Resumen:

El propósito de este artículo es analizar las estrategias de afrontamiento utilizadas por los pacientes con agorafobia (PA) con o sin pánico. Tradicionalmente, se reconocen dos tipos de estrategias: conductas de evitación de los estímulos fóbicos y conductas de huida-escape de tales situaciones. También se suele incluir las conductas de evitación interoceptivas, mediante las cuales se evitan estímulos capaces de evocar sensaciones similares a la sintomatología ansiosa. Un cuarto tipo de estrategias, menos estudiadas, son las conductas de afrontamiento parcial, que permiten a los PA enfrentarse, así sea parcialmente, a los estímulos fóbicos. Estos cuatro tipos de estrategias los hemos denominado conductas de afrontamiento desadaptativas (CAD).

Los objetivos generales de la investigación fueron establecer en qué medida usan esas estrategias los PA, conocer su uso diferencial en relación con el modo en que las utilizan personas con otros trastornos o población no clínica y entender su papel en la evaluación del progreso terapéutico.

Los objetivos específicos del estudio fueron los siguientes: determinar en qué medida utilizan las CAD los PA, en comparación con pacientes de otros trastornos; conocer el uso diferencial de las distintas estrategias de afrontamiento por parte de los PA; establecer el papel de las conductas de afrontamiento parcial en la evaluación que hacen los clínicos del progreso terapéutico.

Para ello se elaboró una escala que recogía una amplia representación de las CAD, tanto en su versión de conducta manifiesta como de conducta encubierta. La escala se administró a una mues tra de 235 personas: 165 con algún trastorno mental (40 con diagnóstico de PA) y en tratamiento en una unidad de salud mental, y a un grupo no clínico de 70 personas.

Los principales resultados muestran que las CAD suelen ser significativamente más utilizadas por los PA en comparación con otros trastornos, y que las conductas más utilizadas suelen ser las de evitación y escape de los estímulos fóbicos e interoceptivos. Una evolución favorable de los pacientes agorafóbicos suele acompañarse de una disminución del uso de esas conductas, salvo en las referidas a los afrontamientosparciales, en que no se encuentran diferencias significativas. Además, el menor uso de estrategias de evitación y escape sólo ocurre en los comportamientos de conducta manifiesta, pues no hay cambios significativos en el uso de estrategias encubiertas.

Estos resultados indican que las estrategias de afrontamiento parcial son las menos utilizadas. Las personas con un problema agorafóbico recurren a la evitación o el escape de las situaciones fóbicas como los métodos más eficientes para reducir la ansiedad y el malestar psicológico, y reservan las conductas de afrontamiento parcial para las ocasiones en que se ven forzadas o necesitan enfrentarse a un estímulo fóbico.

El papel de esas conductas de afrontamiento parcial en el análisis del progreso terapéutico evaluado por los terapeutas indica que éstas permanecen sin cambios, aun cuando los clínicos señalan que los pacientes evolucionan favorablemente. Esto puede indicar un problema de precisión en el juicio clínico, pero también se puede atribuir al papel que cumplen estas estrategias en el mantenimiento y la consolidación de los PA.

Por último, se discute el papel contraterapéutico de las conductas de afrontamiento parcial y la necesidad de considerarlas como un objetivo en sí mismo en el proceso terapéutico.

Palabras clave: Agorafobia; estrategias de afrontamiento; conductas de afrontamiento parcial; muestra clínica

Abstract:

This paper is focused in the coping strategies used by patients with an agoraphobic disorder (AD) when they are forced to confront phobic situations.

Traditionally, the coping strategies considered were those used by agoraphobia patients 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, behaviors used to try to avoid negative physiological responses similar to those occurring in an anxiety crisis (interoceptive avoidance) are also included. A fourth group of behaviors has received less attention: coping strategies that partially allow agoraphobia patients to confront and resist the presence of phobic stimuli. These are stimuli that they need to or are forced to confront.

These partial coping strategies (often rituals behaviors) are behaviors to which patients assign a value in decreasing the anxiety to tolerable levels until they are able to confront and resist the phobic scenes (even partially). These behaviors play a non-adaptative role because they difficult the development of adaptative self-control strategies, interfere with daily living conditions, and support the disorder providing an initial and immediate relief of psychological distress.

We prefer to name all these strategies non-adaptative coping behaviors.

Despite the relevance of these partial coping strategies in the development and consolidation of agoraphobia, their empiric study has been infrequent (especially when compared to the study of both avoidance and escape behaviors).

