Modification of Cognitive-Behavioral Techniques in the Treatment of a Five Year-Old Girl with Social Phobia

Social phobia is a debilitating anxiety disorder that often goes undetected in young children, but can be effectively treated with cognitive-behavioral interventions. For children and adolescents, treatment usually includes education, social skills training, cognitive restructuring, relaxation training, and exposure. However, for very young children who present with social phobia, it is necessary to adapt treatment to the developmental level of the child. A case illustration demonstrates the way in which cognitive behavioral treatment (CBT) was modified for the treatment of a five year-old girl with social phobia. Several modifications were made, including utilizing novel exposure techniques and emphasizing parent management training in order to promote generalization of treatment gains outside of session.     

Virtual reality in the treatment of spider phobia: a controlled study

This study explored whether virtual reality (VR) exposure therapy was effective in the treatment of spider phobia. We compared a treatment condition vs. a waiting list condition in a between group design with 23 participants. Participants in the VR treatment group received an average of four one-hour exposure therapy sessions. VR exposure was effective in treating spider phobia compared to a control condition as measured with a Fear of Spiders questionnaire, a Behavioural Avoidance Test (BAT), and severity ratings made by the clinician and an independent assessor. Eighty-three percent of patients in the VR treatment group showed clinically significant improvement compared with 0% in the waiting list group, and no patients dropped out. This study shows that VR exposure can be effective in the treatment of phobias.     

Changes in Anxiety Control Beliefs Following a Brief CBT Treatment and Their Association With Anxiety Symptom Reduction

Anxiety control beliefs (i.e., beliefs regarding one’s ability to cope with external, fear-inducing threats and internal reactions to those perceived threats) have been found to negatively predict anxiety symptoms in children and adults and to be modifiable by cognitive-behavioral therapy for anxiety disorders. The current study examines whether changes in anxiety control beliefs were seen following a brief, intensive treatment for specific phobias, and whether those changes were associated with improvements in the targeted phobia and comorbid anxiety disorder symptoms. Participants were 135 children and adolescents (M age = 9.01 years, 49% male) who received one-session treatment (OST) with or without parental involvement for their primary specific phobia. Results indicated that self-reported anxiety control beliefs significantly increased following treatment and that these increases significantly predicted reductions in specific phobia severity and symptoms of comorbid anxiety disorders 6 months and 1 year following treatment. Findings illustrate that involvement in a single 3-hour OST was associated with changes in anxiety control beliefs and demonstrate the potential importance of targeting control beliefs in pediatric anxiety treatment.     

Imagery ability and exposure in vivo in spider phobia

The present study deals with the effect of imagery ability on treatment outcome in spider phobias. Thirty-eight spider phobics completed the Questionnaire on Mental Imagery (QMI) and the Spider Questionnaire (SPQ). Subjects also went through a behavioral approach task (BAT) during which heart rate and avoidance behavior were measured. Each subject was then given one-session treatment as described by Ost. Immediately after treatment, SPQ and BAT data were again obtained. On the basis of their QMI scores, subjects were assigned to a 'good', 'moderate', or 'poor' imagers group. Neither pre-treatment nor post-treatment measures were found to vary as a function of imagery ability. Thus it appears that, at least for specific phobias such as spider fear, imagery ability is not a relevant variable for predicting the effects of in vivo exposure.     

Active-imaginal exposure: examination of a new behavioral treatment for cynophobia (dog phobia)

The aims of this study were to investigate exposure-based treatments for cynophobia (dog phobia) and to test a newly developed hybrid imaginal exposure treatment that we have named active imaginal exposure. The treatment introduces an in vivo coping component to imaginal exposure whereby the patient physically performs coping responses to an imagined feared stimulus. Eighty-two participants meeting DSM-IV criteria for specific phobia (animal subtype) were randomly assigned to one of three 30-min. treatments: (a) active-imaginal exposure (AI), (b) imaginal exposure alone (IE), or (c) graduated in vivo exposure (IV). Participants completed a behavioral approach test at pre, post, and four-week follow-up. Significant pre- to posttreatment improvement was observed in all three treatment conditions. Response rates at posttreatment were 51.9, 62.1, and 73.1% for the IE, AI, and IV groups respectively. Likewise, effect sizes at posttreatment were 0.76, 1.41, and 1.55 for the IE, AI, and IV groups respectively. Although in the predicted direction, the between group differences were not significant. A similar pattern of results was observed at follow-up. Further, safety behavior utilization during treatment was associated with less improvement--particularly in the two imaginal treatment conditions. Exposure treatments of dog phobia appear feasible and effective in reducing phobic fear and avoidance associated with dog phobia. Furthermore, preliminary evidence suggests that our active-imaginal exposure treatment may be a viable alternative to in vivo exposure.     

