The modification of agoraphobic avoidance behaviour: some fresh possibilities

A reconsideration of the theoretical basis of the therapy provided for agoraphobic people is warranted on three grounds. Although current methods of behavioural treatment are moderately effective, many patients are left with significant residual problems. Secondly, consideration of the theoretical basis of current behavioural treatments has been neglected and thirdly, there has been insufficient curiosity about the nature of agoraphobia.Three approaches to the problem of persistent avoidance behaviour and/or fear were selected as being of particular promise: Seligman and Johnston's cognitive theory of avoidance behaviour. Gray's elaboration of the safety signal hypothesis and Bandura's self-efficacy theory. Proposals for two new forms of therapy were formulated from an examination of these theories. The most promising possibilities are ‘therapy by repeated disconfirmation’ and ‘safety-signal therapy’. The general lines of these new forms of therapy are set out, examples provided and suggestions put forward for assessment procedures.It is suggested that in many agoraphobic cases, the control of panic attacks is a target of central importance and renewed attempts to find dependable ways of controlling panic attacks by psychological methods should be made. It is also recommended that self-efficacy estimates should be included in experimental investigations of the therapy provided for people with agoraphobic problems.     

The experimental analysis of agoraphobia

A concerted move towards the use of experimental analyses is proposed. It is suggested that our understanding of agoraphobia can best be advanced by taking this step. The argument in support of such a move is illustrated and developed in respect of the role of safety signals in maintaining and influencing agoraphobic behaviour. A detailed analysis is given of the factors postulated to determine the strength of safety signals, and the complex inter-relations between fear and safety are examined.     

Flooding in imagination vs flooding in vivo: A comparison with agoraphobics

In this investigation of agoraphobic patients, 3 different flooding procedures were compared: (1) prolonged exposure in vivo, (2) flooding in the imagination by a ‘live’ therapist and (3) a combination of flooding in the imagination and flooding in vivo. After an intermediate-test all clients were treated by the self-observation method, with a minimum of therapeutic intervention. Assessments were made at the beginning of treatment, during and at the end of treatment and at the follow-up one month later. Assessments were carried out by the therapist (in vivo measurement; phobic anxiety and avoidance scales; anxious mood and panic), by an independent observer (idem. minus in vivo measurement) and by the client (phobic anxiety and avoidance scales; FSS; social anxiety scale; SDS and I-E scale). Prolonged exposure in vivo plainly proved to be superior to flooding in the imagination. Combined flooding resulted in a greater improvement than flooding in the imagination, though only on the therapist's ratings. Self-observation did not add much to the effect of prolonged exposure in vivo and of flooding combined whereas self-observation, preceded by flooding in the imagination, resulted in a significant improvement on nearly all the variables.     

Does escape behaviour strengthen agoraphobic avoidance? A preliminary study

Two groups of agoraphobic patients were treated with one of two forms of exposure-based therapy. In one group, the patients stayed in the target situation until their self-rated anxiety dropped by half (Endurance condition). In the other, the patients were required to leave the fear situation when their anxiety reached a high pre-set level, without waiting for anxiety to drop (Escape condition). The patients in both groups improved, in contrast to those in a Waiting-list control group. There were no significant differences between the two treated groups. The results are discussed in terms of Mowrer's theory of fear and avoidance from which it can be predicted that patients in an ‘escape condition’ should not improve. Contrary to a Mowrerian prediction, patients who were taught to escape when still fearful, did not show increased avoidance behaviour.     

Agoraphobic avoidance and panic frequency as predictors of laboratory induced panic reactions

This study examined the importance of agoraphobic avoidance and frequency of panic as predictors of psychological and physiological responses of panic sufferers to a laboratory based provocation procedure. Psychophysiologic comparisons were made between 22 panic disorder patients and 15 controls, at baseline and across three periods of carbon dioxide gas inhalations (1, 3, 5%; balance oxygen). Subjective measures of anxiety, frightening cognitions and body sensations were obtained across the phases. Physiological measures of minute ventilation, breathing rate, tidal volume, end tidal CO₂ and heart rate were also obtained. Between group comparisons revealed significant differences between the groups on the subjective measures with no significant differences occurring on the physiological measures. Within group analyses revealed that pre-session questionnaire measures of agoraphobia avoidance and panic frequency predicted the degree of anxiety, frightening sensations and cognitions during baseline and 5% CO₂ inhalation. The results indicated that both self-reported agoraphobic avoidance and panic frequency are strong clinical predictors of psychological reactions of panic sufferers during laboratory provocation.     

