Cognitive-behavioral treatment of agoraphobia: paradoxical intention vs self-statement training

Twenty-six agoraphobics were randomly assigned to either Paradoxical Intention (PI) or Self-Statement Training (SST) which consisted of 12 weekly 90-min group sessions with 4–5 patients per group. Major assessments were carried out at pre-treatment, 6th week and 12th week of treatment, and at 1- and 6-month follow-ups. Measures included clinical ratings of severity of condition, phobia, anxiety and depression. Furthermore, a behavioral test was administered during which changes in subjective units of discomfort and cognitions were assessed. The results indicated statistically-significant improvement over time with both treatments. ANCOVAs performed revealed superior effects on several agoraphobia measures for the PI condition at post-treatment. However, by the 6-month follow-up assessment, the groups were equivalent due to marked improvement during the follow-up phase in the SST condition. Cognitive changes were marked by a decrease in self-defeating statements without concomitant increase in coping statements. These results and recommendations for future research are discussed.     

Spouse involvement in the treatment of obsessive-compulsive patients

Twelve married obsessive-compulsive patients were randomly allocated to either selfcontrolled exposure or partner-assisted exposure. Treatment in both conditions consisted of homepactice.The results at the Post-test showed that both versions of exposure in vivo resulted in significant improvements but the partner-assisted group improved more. After a 1-month treatment-free period no significant differences between conditions were found due to a continuing improvement in the selfcontrolled exposure condition. Results were maintained at a 6-month follow-up.It was concluded that home-practice is a cost-effective treatment procedure for obsessive-compulsives and that couple training may be useful with selected patients.     

Exposure and communications training in the treatment of agoraphobia

Twenty-one agoraphobics participated in a 6-month study designed to (a) compare imaginal flooding under high- (no sedation) and low- (sedation used) anxiety conditions: (b) examine the long-term effects of imaginal flooding in the absence of further exposure treatment; and (c) explore the impact of communications training on chronic anxiety and panic attacks. A reevaluation of the effects of sedation is presented in this report.Imaginal flooding without sedation was, on the whole, superior to the attention control placebo and imaginal flooding with sedation on therapists' and clients' ratings of fear and avoidance. However, the superiority of the non-drug flooding group cannot be attributed (as was concluded in an earlier report) to higher levels of anxiety across flooding sessions. Rather the drug (methohexitone sodium) appears to have impeded across-session habituation, perhaps by interfering with long-term memorial processes.The effects of imaginal flooding without sedation were stable over 4 months without further exposure treatment. These clients did receive training in solving important interpersonal problems through self monitoring and increased expressiveness. Contrary to hypotheses, not only was no further improvement obtained on fear and avoidance with this treatment, but also anxious mood and panic attacks remained unaffected. It is surprising to note that in-vivo treatment was no more effective than imaginal flooding on fear and avoidance. These and other findings suggest imaginal flooding well warrants further study.     

Therapist factor in the treatment of insomnia

This quasi-experiment attempted to replicate the finding of Turner and Ascher (1979) in contrasting progressive relaxation, stimulus control and paradoxical intention therapies for the treatment of insomnia using clinicians-in-training as therapists. Progressive relaxation and stimulus control were again shown to be effective, paradoxical intention instructions were not. A significant therapist effect was found which is discrepant with previous findings in the field.     

Exposure in vivo vs applied relaxation in the treatment of blood phobia

Eighteen patients with phobia for bloodt, wounds and injuries were treated with exposure in vivo or applied relaxation. They were assessed on different self-report, behavioral and physiological measures before and after treatment. The patients were treated individually for 9 sessions, 1 per week. The within-group comparisons showed that both groups had improved significantly on most of the measures and that these improvements were sustained or furthered at the 6-month follow-up. Furthermore, 10 of the 16 who completed the treatment became blood donors. The between-group comparisons showed exposure to be better than applied relaxation on three of the self-report measures at post-treatment assessment, but not at follow-up. The groups did equally well on the behavioral and physiological measures. The conclusion that can be drawn is that the coping-orientated method of applied relaxation is as effective as exposure in vivo in the treatment of blood phobia.     

