protection and subsequently for other elaborated and
sophisticated gratifications geared to survival. "Since the
propensity for proximity-seeking, especially with an
attachment figure, is based on organismic trends built in as
a survival measure, it seems likely that humans vary from
individual to individual in the intensity and extent of this
trend" (Hansburg, 1980, p. 36). Hansburg states that the
number of attachment responses to the strong pictures should
be approximately 40% greater than the responses to the mild
pictures. If both areas are sizable, he concludes that the
need for closeness is always intense no matter how mild or
how strong the separation stimulus. Such a high attachment
response is consistent with poor functioning in the absence
of a feeling of accessibility of a highly supportive figure.

Agoraphobics, then, appear as anxiously attached. They
seem not to have succeeded in developing adequate coping
behaviors, either because of early dependence strivings, which
were perhaps responded to with overprotectiveness by parents;
or because their overreactivity to separations interfered
with the development of such skills. The sensations of panic
and anxiety set into motion by separation overwhelm these
individuals.

Hansburg notes that when attachment need is very high,
especially in response to mild separations, other anxious
attachment indicators are likely to be present as well:
attachment responses are highly correlated with separation

pain in this instance. Examining the agoraphobics' painful

63

tension responses makes this clear in the present case.
Painful tension, including anxious, phobic and somatic items,
accounted for a large percentage of total responses for the
agoraphobic subjects. A separate analysis of variance was
performed isolating the phobic, somatic and anxious responses
for the agoraphobic and neurotic groups. Results indicated
that it is the phobic and somatic responses that account for
much of the difference in the mean scores between the two
groups. While both neurotic and agoraphobic subjects
endorsed a relatively high number of items reflective of
anxiety, only agoraphobic subjects had a high frequency of
somatic and phobic responses. Virtually none of the control
and only a few of the neurotic subjects selected somatic
responses. These findings support the notion that neurotic
and agoraphobic subjects respond to separation in
qualitatively different ways, agoraphobics being more likely
to react to separation with fear and with somatic complaints.
Hansburg notes that this painful tension variable is a highly
sensitive indicator of the individual's "alarm system."
Somatic responses as the choices of agoraphobic subjects
are not surprising in light of the physical sensation of
panic which is the hallmark of the disorder. Agoraphobics
often become highly focused upon any changes in bodily
sensations, so vigilent are they of signs on an impending
panic attack. This heightened awareness of alertness may
contribute to a kind of excessive somatic preoccupation that

influences the nature of their responses to anxiety-provoking

64
situations. It may also be that agoraphobics have heightened
physiological responses. Data from the questionnaire which
indicate greater family incidence of agoraphobia and other
psychiatric disorders among agoraphobics may be relevant to
this finding regarding the high painful tension scores of
these subjects. The reported high rate of incidence of
agoraphobia within this group's families may reflect a
genetic predisposition for development of this disorder. It
may be speculated that agoraphobics differ from other anxiety
neurotics in their heightened physiological reactivity to
stimuli.

Hypothesis IV stated that agoraphobic subjects would
select significantly more hostility responses than would
neurotics and controls, a predication that was strongly
supported by the data. As with painful tension and attachment
responses, agoraphobic subjects consistently chose the least
adaptive responses to separations situations. If hostile
responses are viewed as strong protest reactions to the threat
of separation (Bowlby, 1973), reacting to separation with
anger is an appropriate response. It may act as retribution
against an abandoning figure or be an attempt to retrieve
and keep the lost figure. Persistent anger, however, may
serve to alienate that object of attachment and thereby
serve a nonadaptive purpose. Agoraphobic subjects in this
study chose hostile responses to a greater extent than they
selected adaptive responses, suggesting again that their

strong affective response to separation interferes with more

65
adaptive strategies and reflects an ambivalence towards the
object of attachment.