Comorbidity in youth with specific phobias: Impact of comorbidity on treatment outcome and the impact of treatment on comorbid disorders

The purpose of the present study was twofold. In an analysis of data from an existing randomized control trial of brief cognitive behavioral treatment on specific phobias (One-Session Treatment, OST; Ollendick et al., 2009), we examined 1) the effect of comorbid specific phobias and other anxiety disorders on treatment outcomes, and 2) the effect of treatment of the specific phobia on these co-occurring disorders. These relations were explored in 100 youth presenting with animal, natural environment, situational, and “other” types of phobia. Youth were reliably diagnosed with the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent versions (Silverman & Albano, 1996). Clinician severity ratings at post-treatment and 6-month follow-up were examined as were parent and child treatment outcome satisfaction measures. Results indicated that the presence of comorbid phobias or anxiety disorders did not affect treatment outcomes; moreover, treatment of the targeted specific phobias led to significant reductions in the clinical severity of other co-occurring specific phobias and related anxiety disorders. These findings speak to the generalization of the effects of this time-limited treatment approach. Implications for treatment of principal and comorbid disorders are discussed, and possible mechanisms for these effects are commented upon.     

One Session Group Treatment of Spider Phobia by Direct or Modelled Exposure

Exposure therapy is the most effective treatment for specific phobias. The one-session procedure is a further development of the effectiveness of exposure therapy. The aims of this study were to determine whether a modelled version of exposure is also effective and what kind of efficiency gradient different procedures produce. A total of 38 patients with spider phobia participated in the study. They were assigned randomly to 3 different procedures: (i) direct exposure; (ii) model exposure; or (iii) video exposure. Diagnosis was established with DSM-III-R and the Fear Survey Schedule. Self-report questionnaires assessed cognitions, body sensation symptoms, self-efficacy and long-term effect evaluation. The results gave a significant time effect for cognitions, body sensations and self-efficacy. There was also a significant time effect and interaction for the evaluation of treatment and a time by group interaction for self-efficacy. Direct exposure seemed to produce the best long-term results.     

Fear and disgust processing during repeated exposure to threat-relevant stimuli in spider phobia

Although disgust plays a significant role in the etiology of spider phobia, there remains a paucity of research examining the role of disgust in the treatment of spider phobia. Spider fearful participants (N = 46) were randomly assigned to a disgust (view vomit images) or neutral activation (view inanimate objects) condition. They were then repeatedly exposed to a videotaped tarantula, during which time their fear, disgust, and physiological levels were assessed repeatedly. Growth curve analyses indicated that repeated exposure led to significant declines in fear and disgust with no statistically significant differences between the two conditions. However, there was marginal evidence for decreased physiological arousal during repeated exposure among spider fearful participants in the disgust activation condition compared to those in the neutral condition. Reduction in disgust during exposure in the disgust activation condition remained significant after controlling for change in fear, whereas change in fear was no longer significant after controlling for change in disgust. However, the opposite pattern of relations between change in fear and disgust was observed in the neutral activation condition. Higher fear and disgust activation during exposure was also associated with higher fear and disgust responding on a subsequent behavioral task and higher spider fear and disgust at 3-month follow-up. Baseline trait disgust propensity also predicted fear and disgust parameters during repeated exposure. The implications of these findings for the role of disgust in the treatment of spider phobia are discussed.     