Four process studies in the behavioral treatment of chronic headache

Four studies of ‘process’ variables in the behavioral treatment of chronic headache are examined. No relation between headache activity-level reduction and therapist variables such as level of experience (study 1) or warmth, competence or helpfulness as perceived by the patient (Study 2) was found from treatments using relaxation training and/or biofeedback. A significant relation was found, however, between regularity of relaxation practice at home (Study 4) and headache-activity reduction and between regularity of showing some degree of hand warming in thermal biofeedback treatment for vascular headache and headache activity-level reduction (Study 3). Finally, no relation was found between changes in EMG and headache activity-level for tension-headache sufferers treated with frontal EMG biofeedback.     

Anxiety management training in the treatment of essential hypertension

The study was conducted to assess the efficacy of Anxiety Management Training as an adjunctive treatment for essential hypertension. Twenty-one patients with essential hypertension, all but one of whom were on antihypertension medication, were randomly assigned either to an Anxiety Management Training condition or a waiting-list control condition. At the time of a posttest assessment session, compared to subjects in the control condition, subjects in the Anxiety Management Training condition manifested a decrease in resting systolic and diastolic blood pressure and a decrease in systolic and diastolic blood pressure following a stressful task. At the time of a follow-up assessment session, subjects in the Anxiety Management Training condition not only manifested good maintenance of reduced blood pressure but also exhibited a further decrease in resting systolic blood pressure and a decrease in systolic blood pressure during the stressful task.     

Intermittent low-calorie regimen and booster sessions in the treatment of obesity

The present study investigated two new weight-control strategies: an intermittent low-calorie regimen and intermittent scheduling of booster sessions. A new approach to predicting patient weight loss, based on a pretreatment assessment with a highly-structured eating regimen, was also studied. Forty-eight obese patients were randomly assigned to either a Standard Behavioral weight-control condition or to an Intermittent Low-calorie Regimen (< 750 cal for 2 days/week) condition and to one of two maintenance schedules: a Spaced schedule in which the six booster sessions were held at monthly intervals, or a Massed schedule, in which four of the six meetings were held during the third month. Neither the intermittent low-calorie regimen nor the intermittent scheduling of booster sessions significantly affected weight loss. However, weight loss at 1 year was related to compliance to self-monitoring and to self-reported change in eating habits and exercise. In addition, weight loss at 1 year was related to weight loss during the initial pretreatment assessment period.     

Antidepressant medication in the treatment of agoraphobia: A critical review

The present article critically examines research on the use of antidepressants in treating agoraphobia. A number of studies have shown certain classes of antidepressant medication, namely tricyclic antidepressants and MAO inhibitors, to have beneficial effects on certain aspects of the agoraphobic syndrome. However, these studies must be interpreted with caution in light of two major methodological shortcomings, i.e. sole reliance on paper and pencil outcome indices and the confounding of the pharmacological effects of the drug with exposure to feared situations. Recent research, aimed at correcting for these methodological problems, seriously question the efficacy of antidepressant pharmacotherapy by itself as a treatment for agoraphobia. Moreover, it is argued that the disadvantages of drug treatments namely agoraphobics' reluctance to take medication, physical side effects and relapse upon withdrawal of the medication, caution against their routine use in clinical practice.     

Individual response patterns and the effects of different behavioral methods in the treatment of agoraphobia

The importance of individual response patterns in agoraphobic patients was examined in the present study. Forty psychiatric outpatients with agoraphobia were assessed in individually relevant natural phobic situations. During this behavioral test their heart rates were measured continuously, and self-ratings of experienced anxiety were made at fixed intervals. On the basis of their reactions in the test situation, the patients were divided into two groups showing different response patterns—behavioral and physiological reactors. Within each group the patients were randomly assigned to one behaviorally-focused method (exposure in vivo, E) and one physiologically-focused method (applied relaxation, AR). The patients were treated individually for 12 sessions. Both treatments yielded significant improvements on most measures; 60% of the E group and 70% of the AR group patients were clinically improved after treatment. The between-group comparisons showed that both treatments did equally well both for behavioral and physiological reactors. Thus, the differential effects for these methods obtained in previous studies were not seen.     

