Resumen:

El presente artículo analiza las conductas de afrontamiento desadaptativas (CAD) utilizadas por los pacientes afectados por agorafobia (PA) ante la presencia o la anticipación de un estímulo fóbico o interoceptivo. Se parte de la existencia de un volumen importante de investigaciones sobre la agorafobia y, en concreto, de los diversos estilos de afrontamiento. En este sentido, tradicionalmente se han considerado dos estrategias que tratan de disminuir y hacer que desaparezca la ansiedad: los comportamientos de evitación y las conductas de escape de los estímulos fóbicos (una vez que se encuentran inmersos en los mismos). Se analiza también la evitación interoceptiva, relacionada con la evitación de comportamientos que pudieran provocar respuestas fisiológicas negativas, similares a las respuestas de ansiedad. Sin embargo, poco se ha dicho con respecto a los comportamientos que presentan los PA y que les permiten afrontar parcialmente las situaciones fóbicas. A pesar de ello, algunos expertos han informado de la manifestación de estas conductas y estrategias, que facilitan a los pacientes enfrentar una situación fóbica cuando se ven forzados a ella o necesitan hacerlo. Las denominaciones que han recibido estas conductas han sido variadas y sus componentes también. Así, se habla de mecanismos defensivos, estrategias de afrontamiento y estrategias tranquilizadoras (búsqueda de compañía, conductas o señales de seguridad, distracción, objetos contrafóbicos, etc.), entre otras. En todos los casos son procedimientos a los que el paciente asigna el valor de disminuir la ansiedad hasta niveles tolerables, lo que a su vez le permite enfrentar los estímulos fóbicos e interoceptivos.

La anomalía de estas estrategias de afrontamiento parcial es que proporcionan cierta validez aparente ya que la persona es capaz de resistir la presencia de los estímulos temidos (lo que no es posible con las otras conductas de evitación y escape). Sin embargo, la información que proporcionan estas estrategias actúa como un mecanismo reforzante que adquiere en su oportunidad el valor de estímulo discriminativo sobre las condiciones en que puede ser afrontado un contexto fóbico. En este sentido cumplen un papel poco adaptativo y generan a su vez un alto grado de interferencia con los pensamientos y conductas adaptativas, los cuales son los que se deberían imponer en el proceso terapéutico. Paradójicamente, eso hace que lo que parece útil al principio, se convierta en sí en un objetivo terapéutico.

Tomando en consideración lo antes expuesto, en este artículo proponemos una nueva clasificación de tales conductas de afrontamiento, incluidas las estrategias de afrontamiento parcial. Los parámetros tomados en cuenta para proponer esta nueva taxonomía son tres: atender la función que regulan las conductas y pensamientos, considerar la naturaleza de las estrategias (cognitivas o conductuales), e incluir los comportamientos a los que se reconozca un carácter desadaptativo.

A partir de ellos se proponen cuatro patrones conductuales: conductas de evitación (cuya función es reducir o eliminar la ansiedad al evitar los estímulos fóbicos), conductas de escape (su función es reducir la ansiedad huyendo de la situación), evitación interoceptiva (su función es prevenir las respuestas fisiológicas negativas, similares a las provocadas por las crisis de pánico), y las conductas de afrontamiento parcial (su función es ayudar a afrontar los estímulos fóbicos con el menor malestar posible).

Finalmente, esta propuesta se discute de acuerdo con la necesidad de tomar en cuenta todas estas conductas y estrategias (y no sólo las de evitación y escape) e intentar minimizar su uso. Se destaca la importancia de las mismas, ya que no considerarlas podría propiciar un falso progreso terapéutico, de por sí contraterapéutico.

Palabras clave: Agorafobia; trastorno de pánico; conductas de afrontamiento; revisión

Abstract:

The present paper examines the role of a type of coping strategy used by patients with agoraphobic disorders (AD) when they confront phobic stimuli. This strategy consists in a group of overt behaviors and thoughts (ritual behaviors, frequently) which allow agoraphobic patients (AP) to resist the presence of phobic scenes. Those behaviors function like a partial coping in the sense that they allow initially to confront the phobic stimuli, but later they transform themselves in non-adaptative coping behaviors that limit the therapeutic efficiency.

The agoraphobic disorder (AD), with or without panic attack (CIE-10, F 40), is considered the more complex phobia and which produces the highest level of disability. Besides, this phobia, contrary to social or specific phobias, has a pervasive tendency (panphobia), reaching each time more situations and stimuli.

The essential clinical aspects include anxiety, sensitivity, emotional responses of fear-anxiety-panic and shame, anticipatory responses, catastrophic thoughts, and avoidance and escape behaviors toward phobic scenes.

There is an important volume of research about those clinical aspects. But there are only a few studies about the coping strategies used by AP when they need to resist a phobic situation.

Traditionally, coping strategies considered were those used by AP to reduce anxiety and psychological distress: the avoidance behavior (to avoid the phobic stimuli) and the escape behavior (when the phobic stimulus is present). Additionally, it also includes behaviors targeted to avoid the negative physiological responses similar to those occurring in an anxiety crisis (interoceptive avoidance).