Hypothesis V stated that agoraphobic subjects would
choose reality avoidance responses more often than neurotic
and control groups. This finding, confirmed by the data,
provides further evidence that agoraphobic subjects tend to
have maladaptive reactions to separation. They do not appear
to have ways of sublimating or otherwise coping with the
stress of separation, reacting by denying the separation.

The reality avoidance variable included the response items
of withdrawal, fantasy and evasion. Fifteen of the forty
neurotic and control subjects chose no reality avoidance
responses and seventeen others selected only one such
response. Hansburg notes that whenever an individual's
defensive pattern is less than 10% of the total protocol,
that individual is likely to be strongly reality-oriented.
Although the control subjects were expected to show this
pattern, the neurotics' low scores on reality avoidance as
compared with the agoraphobics' scores are more surprising.
This finding may again underscore the difficulty agoraphobics
appear to have specifically with separation situations, as
distinct from other anxiety-provoking situations.

Hypothesis VI, predicting a greater number of maladaptive
responses in agoraphobics who reported early onset of
agoraphobic symptoms than in agoraphobics who reported adult
onset of symptoms, was the only major hypothesis not

supported by the data. There were simply not enough subjects

66

reporting an early onset of symptoms to make the comparison
statistically meaningful. In addition, the questionnaire
item concerning early and late onset of agoraphobia may not
have elicited the intended information. The question could
have been interpreted in several ways; a question asking
whether subjects had had difficulties attending school as
children might have provided more clear-cut information on
which to base the comparison.

To speculate further about the agoraphobics' greater
responsivity to the research instrument, it is possible that
their psychotherapy experiences resulted in their being more
highly sensitized than the other subject groups to the issues
of separation. The neurotic subjects, while also having
experienced successful psychotherapy, may have been less
likely to have focused during treatment on any one precipitant
or cause of their anxiety. It is more likely, in fact, that
the anxiety of the neurotic group stemmed from many disparate
sources, so that the group was less homogeneous than the
agoraphobic group in terms of the ways in which they learned
to identify and cope with their anxiety.

Another explanation for the findings of this study is
that the agoraphobic group may actually be more "disturbed”
than the neurotic group; their problems may involve more
primitive developmental sources, or their neuropsychological
systems may be more generally reactive. Agoraphobics' affect
may be more readily aroused, or they may engage more rapidly

in fantasy. (Many agoraphobics report that the sensation of

67
panic is often accompanied by vivid visualizations of
frightening situations that instantly overwhelm them.) It is
possible that agoraphobics do have greater accessibility to
fantasy and that it is this very accessibility which allows
greater empathy with the protagonists in the SAT pictures.
Two questions remain: l) is it the psychotherapeutic process
that engenders greater access to fantasy in agoraphobics,
or do such individuals already possess this tendency? and
2) does this heightened reactivity mean that agoraphobics
would respond with greater intensity and frequency to any
emotionally-charged stimuli? In future studies, in order to
test whether the agoraphobics' sensitivity to separation can
be distinguished from their reactivity to all stimuli, control
pictures (potentially anxiety-provoking but non—separation
situations) could be presented along with the SAT.

Exploratory Questions

 

The first question asked whether agoraphobic subjects
had experienced more actual losses and separations than had
other subjects. It was expected that there would be no
differences in the numbers of reported losses among the three
groups; the results support this prediction. The purpose in
asking this question was to control for the possibility that
agoraphobic subjects react strongly to separation because
they actually have been traumatized by earlier serious
separations. The view taken in this study is that maladaptive
responses to separation develop not as reactions to actual

traumas, but as hypersensitive responses to normal

68
separations. That agoraphobic subjects did not report a
greater frequency of losses and separations than the neurotic
and control subjects supports this hypothesis.

The secondary exploratory question was concerned with
the connection between losses and the onset of agoraphobia.
It was expected that reported losses would coincide in time
with the onset of the disorder, a prediction not supported
by the data. A possible explanation for this lack of support
may have been problems in the wording of the questionnaire
item. In addition, many agoraphobic subjects were very
uncertain about what precipitated their first panic attacks,
and thus might not associate separations and losses with the
onset of their symptoms.