Agoraphobia--a safety-signal perspective

The addition of a ‘safety perspective’ to the construal of agoraphobia as avoidance behaviour is proposed as a means of addressing several theoretical problems. Regarding agoraphobia as a balance between danger and safety signals enables one to re-examine the problem of the undue persistence of the avoidance behaviour component. It also opens for consideration the ‘non-exposure’ onset of agoraphobia (e.g. after loss or bereavements), the age of onset, the sex ratio, the role of trusted companions and talismen. A method for studying safety signals and safety factors is adumbrated, and some predictions are made. The advantages and limitations of the ‘safety perspective’ are considered.     

The Effects of Assertive Training on Sex Role Concept in Female Agoraphobics

Agoraphobia in women has often been associated with a restricted, "overly-feminine" sex role definition. We investigated whether assertiveness training from a female therapist would benefit agoraphobic women not only by teaching skills but incidentally by modeling a broader feminine gender role. Of 14 clients from an agoraphobic treatment program seven received assertiveness training as an adjunct to regular therapy. Sex role definition and assertiveness attitudes were measured with the Personal Attributes Questionnaire (Spence, Helmreich, & Stapp, 1974) and the Rathus Assertiveness Schedule (Rathus, 1973), administered before and following a 7-week treatment period. All the agoraphobics initially had significantly lower Masculinity scores on the PAQ than did large normative samples. T-tests performed on the data indicated that the assertiveness group's Masculinity scores increased after treatment to the level of the normative samples, while the comparison group did not change. Results supported the clinical observation that many agoraphobic women have limited gender role definitions, and indicated that this limitation consists of a deficit of masculine traits rather than a surplus of feminine ones.     

Brief treatment with alprazolam and behavioral guidance in panic disorder

Abstract

Thirty-two patients with panic disorder, with or without agoraphobic limitations, were treated with alprazolam (mean dose 3.5 mg/d) plus brief behavioral guidance in an open study during eight weeks. The sample had a notorious severity in the frequency of panics and phobic avoidance but was only mildly depressed. Before starting treatment the presence of demoralized mood and extensive avoidance were significant indicators of clinical severity, whereas the presence of dizziness as a relevant somatic complaint was not related to higher severity. After eight weeks of treatment a clinical improvement equal to or exceeding 80% of change was obtained in all cases (29) who completed treatment. Ninety-two percent of the patients were panic free at the end of treatment. There were significant reductions in all the scales with comparable declines in the subgroups formed according to the presence or absence of agoraphobic avoidance and demoralization. The data suggested that moderate doses of alprazolam could be a quick and effective treatment for panic-agoraphobic patients in the short term. The behavioral guidance probably helped in reducing agoraphobic avoidance and in obtaining global good effectiveness although this awaits controlled tests. Finally, the similarity in the response to treatment regardless of the presence of extensive avoidance or demoralized mood argues in favor of not considering the different variants of panic-agoraphobic syndrome differently, at least in samples with similar severity to the present one.     

Safety behaviour: a reconsideration

There is ample evidence that the use of safety behaviour can interfere with the progress of therapy, particularly if exposure is involved. As a result, it is widely asserted that safety behaviour is anti-therapeutic. However, an unqualified rejection of safety behaviour should be reconsidered because we now have theoretical justification, experimental evidence and clinical observations showing that the judicious use of safety behaviour, especially in the early stages of treatment, can be facilitative. Experiments in which escape behaviour facilitated fear reduction, and others in which the use of safety gear facilitated fear reduction, are reviewed. It also appears that safety behaviour does not necessarily prevent disconfirmatory experiences. We propose that additional investigations of the judicious use of safety behaviour will help to elucidate therapeutic uses of safety behaviour in the treatment of anxious and related types of psychopathology.     

