伴有广场恐怖症的惊恐障碍的网络心理学治疗新技术

近年来,加拿大Universitédu Québec en Outaouais大学Bouchard教授领导的团队进行了一系列网络心理学的研究,这种研究尝试将最新的计算机技术融合到传统临床心理治疗中去,并通过实验来评估其疗效。针对伴有广场恐怖症的惊恐障碍的研究一直是其研究重点,其包括对传统认知行为疗法(Cognitive Behavior Therapy,CBT)的评价研究、将远程视频会议技术应用于CBT疗法的研究,以及将虚拟现实技术与传统CBT疗法相结合的研究。     

Posttraumatic Stress Disorder and Chronic Pain Arising from Motor Vehicle Accidents: Efficacy of Interoceptive Exposure Plus Trauma-Related Exposure Therapy

Preliminary data are presented on the pattern of treatment response of combining interoceptive exposure (IE) with trauma-related exposure therapy (TRE) in five female patients with posttraumatic stress disorder (PTSD) and comorbid chronic musculoskeletal pain originating from motor vehicle accidents. Treatment consisted of four sessions of IE followed by eight sessions of TRE. Four participants reported a reduction in PTSD symptoms after completing treatment, and three no longer met diagnostic criteria for PTSD. Although both interventions were associated with reductions in PTSD symptoms, TRE was associated with greater reductions in PTSD symptoms than IE and was particularly effective at reducing avoidance. IE was associated with larger reductions in anxiety sensitivity than TRE. Pain symptoms lessened slightly during IE and then worsened following TRE. Anxiety decreased after completing treatment, whereas panic and depressive symptoms responded less so. Three individuals completed a 3-month follow-up assessment. There was no change in their PTSD diagnostic status, and all experienced a slight loss of pre–post gains, particularly involving the return of pain. Clinical and research implications are discussed.     

Cigarette Smoking and Panic Psychopathology

ABSTRACT— The present paper summarizes empirical evidence suggesting that smoking and panic problems often co-occur; that smoking is a risk factor for, and may serve to maintain, panic attacks and panic disorder; and that premorbid panic-specific vulnerability variables and full-blown panic problems are related to coping-oriented smoking motives and perhaps to the maintenance of smoking behavior. An integrative model is offered to stimulate further work on this topic, followed by future directions for research.     

Emotion Regulation Strategies in Cognitive Behavioral Therapy for Panic Disorder

Emotion regulation (ER) has been incorporated into many models of psychopathology, but it has not been examined directly in cognitive behavioral therapy (CBT) for panic disorder with agoraphobia (PD/A). In this study, a preliminary model of ER in CBT for PD/A is proposed based on existing theories, and several propositions of the model are tested. We hypothesized that increases in cognitive reappraisal would precede decreases in biased cognitions, decreases in expressive suppression would follow decreases in biased cognitions, and a reduction in symptom severity would follow decreases in expressive suppression. Twenty-nine patients who received CBT for PD/A completed weekly self-report measures of symptom severity, anxiety sensitivity, reappraisal and expressive suppression. In addition, patients were compared to a matched normal sample. Cross-lagged analyses partially supported the hypotheses. Reappraisal did not change until late stages of therapy and was generally not associated with treatment outcome. Suppression decreased significantly and exhibited a reciprocal relationship with biased cognitions. Symptom reduction followed decreases in suppression as hypothesized. However, patients did not differ in ER from matched controls at either pre- or posttreatment. Results suggest the important distinction between reappraisal and appraisal, and stress the role of session-by-session decreases in suppression as a predictor of symptom reduction.     

虚拟现实暴露疗法在社交焦虑中的应用:效果、机制及展望

由于传统干预方法的诸多局限,虚拟现实暴露疗法(virtual reality exposure therapy,VRET)逐渐应用于对社交焦虑的干预,VRET是将虚拟现实技术与传统行为暴露治疗相结合而形成的一种新的干预方法。文章总结了VRET的三个发展阶段及其研究范式,述评了在VRET过程中的作用机制。未来研究可致力于设计更加自然的人机交互技术,实现技术与社交焦虑治疗的深度融合以及关注第三人称视角应用的作用及机制。     

Modification of the catastrophic cognitions questionnaire (CCQ-M) for normals and patients: Exploratory and LISREL analyses