The question predicting greater family closeness in the
agoraphobic group was not supported by the data. This
finding does not agree with those of previous studies holding
that agoraphobics tend to come from closely-knit families.
One reason for this discrepancy is that responses to the
questionnaire item were necessarily limited by the subjects'
interpretations of closeness. The wording of the item was
broad; its possible meanings depend upon the perspective of
the subject. Stating the degree of closeness does not reveal
the quality of the relationships or how the subject felt
about the closeness within the family; so that, for example,
extreme closeness could be associated with smothering
relationships for some and with loyalty and dependability

for others. It is noteworthy, however, that agoraphobic

69
subjects chose the extremes of closeness and distance more
often than the other subjects; this may reflect agoraphobics'
very strong ambivalent attachment need.

The fourth question stating that familial incidence of
psychiatric disorders, including agoraphobia, would be higher
in agoraphobic subjects than in neurotic and control subjects
was partially supported by the data. Agoraphobic subjects
reported a high incidence of agoraphobia in their families,
while the neurotic and control groups gave only one report
each of this disorder within their families. The differences
between groups in reporting other psychiatric disorders
within their families, however, were negligable. A possible
reason for this is that the questionnaire item did not
specify any psychiatric disorder,s thus reporting may not
have been accurate. Similarly, because a high frequency of
panic attack and agoraphobia were reported only in families
of the agoraphobics, it is possible that the other subjects
were not familiar with these terms. Finally, agoraphobics
may be so sensitized to the symptoms of this disorder that
their own diagnoses of their families are unreliable. One
subject, for example, reported that his entire immediate
family showed signs of agoraphobia. It seems more likely
that his interpretation of his family's functioning is
biased.

It was speculated that oldestand youngest children
would be more likely represented within the agoraphobic

groups, an idea based on the notion that families may

70
experience difficulties in connection with a firstborn
leaving home--when agoraphobia often appears. Youngest
children, on the other hand,might encounter the same difficulty;
families may unconsciously wish to have a child at home in
order to maintain the family structure. In both of these
situations, unresolved conflicts between parent and child
from earlier developmental stages were thought to be
restimulated by the attempt of the adolescent to separate.
However, no differences in birth order were found among the
three groups, and the small sample size mitigated against
such differences being statistically significant. It is also
possible that the issues of separation have less to do with
an individual's being the first or last to leave the home
than they do with the idiosyncratic nature of the
relationships between parents and their children.

Implications for Future Research

 

The present study succeeds in offering strong evidence
that agoraphobics are extremely sensitive to separation
situations, and that it is this sensitivity that
distinguishes them from other anxious individuals. More
specifically, the data supported the prediction that
agoraphobic subjects would select more maladaptive and fewer
adaptive responses to the research instrument than would
neurotic and control subjects. The results of the study
provide further validation of the separation anxiety test in

its ability to differentiate separation reaction patterns in

71

two groups of anxious subjects and in its usefulness in an
adult population.

Future research might be directed towards using this
measure to explore differences in response patterns between
agoraphobic and clinically depressed individuals, groups whom
previous studies have suggested are equivalent, based on
their similar response to anti-depressant medication and the
frequent diagnosis of affective disorders in the families of
agoraphobics. Klein's (1981) hypothesis that agoraphobia
and depression involve different parts of the same proposed
biological mechanism controlling separation anxiety responses
(protest and despair respectively) might be examined by an
analysis of these two groups' responses to the SAT. Such an
investigation might provide further support for the
significance of the role of separation anxiety in the
development of panic disorder and agoraphobia.

Although the present study was not able to distinguish
agoraphobia subjects with early onset of separation anxiety
symptoms from those with late onset of symptoms, an informal
examination of this group's responses to the SAT indicated a
high degree of variability amongst these subjects and
suggests that a larger sample and improved methodology for
obtaining historical information might provide further
differentiation amongst subjects in this group that is
relevant to preventive strategies and to treatment outcome.