Safety behaviour does not necessarily interfere with exposure therapy

There has been much recent controversy regarding whether or not the use of safety and other neutralizing behaviour interferes with exposure-based therapy. The aim of this study was to examine the role of safety behaviour in the treatment of specific phobia. Sixty-two snake-fearful participants were randomized to a 45-min exposure session with or without the use of safety gear, such as gloves and goggles. During the treatment, participants in the safety behaviour group were able to achieve a significantly closer initial distance of approach to the snake compared to controls. When tested post-treatment without any safety gear, both groups demonstrated comparable treatment gains involving significant reductions in fearful cognitions and subjective anxiety, as well as significant improvements in distance of approach. Results suggest that reliance on safety behaviour during exposure therapy for anxiety disorders may not interfere with treatment outcome.     

An investigation of various performance-based treatments with acrophobics

Five different performance-based treatments (participant modeling, participant modeling without therapist physical contact, modeling plus exposure, therapist-controlled exposure in vivo and rationale only) were compared to evaluate their relative effectiveness in the treatment of acrophobia. Ten subjects were assigned to each of the five groups. Avoidance behavior was assessed using a behavior test, self-report fear measures, heart-rate and self-efficacy expectation measures. Subjects were first submitted to two behavioral approach tests. These two pre-tests were administered 1 week apart, and no significant differences occurred between the evaluations. Analyses of variance for repeated measures at pre-test. post-test and follow-up revealed a significant improvement on all main outcome measures for the five groups. No significant differences among groups were observed. The total treatment time, which was also used as a dependent measure, did not yield any significant differences among treatment conditions. These findings have many implications. For instance, the need for induction aids, such as physical contact with the therapist and modeling, is questioned. Also, exposure per se whether therapist or self-controlled is shown to be effective in reducing avoidance behavior. Finally, the theoretical and clinical implications of these results are discussed.     

The Role of Cardioprotective Avoidance Beliefs in Noncardiac Chest Pain and Associated Emergency Department Utilization

This study examined cardioprotective avoidance beliefs and general panic/agoraphobia variables among 45 Emergency Department patients with a primary complaint of noncardiac chest pain (NCCP) in the absence of coronary artery disease or other medical explanation. Cardioprotective beliefs about the dangerousness of work and physical activity were assessed with the Fear-Avoidance Beliefs Questionnaire (FABQ). Additional measures assessed complaints of cardiac distress and panic, anxiety sensitivity, panic-related beliefs, agoraphobic avoidance, and depressive symptoms. Hierarchical regression analysis indicated that cardiac distress symptoms are a function of panic symptoms and cardioprotective beliefs concerning both physical activity and work, with 62% of the total variance explained. The predictors also explained 57% of the variance in Emergency Department utilization, which was significantly related to cardiac distress symptoms, number of illnesses, and work-avoidance beliefs. Neither outcome was related to demographics, depression symptoms, general anxiety sensitivity, general panic cognitions, or agoraphobic avoidance. Results suggest that current behavioral understandings of NCCP might be advanced by further examination of cardiac-specific avoidance beliefs and behavior and the potential role these factors play in both symptom experience and medical utilization.     

The effect of an extinction cue on ABA-renewal: Does valence matter?

The present human fear conditioning study examined whether the valence of an extinction cue has a differential effect on attenuating renewal that is induced by removal of the extinction context. Additionally, the study aimed to assess whether such attenuating effect is based on a modulatory or safety-signal role of the cue. In acquisition, extinction, and test stages of the experiment, human participants received pairings of human faces, presented against a particular background color, with the presence or absence of an aversive auditory stimulus. Experimental groups differed in the valence of a cue that was presented during extinction, in whether or not extinction took place against a different background color than present during acquisition and testing, and in whether the extinction cue was present or absent at test. The conditioned response consisted of auditory-stimulus expectancy ratings. It was hypothesized that a positively valued extinction cue yields faster extinction, stronger attenuation of renewal, and better transfer of its inhibitory power to non-extinguished stimuli than a negatively valued cue. All three hypotheses were confirmed, suggesting that the positive, but not the negative, cue had become a safety signal. The results were discussed in the framework of extinction-based exposure treatments.     