The Recently developed Catastrophic Cognition Questionnaire (CCQ) was further investigated using both student and anxiety patient samples. LISREL confirmatory factor analyses was used. The results showed that the CCQ could be explained by a three-factor oblique solution. These are Emotional Catastrophes, Physical Catastrophes, and Mental Catastrophes. The modified version of CCQ (CCQ-M) revealed good internal consistency, test-retest reliability, and concurrent validity. It has also good discriminant validity. The CCQ-M can therefore be used with both normal and anxiety-disordered patients.We would like to thank the staff of the Anxiety Disorder clinic, in particular Dr. Larry Evans and Ms. Elly Staunton-McKenzie, for their assistance in data collection, and the subjects for their participation in this study. Dr. Khawaja was supported by a scholarship from the Government of Pakistan. She was on leave from the University of Punjab, Lahore, Pakistan. We would like to thank the anonymous reviewers for their excellent suggestions.     

Is Acoustic Startle a Viable Exposure Protocol for Posttraumatic Stress Disorder? A Clinical Case Study

Exaggerated startle is a common symptom (based on Diagnostic and Statistical Manual of Mental Disorders [fourth edition] Criterion D) for many patients with posttraumatic stress disorder (PTSD). Findings from previous studies suggest that exaggerated startle may be due to trauma exposure or pretrauma vulnerability factors for PTSD development. The present clinical case study reports on a patient with PTSD characterized by a very prominent startle response and preference against standard trauma-related exposure strategies. On the basis of recent findings that interoceptive exposure exercises (e.g. shaking head side to side, hyperventilation) elicit trauma-related memories (Wald & Taylor, 2008), the authors sought to determine whether repeated application of an acoustic startle stimulus would serve to diminish the prominent startle response and facilitate exposure and overall symptom reduction by eliciting trauma-related memories. The protocol was successful in eliciting vivid and distressing trauma-related memories. Over the course of seven exposure trials, the patient demonstrated a decrease in distress elicited during the protocol, improved mood, and reduced general anxiety and trauma-related distress. He also reported significantly decreased startle response to loud noises encountered during activities of daily living. Although preliminary, these finding suggest that the acoustic startle protocol may be a viable (interoceptive) exposure strategy for individuals with PTSD, particularly those with exaggerated startle responses and those who are not amenable to standard trauma-related exposure strategies.     

Interoceptive Exposure: An Overlooked Modality in the Cognitive-Behavioral Treatment of OCD

Accumulated research implicates anxiety sensitivity (AS) as a transdiagnostic construct important to the maintenance of OCD. Yet despite the clinical implications of targeting fears of body-related sensations during treatment, interoceptive exposure (IE) is an often-overlooked therapeutic procedure in the cognitive-behavioral treatment of OCD. In this article, we discuss the rationale for—and procedures of—addressing AS during treatment for OCD. We provide two case examples, illustrating how a clinician might approach clinical assessment, case formulation, and treatment planning with each of these patients. We conclude by discussing future research directions to better understand if (and how) targeting AS during therapy might enhance OCD treatment outcome.     

Treatment of Panic Disorder with Agoraphobia: Randomized Placebo‐Controlled Trial of Four Psychosocial Treatments Combined with Imipramine or Placebo

Few randomized controlled trials have included panic disorder patients with moderate to severe agoraphobia. Therefore, this population was studied using pharmacotherapy as well as psychotherapy. At the time of the study, imipramine was widely used as a pharmacological treatment. Also, current practice guidelines for patients with panic disorder find selective serotonin reuptake inhibitors and tricyclic antidepressants roughly comparable in terms of efficacy. Therefore, the main objective of this study is to compare four psychosocial treatments—cognitive and graded in vivo exposure treatments, graded in vivo exposure, cognitive treatment, and supportive therapy—to evaluate the benefits of combining cognitive therapy with exposure in vivo. These treatments were combined with imipramine or placebo for a total of eight experimental conditions. Participants presented moderate to severe agoraphobia. The method involved a randomized, double‐blind, placebo‐controlled trial with 137 participants who completed a 14‐session protocol involving the treatments just mentioned. Measures were taken at baseline and posttreatment and at 3‐, 6‐, and 12‐month follow‐up. All treatment conditions were statistically and clinically effective in reducing self‐reported panic–agoraphobia symptoms over the 1‐year follow‐up. No statistical differences were observed between imipramine and placebo conditions. This study found that all treatment modalities helped reduce panic and agoraphobic symptomatology over a 1‐year follow‐up period. These surprising results support the need to document the relations among the various components of an intervention. This would make it possible to assess the relative efficacy of the treatment components rather than of the intervention as a whole.     