It would be of interest, both in terms of providing

further validation of the SAT and testing other theoretical

72
concepts of agoraphobia to compare agoraphobics' responses
to the SAT with their responses to other instruments
measuring dependency and anxiety. In light of the
agoraphobic's tremendous responsivity to the SAT, a comparison
with their responses to other projective tests might further
distinguish their reactions to separation from their reactions
to situations which tap other unconscious processes, and
might test the notion that agoraphobics have a heightened
physiological response to stressful stimuli.

Since agoraphobia may be the result of reaction patterns
begun in childhood, it would be interesting to test the
validity of the SAT in differentiating children with
separation anxiety disorder from depressed children and
compare their responses to the SAT with temperament measures.

A more ambitious undertaking involving children would
be a longitudinal study of school phobic and highly anxious
children, which would investigate the evolution of panic
disorder and agoraphobia by examining the outcomes in
adulthood of these childhood symptoms, and by evaluating the
effectiveness of various treatment interventions with
children.

Parents react variously to apprehension and fearfulness
in their children, which often sets off either
overprotectiveness by parents, resentment of the child's
demandingness and dependency, or a combination of both of
these, which then charges the relationship with much

ambivalence and conflict. Studies assessing various parental

73
responses to their fearful children might provide evidence
for the contribution of this interaction to the development
of agoraphobia and might suggest methods of improving

psychotherapeutic interventions.

APPENDICES

APPENDIX A
Telephone Script for Contacting Subjects

Subject Matching

74

Telephone Script for Contacting Subjects

Greeting and introduction: "Hello, Ms. . This is
Dr. calling."

General inquiry about patient's health since terminating
treatment, in part to determine symptom status.

Describe reason for your call: "I am calling to ask
whether you would be interested in participating in a
research project being done by a colleague of mine,
Maxine Liberman. She is conducting a study on anxiety
and phobias and is looking for subjects who have been in
treatment for these problems, but who are not now in
treatment and are free of their previous symptoms."
Inquire further about symptoms and treatment status. If
patient does not meet these criteria, thank them for
their time in listening. If patient does meet the
criteria, ask whether they would be interested in hearing
more about the study.

Describe the study: "Briefly, the study involves your
filling out research materials which will be mailed to
you. Completing these forms should take less than one
hour, and there is no payment for taking part in the
study. Your decision to participate is entirely
voluntary. You are under no obligation to decide to
participate, and if you do decide to be a subject in the
study, you may withdraw from participating at any time
during the study."

"Please feel free to contact me or the researcher if you
have any concerns about your participation in the study

or about the study itself. The results of the research

will be available to you when the study is completed."

75

Subject Matching

Agoraphobic Subjects

Gender Age Marital Status Education

 

 

E 30 m college, medical school (n.c.)
F 38 sep 1 yr. college

F 41 m high school

F 30 m high school

F 27 m college

F 25 m high school (n.c.)

F 29 m college, grad. school (n.c.)
F 44 m high school

F 33 m master's degree

F 45 m college (n.c.)

M 36 m grad. school

M 24 8 college

M 37 m college (n.c.)

M 31 m college (n.c.)

M 31 m master's degree

M 33 m college

M 38 div college

M 26 3 high school

M 29 m college (n.c.)

M 48 m college (n.c.)

m = married
3 = single
sep = separated
div = divorced
(n.c.) = not completed

76

Neurotic Subjects

Gender Age Marital Status Education

 

 

F 30 m grad. school

F 35 div college (n.c.)
F 42 m high school

F 29 m high school

F 29 m college

F 24 m high school

F 31 m grad. school

F 45 m high school

F 32 m master's degree
F 42 m college

M 36 m grad. school

M 25 3 college

M 37 m college

M 30 m college

M 32 m master's degree
M 32 m college

M 39 div college, grad. school (n.c.)
M 24 5 high school

M 30 m college

M 48 m college

Gender

F

in Hi'd fii'fl uu'a Hi’fi

3333333333

Ag_e_
30
37
42
3o
28
25
30
43
32
47

36
25
36
29
30
30
42
27
28
44

77

Control Subjects

Marital Status
m

 

div

888999853

SBBBMB

div

9

Education

 

grad. school
college (n.c.)
high school
high school
college

high school
grad. school
high school
master's degree
college

Ph.D.