In that sense, with the present study we try to provide data about the following issues: 1) to know how frequently AP' use non-adaptative coping behaviors compared with a group of patients with other disorders. 2) The differential use of behavioral patterns by agoraphobic patients (AP): avoidance behaviors, interoceptive avoidance, escape behaviors, and, especially, the partial coping strategies. 3) The role of partial coping strategies in the evaluation of therapeutic outcome, according to the clinician opinion.

The empirical study was designed in two stages: First, the elaboration of a scale to measure coping strategies of phobic stimuli. For that purpose, we took into account literature on the topic, observational data and clinical histories of patients with agoraphobia. The result was a scale (CAD scale) composed by 87 overt behavior items, and 52 covert behavior items. All of these items allowed for the formation of four behavioural patterns, grouping items according to their functions in coping with phobic stimuli: 1) avoidance behavioral pattern; 2) interoceptive avoidance pattern; 3) escape behavioral pattern; and 4) partial coping behavioral pattern.

Second stage: The application of the CAD scale to a clinical simple. A group of psychologists and psychiatrists (from a local mental health service unit) were requested to administrate the scale to their patients, with their informed consent. The final sample (n = 235) was as follows: 40 with agoraphobic disorder (30 women and 10 men); 30 with panic disorder (18 women and 12 men); 30 mixed with anxious-depressive disorder (25 women and 5 men); 40 with depressive disorders (32 women and 8 men); 25 with psychotic disorders (10 women and 15 men). A matched group without any clinical disorders was added later (N = 70, 49 women and 21 men).

After analysing the results related to the use of non-adaptative coping behaviors, these may be summarized as follows: In gene ral, the group which used less the CAD strategies was the non-clinical group. The patients with agoraphobia were the ones who used the CAD strategies in a more significant level, compared with both the non-clinical group and the groups with other disorders. This includes the use of partial coping behaviors. Results were similar both to CAD overt strategies and covert strategies.

Comparing the differential use of CAD strategies by patients with agoraphobia, results show a more significant use of avoidance behaviors (especially in overt behavior form), followed by escape behaviors. Interoceptive avoidance was the third CAD more frequently used. Partial coping behaviors were less used in contrast with other CAD strategies.

According to therapist judgments with respect to the relationship between the use of coping strategies and the therapeutic progress evaluation, the AP sample was divided into two groups: positive progress and non-positive progress (negative, unstable or no progress).

The positive progress group shows a significant lower use of avoidance behaviors, interoceptive avoidance, and escape behaviors, but only in the overt behavior form. There were no significant effects for partial coping behavior. In other words, a positive evolution in PA was joined by a decrease in avoidance overt behaviors, interoceptive overt avoidance, and escape overt behaviors, but there were no changes in the use of both cognitive coping strategies and partial coping behaviors.

Our findings confirm that CAD strategies are more used by AP. Partial coping behaviours are included among these. It was a well-known fact (and previous data supported it), that agoraphobia patients tended to use more both avoidance and escape strategies as procedures which relieved them from anxiety and psychological distress. But, also, there were few data about the role of strategies allowing AP to confront and resist the phobic scenes: the partial coping behaviors. Our data provide information about this kind of coping.

Results support that it is more frequently used by agoraphobia patients. This is true when comparing it with patients with other disorders, and, obviously, in contrast with the normal population. But the use of partial coping behaviors is not commonly compared with "more traditional" behaviors such as avoidance or escape behaviors. It may be said that people with agoraphobia choose to avoid or to escape from phobic situations as the best way for them to reduce anxiety. But there is a group of phobic situations an agoraphobic patient must confront on some occasions (attending a medical service, buying something, etc.). These few occasions represent an opportunity to use partial coping strategies. The limited use of these strategies may be due to the fact that other strategies reduce anxiety in a more effective way. In that sense, they may be considered as behaviors having a low frequency of occurrence and a high intensity.

We especially appreciate findings about the role of partial coping strategies in the therapeutic progress when a clinician emits judgments about the improvement of agoraphobia patients. These judgments are linked to a decrease of several non- adaptative overt strategies, but there is no change in cognitive coping strategies and neither in partial coping behaviors. These may be interpretated as imprecise therapist judgments, but also as the role played by this kind of strategies in the latent maintenance of agoraphobic responses.

Finally, this paper discusses these results according to the counter-therapeutic role of partial coping strategies, and the need to consider them as a target objective in treatment process.

Key words: Agoraphobia; coping strategies; partial coping behaviors; clinical sample