Psychometric properties of the mobility inventory for agoraphobia: convergent, discriminant, and criterion-related validity

Aims of this study were (a) to summarize the psychometric literature on the Mobility Inventory for Agoraphobia (MIA), (b) to examine the convergent and discriminant validity of the MIA's Avoidance Alone and Avoidance Accompanied rating scales relative to clinical severity ratings of anxiety disorders from the Anxiety Disorders Interview Schedule (ADIS), and (c) to establish a cutoff score indicative of interviewers’ diagnosis of agoraphobia for the Avoidance Alone scale. A meta-analytic synthesis of 10 published studies yielded positive evidence for internal consistency and convergent and discriminant validity of the scales. Participants in the present study were 129 people with a diagnosis of panic disorder. Internal consistency was excellent for this sample, α = .95 for AAC and .96 for AAL. When the MIA scales were correlated with interviewer ratings, evidence for convergent and discriminant validity for AAL was strong (convergent r with agoraphobia severity ratings = .63 vs. discriminant rs of .10–.29 for other anxiety disorders) and more modest but still positive for AAC (.54 vs. .01–.37). Receiver operating curve analysis indicated that the optimal operating point for AAL as an indicator of ADIS agoraphobia diagnosis was 1.61, which yielded sensitivity of .87 and specificity of .73.     

Social anxiety and fear of bodily sensations in panic disorder and agoraphobia: A matched comparison

This study tests the hypothesis that social anxiety and fear of bodily sensations are associated with the development of agoraphobic avoidance behavior in panic disorder patients. Twenty patients with panic disorder were compared to 20 patients with panic disorder with agoraphobia, matched by sex and duration of disorder. The two groups did not differ on measures of fear and frequency of assertive social responses. However, the agoraphobics scored higher on measures of interpersonal sensitivity, depression, feelings of inadequacy, and hostility. They also reported higher fear of bodily sensations. Although definitive conclusions need to be postponed until prospective studies have been conducted, there is evidence suggesting that the development of agoraphobia in panic patients is associated with hypersensitivity to bodily sensations and interpersonal situations.This research was supported by Grant 560-268-009 of the Dutch Organization for Scientific Research.     

Goal attainment scaling: An idiosyncratic method to assess treatment effectiveness in agoraphobia

Goal attainment scaling (GAS) is an individually tailored way to measure treatment gains, using a highly standardized procedure. An advantage of the method is that it takes into account individual characteristics of the patients, and at the same time the data are suitable for quantitative analysis and comparable across patients. Despite the wide acceptance and use of the method in the evaluation of psychotherapy, data on its psychometric properties are rather scarce. In the current study, GAS was used as one of several outcome measures in a research project on the effectiveness of various treatments for panic disorder with agoraphobia. Guidelines for GAS are presented as well as data on the reliability and validity of the procedure. Results indicate that the procedure is reliable, valid, and sensitive to the improvement of patients during treatment. Comparison of GAS with standardized measures revealed considerable concordance, although the clinical end status of patients diverged somewhat dependent on the measure considered.     

Testing Clinical Intuitions About Barriers to Improvement in Cognitive-Behavioral Therapy for Panic Disorder

Although clinical intuitions influence psychotherapeutic practice and are a rich source of novel hypotheses for research, many remain to be empirically tested. This study evaluates whether clinicians’ beliefs about barriers to progress in cognitive-behavioral therapy (CBT) for panic disorder are supported by data. Data from a randomized-controlled trial comparing CBT to panic-focused psychodynamic psychotherapy (PFPP) for adults with primary panic disorder (N = 161) were used to evaluate 15 factors endorsed by clinicians as impediments to CBT in a recent survey. Panic severity was assessed before, during (at Weeks 1, 5, and 9), and at termination of treatment (Week 12) using the Panic Disorder Severity Scale. Hierarchical linear modeling revealed that none of the perceived barriers were predictive of poor outcome. Contrary to clinicians’ intuitions, dissociation during panic attacks was associated with greater symptomatic improvement in both treatment arms (β = ?0.69, p < .05), above the effect of established predictors. Moderation analyses revealed that when patients had PTSD diagnosed with the Anxiety Disorders Interview Schedule (β = 1.71, p < .05) or less severe panic disorder (β = 0.45, p = .04), they changed more rapidly in CBT than in PFPP. Overall, clinician agreement was inversely related to the strength of a predictor (r = ?.24, p = .39). Although clinical intuitions can be useful as clinical and empirical signals, such beliefs should be critically examined before informing practice. Dialogue between academics and clinicians might be enhanced through research that incorporates input from front-line practitioners.     