college

college

college
master's degree
college

college plus
high school
college

college

APPENDIX B
ANOVA Tables

78

Table II-l: ANOVA for Agoraphobic, Neurotic and Control
Groups: Frequency Strong Pictures

 

Source Sum of Squares d.f. Mean Square F-ratio p
Gender 69 l 69 1.42 n.s.
Blocks* 878 18 48.7
Group 838 2 419 11.02 .01
G X G 3 2 1.5 .04 n.s.
Residual 1369 36 38.0

Total 3157 -59

 

*of matched subjects

Table II-2: ANOVA for Agoraphobic, Neurotic and Control
Groups: Frequency Mild Pictures

 

Source Sum of Squares d.f. Mean Square F-ratio p
Gender 3 l 3 .12 n.s.
Bocks 436 18 24.2

Group 591 2 295.5 4.73 .05
G X G l 2 1.0 .02 n.s.
Residual 2251 36 62.5

Total 3282 59

 

79

Table II-3: ANOVA for Agoraphobic, Neurotic and Control
Groups: Total Frequency

 

Source Sum of Squares d.f. Mean Square F-ratio p
Gender 3 l 0 .02 n.s.
Blocks 2361 18 131.2
Group 2824 2 1412.0 14.5 .01
G X G 41 2 20.5 .21 n.s.
Residual 3495 36 97.0

Total 8724 59

 

Table II-4: ANOVA for Neurotic and Control Groups: Total

 

Frequency
Source Sum of Squares d.f. Mean Square F-ratio p
Gender 26.0 1 26.0 4.5 .05
Blocks 104.0 18 5.7
Group 78.4 1 78.4 14.2 .01
G X G O l 0 O n.s.
Residual 99.6 18 5.5

Total 308.0 39

 

80

Table II-S: ANOVA for Agoraphobic, Neurotic and Control
Groups: Attachment

 

Source Sum of Squares d.f. Mean Square F-ratio p
Gender 0 l 0 0 n.s.
Blocks 3476 18 193.1
Group 11592 2 5796 23.2 .01
G X G 882 2 41 .16 n.s.
Residual 8999 36 250

Total 24149 _59

 

Table II-6: ANOVA for Neurotic and Control Groups:

 

Attachment
Source Sum of Squares d.f. Mean Square F-ratio p
Gender 0 1 n.s.
Blocks 1674 18 93.0 0
Group 970 1 970.3 8.13 .05
G X G 81.4 1 81.4 .68 n.s.
Residual 2149 18 119.4

Total 4873 39

 

81

Table II-7: ANOVA for Agoraphobic, Neurotic and Control
Groups: Hostility

 

Source Sum of Squares d.f. Mean Square F-ratio p
Gender 1 1 l .003 n.s.
Blocks 5253 18 291.8
Group 9776 2 4888 17.09 .01
G X G 76.1 2 38 .13 n.s.
Residual 10297 36 286

Total 25403 :9

 

Table II-8: ANOVA for Neurotic and Control Groups: Hostility

 

Source Sum of Squares d.f. Mean Square F-ratio p
Gender 1 1 l .01 n.s.
Blocks 1855 18 103

Group 519 l 519 5.8 .05
G X G 72 l 72 .81 n.s.
Residual 1610 18 89.4

Total 4057 39

 

82

Table II-9: ANOVA for Agoraphobic, Neurotic and Control
Groups: Reality Avoidance

 