Nevertheless, some experts have reported that AP used some other coping strategies that allowed them to accomplish partial and temporary confrontations toward phobic elements (elements that they needed to confront).

In that sense, some authors have proposed other strategies beyond avoidance and escape behaviors, including those partial coping behaviors in the repertories used by agoraphobic patients. So, there are several classifications that take into account these behaviors, but under different terms: Distractions (thoughts or conducts that relieve anxiety in the presence of phobic stimuli). Calming strategies (behaviors that they use when they need to confront a phobic scenario). Searchingfor company (looking for the company of a relative, friend or pet). Safety behaviors or safety signs (behaviors adopted to limit the level of distress as a consequence of feeling "caught" in a phobic situation). Counter-phobic objects (objects or persons to which patients assign the ability to diminish the distress in the case of crisis). Different experts have denominated these strategies "defensive mechanisms", "useless coping strategies", "partial coping strategies" or "non-adaptative coping behaviors".

This kind of behaviors and thoughts can be useful in the short-term, but in the long term they favor the continuity of anxiety and the avoidance cycle. These partial coping strategies allow patients with agoraphobia to confront and to resist the presence of the phobic stimuli, but this is done with a high cost, since the confrontations are only partial (they confront the phobic scenarios in certain contexts and with certain characteristics) and temporary, generalizing the use of these strategies to future confrontations.

These strategies provide a certain apparent validity: the person is capable to resist the phobic element (that is not possible with both avoidance and escape strategies). Nevertheless, the information provided by these behaviors acts as a reinforcing mechanism and acquires by itself a value of discriminative stimulus about the circumstances in which are possible for confronting the phobic scenes. The role of these behaviors and thoughts in the development of agoraphobia in a chronic disorder is also evident.

In this sense, they play a non-adaptative role. These strategies turn to be the unique ways to confront (some part of) phobic stimuli. Then, they generate a high degree of interference with both adaptive behaviors and thoughts that must be dominant in the therapeutic process.

Finally, the partial coping strategies pass from being a resource that allows them to resist the phobic stimuli, to a therapeutic aim that clinicians must reduce and eliminate.

Taking into account the state of the question, we propose in this paper a new classification of non-adaptative coping strategies used by agoraphobic patients, for including the partial coping strategies. The parameters for constructing a new taxonomy are three: (i) the coping strategies must be grouped according to its function role (i.e., to avoid anxiety and negative physiological responses, to reduce anxiety if it appears, to confront the stimuli with the lower level of distress). So, we prefer the term behavioral patterns, like a group of behaviors and thoughts which rule similar functions. (ii) The classification has to attend to the nature of behaviors, differentiating between overt (manifest) and covert (cognitive) behaviors. This distinction is elemental from an applied point of view. (iii) The third element is to identify the non-adaptative character of the confrontation behaviors, because they incapacitate and interfere in the normal development of the daily life.

Additionally, a terminology question: there is several concepts that are being used in an indistinct manner, such as behavioral patterns, strategies or, even, styles. According to what the agoraphobic patients do (in an overt or covert way), we prefer the term behavior, in the sense that this term emphasizes what the people do (and not what they believe o what they would like to do).

According to those three parameters, we propose four behavioral patterns. These behavioral patterns have two versions: overt and covert behavior. The components of each pattern share similar functions and they cover all of those strategies that can be used for persons with agoraphobia for coping with the different phobic scenes. The four behavioral patterns are as follow:

Avoidance behaviors. This pattern includes all of those behaviors and thoughts that the agoraphobic patients do to avoid the phobic stimuli. Its function consists in to prevent the anxiety and psychological distress by means of avoidance of phobic elements.

Interoceptive avoidance. This pattern refers to all behaviors and thoughts that try to avoid the interoceptive signs (negative physiological responses) similar to those that occur during an agoraphobic crisis. Its function consists to prevent physiological negative states by means of avoidance of those behaviors that can generate those states and can be interpreted like the beginning of a crisis.

Escape behaviors. This group of behaviors refers to all behaviors and thoughts that are used to remove the patients from a phobic scene. So, its function consists in to reduce and to eliminate the anxiety states by means to run away from the phobic stimuli.

Partial coping behaviors. Finally, this fourth behavioral pattern includes all of those strategies that allow AP to resist the presence of phobic elements. This resistance is doing according to some contexts and according to certain characteristics of those elements. The strategies consist on behaviors and thoughts, such as safety signs, distractions, or rituals that reduce the anxiety to tolerable levels. Its function consists to provide several resources that allow to a person with agoraphobia to cope with a phobic situation. Usually, the anxiety does not disappear, but the psychological distress does not reach disability levels. Frequently, the patients carry out these strategies because they are forced or need it.

This approach is discussed according to the utility to take into account these four behavioral patterns, and not only the avoidance and escape behaviors. An special consideration have the partial coping strategies in the extent in which these behavior may suppose a false therapeutic progress, at the time that they turn into a resistant element that interferes with the therapeutic resources.

Key words: Agoraphobia; coping behavior; review