Symptoms and cognitions during situational and hyperventilatory exposure in agoraphobic patients with and without panic

The purpose of this study was to explore the relationship between reported bodily symptoms and fearful cognitions in the anxiety episodes experienced by agoraphobic patients. Thirty-one inpatients, 16 with panic disorder (PD) with agoraphobia and 15 with agoraphobia without PD, performed a behavioral avoidance test (BAT) and a provoked hyperventilation test (PHT). The results of regression analyses indicated that feeling of unreality was related to number of reported thoughts concerning physical incapacitation during the BAT. On the PHT, shortness of breath was related to reported fears concerning physical incapacitation and loss of control. The results indicated that there were meaningful links between reported symptoms and catastrophic thoughts on both tests. Social/behavioral control fears were stable across the two tests, whereas physical fears, subjective anxiety increase, and number of symptoms reported showed no stability. More of the PD with agoraphobia patients than of the agoraphobia without PD patients reported fantasies of physical catastrophes associated with the BAT, whereas more of the agoraphobia without PD patients exhibited safety seeking behavior during the PHT.     

Mobility,Cognitions, and panic

Responses to the Mobility Inventory for Agoraphobia and the Cognitions Questionnaire were compared from samples of agoraphobics, social phobics, senior citizens, students, and students' relatives. The data illustrate the occurrence of avoidant behavior and panic in groups other than agoraphobics. The Mobility Inventory was shown to have good discriminative power, but the Cognitions Questionnaire failed to discriminate between agoraphobics and social phobics. The relationship of panic to mobility and cognitions is considered.     

Anxiety Sensitivity and Interoceptive Exposure: A Transdiagnostic Construct and Change Strategy

Recent findings support the relevance of anxiety sensitivity (AS) and interoceptive exposure (IE) across emotional disorders. This study (a) evaluated levels of AS across different anxiety disorders, (b) examined change in AS over the course of transdiagnostic psychological intervention, and its relationship with outcome, and (c) described the implementation of IE to address AS with patients with different anxiety disorders. Participants (N = 54) were patients who received treatment with the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) in two consecutive treatment trials. Participants completed a measure of AS at pre- and posttreatment, and multiple occasions during treatment. Symptom severity was assessed at pre- and posttreatment, and clinical information related to physical symptoms and IE were collected as part of routine clinical practice. Elevated AS was observed at pretreatment across diagnoses and decreases in AS were observed from pre- to posttreatment. Similar changes occurred across the diagnostic categories, notably coinciding with the introduction of IE. Change in AS was correlated with reduced symptom levels at posttreatment and 6-month follow-up. Patients with different anxiety disorders endorsed similar physical symptoms and practiced similar IE exercises with similar effects. Results provide preliminary support for the usefulness of IE as a treatment strategy across the spectrum of anxiety disorders, and additional support for the transdiagnostic relevance of AS.     

焦虑障碍的虚拟现实暴露疗法研究述评

虚拟现实暴露疗法(VRET)是传统的行为疗法的一种转换形式, 也是经典的现实情境暴露疗法的替代性治疗形式。虚拟现实整合了即时计算机图形学、身体感觉传感、视觉成像技术, 给来访者提供近似真实的、可以沉浸(immersion)和交互作用的虚拟环境。研究者采用虚拟现实暴露疗法治疗幽闭恐怖症、恐高症、飞行恐怖症、创伤后应激障碍、惊恐障碍等焦虑障碍, 并且关注虚拟现实暴露疗法的认知机制以及心理生理机制。实验研究表明, 虚拟现实暴露疗法在治疗焦虑障碍时是有效的。被试经过治疗之后, 对情境的控制感和自我效能感提升, 消极自我评价降低, 对创伤事件的容忍力提高, 重新获得对情境的控制感。与心率指标相比, 皮肤电是预测虚拟现实暴露疗法治疗效果更好的指标。虚拟现实暴露疗法还处于实验验证阶段, 并没有应用到实际临床中, 需要更加规范的实验设计验证该疗法的认知机制以及心理生理机制。虚拟现实暴露疗法结合功能磁共振成像(FMRI)用于心理治疗, 会是未来发展的新方向。