Source Sum of Squares d.f. Mean Square F-ratio p
Gender 700 l 700 1.65 n.s.
Blocks 7603 18 422.4
Group 14132 2 7066 17.0 .01
G X G 127 2 63 .15 n.s.
Residual 14874 36 413.2

Total 37436 _39

 

Table II-lO: ANOVA for Neurotic and Control Groups: Reality

 

Avoidance
Source Sum of Squares d.f. Mean Square F-ratio p
Gender 1864 1 1864 87.5 .01
Blocks 384 18 21.3
Group 435 l 435 6.7 .05
G X G 116 l 116 1.79 n.s.
Residual 1171 18 65

Total 3970 39

 

83

Table II-ll: ANOVA for Agoraphobic, Neurotic and Control
Groups: Painful Tension

 

Source Sum of Squares d.f. Mean Square F-ratio p
Gender 778 l 778 4.14 n.s.
Blocks 3387 18 188
Group 23993 2 11997 179.0 .01
G X G 177 2 88.5 .32 n.s.
Residual 9975 36 277.1

Total 38310 -59

 

Table II-12: ANOVA for Neurotic and Control Groups: Painful

 

Tension
Source Sum of Squares d.f. Mean Square F-ratio p
Gender 230 1 230 3.06 n.s.
Blocks 1351 18 75
Group 1416 l 1416 14.26 .01
G X G 4.2 l 4.2 .04 n.s.
Residual 1787 18 99,3

Total 4788 39

 

APPENDIX C
Consent Form

Background Information Questionnaire

84
Consent Form For Voluntary Participation
In Psychological Research

I agree to participate in a study exploring the
relationship between early life experiences and later
psychological adjustment. I understand that I will complete
two forms, one a background information questionnaire, and
the other a research instrument which will assess my feelings
and thoughts about certain childhood situations; and that the
time required to complete these forms is approximately one
hour or less.

It has been explained to me that I may withdraw from
participation in the research at any time during the course
of the study without any penalty to me. I understand that
the information I provide will be used anonymously, and that
no one will be informed of my participation or the content of
the information I provide. I also understand that the purpose
of the identification number on each page of the research
forms is to identify the entire questionnaire when the pages
are separated for analysis; the identification numbers will
not be used in any way to identify me or the answers I give.

I have been informed that the results will be analyzed
by the researcher, Maxine Liberman, and may eventually be
published. I know that I will not be paid for my participation
in this study and that its purpose is to advance our
understanding of psychological development. I have been
given the opportunity to ask any questions I may have about
this study, which have been answered to my satisfaction.

Date Signature

 

 

Signature of Witness

 

85
Background Information Questionnaire
General Instructions

This packet contains two forms. One is a Background
Information Questionnaire (A) and the other is the Research
Questionnaire (B), which requires that you think about and
select responses to various illustrated situations. It is
recommended that you find a place to fill out the
Questionnaires where you will not be distracted, as
Questionnaire B requires some degree of reflection and
concentration. Please do not consult anyone else, either
family members or friends, about your answers. We need to
know how you, yourself, would react to these situations.
Please give the best answers that you can. Although it is
unlikely, if you find you have no response to a question,
please indicated this so that it will not appear as though a
question has simply been overlooked.

Again, thank you for your participation in this study.

************k***
Questionnaire A
Instructions: Please answer all of the questions presented
below either by circling the letter before

the appropriate answer or by writing the
information in the spaces provided.

 

 

1. Age:
2. Sex:
3. Marital Status: a. single d. separated

b. married e. divorced
c. living with someone f. widowed

g. other

10.

ll.

12.

13.

86
Questionnaire A (continued)
If married, is this your: a. first marriage
b. second marriage
c

. third marriage
d. more than three marriages

If not currently married, but married previously, how
many times were you married?

 

If married or living with someone, how long has it been
since this relationship began?

 

How many children do you have? (Please include children
who are deceased.)

 

What are their sexes and ages? Sex: Age:

 

 

 

 

 

 

 

How old were you when you first left home?

 

After leaving home, did you ever return to live there
again? When and for how long?