Effect of varying alarm schedules on acquisition and relapse parameters in the conditioning treatment of enuresis

Acquisition and relapse rates for 178 enuretic children were examined as a function of varying intermittent alarm schedules ranging from the standard (100%) bell-and-pad conditioning alarm treatment to a variable-ratio (VR) alarm schedule of 30–59%. Median follow-up time was 25 months. Children who experienced multiple wetting (MW) events beyond the third treatment week experienced twice as many wettings to reach dryness criterion as non-multiple wetting (NMW) children. Approximately one-third of the sample proved to be MW children. Optimal relapse results for NMW children were achieved with the 70–79% VR alarm schedule (10% relapse rate). MW children treated with the standard experienced a 100% relapse rate. For MW children the lowest relapse rates were attained with a 60–69% VR schedule (42% relapse). Older children experienced higher relapse rates than younger children, but age differences were eliminated with a 70–79%, VR alarm schedule. Collectively, the results demonstrate optimal VR intermittent alarm schedules for differen: categories of enuretic children.     

Prognostic utility of Locus of Control in treatment of agoraphobia

The purpose of the present study was to examine the prognostic utility of the Rotter Internal-External Locus of Control Scale with agoraphobics undergoing behavioral and pharmacological treatments. Fifty subjects meeting DSM-III criteria for agoraphobia, completed the instrument at pre- and post-assessments. Despite marked pre-post improvements, the scale was found to be lacking in discriminative power and clinical sensitivity to detect these changes. However, the scale was found to have utility as a prognostic index of post-treatment levels of improvement, with ‘externality’ being strongly associated with improvement. These findings and related issues are discussed.     

Generalization of treatment effects in training public speakers

Three studies compared the efficacy of various treatments for public-speaking incompetence. These effects were evaluated for the target behavior as well as for generalization effects across situations (conversations), settings (different sizes and types of audiences) and time (6-month follow-up). The first study showed that Self-instructional Training, either alone or in combination with other procedures, produced little or no benefits. The second study demonstrated the superiority of a Skills Training program over flooding therapy, while the final study failed to detect any enhancement of treatment benefits for the addition of home-practice to the Skills Training. In the first two studies generalization occurred across the three dimensions (settings, situations and time), while in the final study it was shown that the program was effective for a clinical population as well as recruited volunteers.     

Assertion training: the effectiveness of a comprehensive cognitive--behavioral treatment package with professional nurses

The purpose of the study was to evaluate the effectiveness of a comprehensive cognitive-behavioral treatment package with a professional population of registered nurses using multiple self-report and role-play measures. Twenty-six self-referred registered nurses were randomly assigned to either a Treatment or Control group. The treatment package consisted of five weekly 2-hr sessions of group assertion training using the cognitive-behavioral model of Lange and Jakubowski. The Assertiveness Self-statement Test, the Rathus Assertiveness Schedule, the Adult Self-expression Scale, two Likert scales and role-play were used to evaluate changes over time. The results indicated: (1) the nurses in both groups at Pretreatment were clearly subassertive; (2) by Posttraining the Treatment-group members increased significantly their assertiveness as indicated on the self-report tests; (3) Treatment-group members had successfully maintained their improved assertiveness by the 2-month Follow-up; (4) the role-play ratings paralleled and supported the self-report results, but not at significant levels; (5) there was strong empirical support for the social validity of the treatment package; and (6) there was a high degree of treatment credibility for the cognitive-behavioral Assertion-training group. Overall, the results indicate clear support for the effectiveness of a broad-based cognitive-behavioral treatment package for treating subassertive behavior in a professional population of registered nurses.     

Expectations of sensations,discomfort and fear in dental treatment

A hundred dental patients and 40 dentists were asked to describe the sensations, discomfort and fear which they associated with a number of dental treatments. A number of patients were also asked to describe their experiences immediately after routine conservation procedures. It was concluded that although patients could accurately anticipate the pattern of sensations involved in treatment (even if they had not experienced some of the procedures), they expected more intense sensations and greater discomfort and apprehension than they were likely to experience. Dentists expressed more realistic ideas about the sensations produced by dental treatment. The discrepancy in patients' expectations appears to persist in spite of many discontinuing experiences, the fear of treatment being fostered by discomfort and the intensity of sensations expected, by lack of experience and, to a modest degree, by uncertainty about the sensations anticipated. Cognitive theories of fear do not appear to explain all these influences adequately. These observations support the need for information about sensations in treatment to help not so much with the experience of dentistry but rather with its anticipation.     