Therapist Behavior During Exposure Tasks Predicts Habituation and Clinical Outcome in Three Randomized Controlled Trials for Pediatric OCD

This study measured therapist behaviors in relation to subsequent habituation within exposure tasks, and also tested their direct and indirect relationships (via habituation) with clinical outcomes of exposure therapy. We observed 459 videotaped exposure tasks with 111 participants in three clinical trials for pediatric obsessive-compulsive disorder (POTS trials). Within exposure tasks, therapist behaviors and patient fear were coded continuously. Outcomes were habituation and posttreatment change in symptom severity, global improvement, and treatment response. More therapist behaviors that encourage approach—and less use of accommodation, unrelated talk, and externalizing language—predicted greater subsequent habituation during individual exposure tasks (exposure-level), and also predicted improved patient clinical outcomes via higher “total dose” of habituation across treatment (patient-level indirect effect). For six of seven therapist behaviors analyzed, the relationship with subsequent habituation within exposure differed by patient fear (low, moderate, or high) at the time the behavior was used. Two therapist behaviors had direct effects in the opposite direction expected; more unrelated talk and less intensifying were associated with greater patient symptom reduction. Results shed light on the “black box” of in-session exposure activities and point to specific therapist behaviors that may be important for clinical outcomes. These behaviors might be best understood in the context of changing patient fear during exposure tasks. Future studies should test whether therapist behaviors can be experimentally manipulated to produce improvement in clinical outcomes.     

Promoting traffic safety among young male drivers by means of elaboration-based interventions

Previous research in social psychology has brought about significant changes in attitudes and behaviour by merely asking respondents to imagine, or reflect, on a phenomenon and arrive at their own conclusions. To test the potential of such interventions in the traffic safety area, an experiment comprising 353 young men 18–23 years old with a driver’s licence was conducted. Two experimental groups were induced to imagine a severe accident scenario and to visualize their feelings and the consequences on their future lives. A control group was interviewed about neutral issues. Attitudes towards risk-taking were measured post-intervention and at follow-up. The experimental groups showed more “ideal” attitudes than the control group post-intervention. At follow-up the attitudes of the experimental group remained unchanged, whereas the control group had changed towards more “ideal” attitudes. Self-reported risk-taking behaviour was measured pre-intervention and at follow-up. At follow-up all groups reported significantly less risk-taking behaviour than at pre-intervention. It is suggested that answering the questionnaires increased mental elaboration concerning risky driving, and it is concluded that interventions that unobtrusively make drivers reflect on their driving should be explored further as a means to promote traffic safety.     

Differential effects of safety behaviour subtypes in social anxiety disorder

Clinical observations indicate that individuals with Social Anxiety Disorder (SAD) use a variety of safety behaviours; however, virtually no research has examined the functional effect of different safety-seeking strategies. Accordingly, we conducted two studies to address this issue. Study 1 measured global patterns of safety behaviour use in a large analogue sample. Factor analysis revealed two primary safety behaviour categories, avoidance and impression management. Study 2 assessed situational use of safety behaviours during a controlled social interaction in a clinical sample of 93 patients with Generalised SAD. Factor analysis again revealed support for avoidance and impression-management subtypes. Notably, the two types of safety behaviours were associated with different social outcomes. Avoidance safety behaviours were associated with higher state anxiety during the interaction and negative reactions from participants’ interaction partners. Impression-management strategies appeared to impede corrections in negative predictions about subsequent interactions. These findings suggest that it may be beneficial to consider the unique effects of different safety-seeking strategies when assessing and treating SAD.     