 

 

 

What is the highest level of formal education you have
completed?

 

What is your birth order in the family in which you were
raised (were you oldest, youngest, etc.?)

 

Please list the ages and sexes of your brothers and
sisters, beginning with the oldest and including yourself.

Sex: Age:

 

 

 

 

 

 

 

 

 

 

Please list the ages of your parents: mother
father

 

 

14.

15.

16.

17.

18.

19.

20.

21.

87

What is the marital status of your parents?

 

 

If your parents are divorced or widowed, how old were you
when this occurred?

 

Did your mother work outside your home when you were a
child? If yes, how old were you when she

started work?

 

Did you have any major losses, such as the death of a
friend or relative, when you were a child?
If yes, please specify this loss.

 

 

 

as an adult?

 

Have you ever experienced panic attacks or agoraphobia?
If yes, how old were you when the symptoms
began? Did the sumptoms first occur
following a specific event? Please
specify that event.

 

 

 

Please list any other relatives who have experienced
panic attacks or agoraphobia.

 

Has a relative had any other psychiatric disorder of
which you are aware? If so, please specify.

 

On a scale of l to 5, how closely-knit would you describe
the family in which you were raised. Please circle the
appropriate number.

2 3 4 5

extremely not especially averagely more than extemely
distant close close averagely close close

APPENDIX D
Separation Anxiety Test
Sample of Test Items

Scoring Forms

PLEASE NOTE:

Copyrighted materials in this document
have not been filmed at the request of
the author. They are available for
consultation, however, in the author's
university library.

These consist of pages:
88-104

 

 

 

 

 

 

University
Microfilms
lntemational

300 N. ZEEB 90.. ANN ARBOR. Ml 48106 (313) 761-4700

88

Questionnaire B

 

INSTRUCTIONS: This questionnaire consists of twelve
illustrations depicting a child in various situations. This
is not a test, nor are there any right or wrong answers. We
are interested only in the way you felt, or the way you would
have felt, if you had been the child in each of the pictures
you are about to see. In other words, we are asking you to
imagine that you are a child and to react as if the situation
had occurred when you were a child. For each situation there
are a number of statements about the child in the picture and
you are to select as many statements about the child in the
picture and you are to select as many statements as you wish
which indicate how the child feels. Please read through all
of the responses for each picture and then circle the number
of the response(s) you are selecting. If there is anything
else which you would like to say about how the child feels,
please write it in at the bottom of the page. Also, please
view the pictures in the order that they appear.

When you have completed both Questionnaire A and B, and
have signed the consent form, please return them in the
envelope provided. Again, thank you very much for

contributing your time and effort to this study.

ID #

 

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Sample Statements, Associated Feelings, and

 

Anxiety Test*

STATEMENTS

The girl feels....

l.

10.

ll.

12.

13.

that her parents don't
love her any more.

alone and miserable.
sorry for her parents.

that she will do her
best to get along.

that she will be much
happier now.

like reading a book,
watching TV, or
playing games.

angry at somebody.

that it's all the

fault of her neighbors.

that if she had been a
good girl, this

wouldn't have happened.

like curling up in a
corner by herself.

that she doesn‘t care
what happens.

that it's only a
dream-it isn't really
happening.

that this house will
be a scary place to
live in.

FEELINGS

rejection
loneliness

empathy

adaptation

well-being

sublimation

anger

projection

intrapunitive

withdrawal

evasion

fantasy

Thematic Classification for Separation

THEME

attachment
attachment

attachment

individuation

individuation

individuation

hostility

hostility

hostility

reality avoidance

reality avoidance

reality avoidance

phobic feeling painful tension

*These statements accompany the first Separation Anxiety Test
picture entitled "The girl will live permanently with her
grandmother and without her parents."

14.

15.

STATEMENTS

a terrible pain in her
chest.

that something bad is
going to happen to
her now.

102

FEELINGS

somatic

anxiety

THEME

painful tension

painful tension

103

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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