The treatment of sleep-maintenance insomnia with stimulus-control techniques

Sleep-maintenance insomniacs received either a stimulus-control (n = 7) or a credible placebo treatment (n = 8), administered in small groups for 4 weeks. Self-reports of time awake after sleep onset, total number of arousals and number of arousals exceeding 10 min were collected at baseline, at termination of treatment (post-treatment), and at a 3-month follow-up. Results showed a statistically- and clinically-significant reduction on all three dependent measures from baseline to post-treatment for both groups; these gains were maintained through the follow-up period. However, the results achieved with stimulus-control procedures were not significantly different from reductions found with a credible placebo condition. These findings compare favorably with other reports of behavioral treatments of both onset and maintenance insomnia.     

Problems with stimulus/response equivalence and reactivity in the assessment and treatment of obsessive-compulsive neurosis

Self-recording was used as part of a comprehensive package of interventions to treat a case of obsessive-compulsive neurosis. The discrepancy between the self-recording data and other indices of improvement provoked consideration of the value of self-monitoring in light of Rachman's (1976) typology of obsessive-compulsives and the three major theoretical explanations of the reactivity of self-monitoring (Nelson and Hayes, 1981). It is hypothesized that self-monitoring may be countertherapeutic and misleading when there is stimulus/response equivalence or a checker type of obsessive-compulsive client.     

Factors in the referral of children for behavioral treatment: A comparison of mothers of clinic-referred deviant,clinic-referred non-deviant and non-c

The purpose of this study was to compare a non-clinic sample of mothers and children to two groups of clinic-referred children and their mothers. The two clinic-referred groups differed from one another in that the selection criterion for one group of children (Clinic Deviant) was that they were significantly more deviant and non-compliant than the non-clinic group whereas the selection criterion for the second group of children (Clinic Non-deviant) was that they did not differ significantly from the non-clinic group on deviant and non-compliant behavior. Home observations by independent observers and parent questionnaires examining parental adjustment and parental perceptions of child adjustment were completed. The results indicated that both clinic groups perceived their children as more maladjusted than parents in the non-clinic groups perceived their children. Parents of the children in the Clinic Non-deviant group were significantly more depressed than those in the remaining two groups, whereas parents in the Clinic Deviant group issued more vague, interrupted commands than those in the Clinic Non-deviant group. Implications of the findings are discussed.     

The management of children''s distress in response to painful medical treatment for burn injuries

The purpose of the current study was to develop an initial assessment of the efficacy of astress-management program designed to reduce the behavioral distress of children undergoing highlypainful medical treatments for their burn injuries. The stress-management program was delivered to 4 male patients, ages 5–12 yr and its effects assessed in a combined multiple-baseline and reversal design. Results indicated that the program was moderately effective at reducing behavioral distress during the burntreatment procedures for 3 of the 4 patients and less effective with the fourth. However, the design also revealed that the presence of a therapist to coach the patient in the use of these techniques was essential and that distress levels rose substantially on days when there was no therapist present. Finally, speculations concerning the factors responsible for the effectiveness of the stress-management program as well as its reduced efficacy with 1 S were discussed.     

Sequential comparisons of relaxation training and biofeedback in the treatment of three kinds of chronic headache or,the machines may be necessary some time of the time

Two studies are reported in which patients with chronic headache, who did not improve significantly as a result of a 10-session, 8-week relaxation training program, were subsequently treated with biofeedback. For the tension headache sufferers, 36% of the relaxation non-responders showed significant improvement with frontal EMG biofeedback training. For those with vascular headaches, 44% of the relaxation non-responders showed significant improvement with thermal biofeedback. Vascular headache patients with combined migraine and tension symptoms did better than those with only migraine. Psychological test scores significantly differentiated successful vs non-successful biofeedback responders.