Safety Behaviour Enhances the Acceptability of Exposure

Compulsive washing and contamination fears are among the most common symptoms of obsessive-compulsive disorder (OCD). Research suggests that exposure and response prevention (ERP) is effective for OCD. However, ERP is prone to dropouts and refusals, and a substantial proportion of clients therefore do not receive the care they need. A proposed solution involves the judicious use of safety behaviour to enhance the acceptability of exposure-based interventions. The current study aimed to test this proposed solution. Participants were 70 undergraduate students who completed two exposure exercises for contamination fear, one with safety behaviour and one without. Participants then rated the acceptability of the two exercises. Exposure with safety behaviour (ESB) was rated as significantly more acceptable than ERP. Furthermore, subjective fear ratings were lower and behavioural approach to a series of contaminants was greater in the ESB condition. Results demonstrated the acceptability-enhancing potential of safety behaviour in exposure, and are discussed in terms of both theoretical and practical aspects of safety behaviour, exposure, and evidence-based interventions for anxiety disorders.     

The effect of social learning on avoidance of aposematic prey in juvenile great tits (<Emphasis Type="Italic">Parus major</Emphasis>)

Social learning plays an important role in acquiring new foraging skills and food preferences in many bird species but its potential role in learning to avoid aposematic prey has never been studied. We tested the effect of social learning on the acquisition of avoidance of aposematic insect prey (firebug Pyrrhocoris apterus; Heteroptera) in juvenile, hand-reared great tits (Parus major). Behaviour towards aposematic prey was compared between two groups of birds: (1) the observers that were, prior to encounter with firebugs, allowed to watch the experienced conspecific demonstrator repeatedly refuse to attack the prey, and (2) the control birds that lacked this opportunity. Observing an experienced demonstrator was not sufficient for learning complete avoidance, because birds from both groups attacked at least the first firebug they had encountered in avoidance training. However, the opportunity to observe the avoidance behaviour of another bird significantly increased the rate of subsequent individual learning of observers in comparison with control birds. Social learning also decreased mortality of firebugs killed by the birds during the avoidance learning. Socially enhanced learning to avoid aposematic prey might be a mechanism important especially for naive juvenile birds learning from their parents, but it could also enhance learning in adults from their more experienced flock mates. Because social learning of avoidance may also lead to decreased mortality of aposematic prey, its effect should be taken into account in scenarios considering evolution and maintenance of prey warning signals.     

Effects of forward collision warning and repeated event exposure on emergency braking

Many experimental studies use repeated lead vehicle braking events to study the effects of forward collision warning (FCW) systems. It can, however, be argued that the use of repeated events induce expectancies and anticipatory behaviour that may undermine validity in terms of generalisability to real-world, naturalistic, emergency braking events. The main objective of the present study was to examine to what extent the effect of FCW on response performance is moderated by repeated exposure to a critical lead vehicle braking event. A further objective was to examine if these effects depended on event criticality, here defined as the available time headway when the lead vehicle starts to brake. A critical lead vehicle braking event was implemented in a moving-base simulator. The effects of FCW, repeated event exposure and initial time headway on driver response times and safety margins were examined. The results showed that the effect of FCW depended strongly on both repeated exposure and initial time headway. In particular, no effects of FCW were found for the first exposure, while strong effects occurred when the scenario was repeated. This was interpreted in terms of a switch from closed-loop responses triggered reactively by the situation, towards an open-loop strategy where subjects with FCW responded proactively directly to the warning. It was also found that initial time headway strongly determined response times in closed-loop conditions but not in open-loop conditions. These results raise a number of methodological issues pertaining to the design of experimental studies with the aim of evaluating the effects of active safety systems. In particular, the implementation of scenario exposure and criticality must be carefully considered.     

Massed vs. spaced exposure sessions in the treatment of agoraphobia

The differential effects of massed and spaced sessions of exposure in vivo were investigated with 11 agoraphobics in a crossover design. Clients were randomly assigned to one of the following two groups: (a) 10 daily sessions followed by 10 weekly sessions, or (b) 10 once-weekly sessions followed by 10 daily sessions. The results indicated that both massed and spaced sessions of exposure in vivo effected changes in avoidance behavior and subjective anxiety of agoraphobics, massed practice being superior especially with respect to avoidance. It was suggested that the superiority of massed practice is due to the lack of opportunity to engage in avoidance or escape during short inter-session intervals. The relationship between subjective anxiety and avoidance were considered and the differences between clinical and statistical significance were discussed.