Targeting the probability versus cost of feared outcomes in public speaking anxiety

Cognitive-behavioral theory suggests that social phobia is maintained, in part, by overestimates of the probability and cost of negative social events. Indeed, empirically supported cognitive-behavioral treatments directly target these cognitive biases through the use of in vivo exposure or behavioral experiments. While cognitive-behavioral theories and treatment protocols emphasize the importance of targeting probability and cost biases in the reduction of social anxiety, few studies have examined specific techniques for reducing probability and cost bias, and thus the relative efficacy of exposure to the probability versus cost of negative social events is unknown. In the present study, 37 undergraduates with high public speaking anxiety were randomly assigned to a single-session intervention designed to reduce either the perceived probability or the perceived cost of negative outcomes associated with public speaking. Compared to participants in the probability treatment condition, those in the cost treatment condition demonstrated significantly greater improvement on measures of public speaking anxiety and cost estimates for negative social events. The superior efficacy of the cost treatment condition was mediated by greater treatment-related changes in social cost estimates. The clinical implications of these findings are discussed.     

Treating Cockroach Phobia With Augmented Reality

In vivo exposure is the recommended treatment of choice for specific phobias; however, it demonstrates a high attrition rate and is not effective in all instances. The use of virtual reality (VR) has improved the acceptance of exposure treatments to some individuals. Augmented reality (AR) is a variation of VR wherein the user sees the real world augmented by virtual elements. The present study tests an AR system in the short (posttreatment) and long term (3, 6, and 12 months) for the treatment of cockroach phobia using a multiple baseline design across individuals (with 6 participants). The AR exposure therapy was applied using the “one-session treatment” guidelines developed by Öst, Salkovskis, and Hellström (1991). Results showed that AR was effective at treating cockroach phobia. All participants improved significantly in all outcome measures after treatment; furthermore, the treatment gains were maintained at 3, 6, and 12-month follow-up periods. This study discusses the advantages of AR as well as its potential applications.     

Phobic tendency within the Five-Factor and HEXACO models of personality structure

Recent research has indicated that the various specific phobias are only modestly correlated with the personality dimensions of the Big Five or Five-Factor Model (B5/FFM). We tested the hypothesis that the specific phobias would be more strongly associated with the dimensions of an alternative framework, the HEXACO model of personality structure. Self-reports on the Phobic Stimuli Response Scales (PSRS) were obtained along with self- and peer reports on measures of the B5/FFM and HEXACO dimensions from a sample of 248 non-clinical participants. The PSRS variables assessing specific phobias showed stronger correlations with the HEXACO Emotionality factor than with any B5/FFM dimension, and a stronger multiple correlation with the HEXACO factors than with the B5/FFM dimensions. Findings were similar across self- and peer reports of the personality variables. The results suggest that phobic tendency can be understood in terms of normal personality variation as conceptualized in the HEXACO framework.     

Utilizing physiological measures to facilitate phobia treatment with individuals with autism and intellectual disability: A case study

Despite the conceptualization of phobic fear as a multi‐factorial response, the measurement and treatment of phobias is often not comprehensive. The extant literature on the treatment of phobias for individuals with intellectual disabilities has exclusively focused on indices of behavioral avoidance. The present study demonstrates the treatment of behavioral avoidance and physiological reactivity in a child diagnosed with autism, intellectual disability, and a dog phobia. The results indicate that the individual often experienced physiological reactivity in the presence of the feared stimulus despite engaging in behavioral approach. Treatment of both behavioral avoidance and physiological reactivity resulted in successful generalization of treatment effects across three additional dogs and maintenance of treatment effects during a six‐month follow‐up assessment. Implications for examining multiple aspects of the anxious response when treating children with intellectual disabilities and severe language delays are discussed. Copyright © 2010 John Wiley & Sons, Ltd.     

Internet-Based Exposure Treatment Versus One-Session Exposure Treatment of Snake Phobia: A Randomized Controlled Trial

In this study, the authors compared guided Internet-delivered self-help with one-session exposure treatment (OST) in a sample of snake phobic patients. A total of 30 patients were included following a screening on the Internet and a structured clinical interview. The Internet treatment consisted of four weekly text modules which were presented on a web page, a video in which exposure was modelled, and support provided via Internet. The OST was delivered in a three-hour session following a brief orientation session. The main outcome was the behavioural approach test (BAT), and as secondary measures questionnaires measuring anxiety symptoms and depression were used. Results showed that the groups did not differ at post-treatment or follow-up, with the exception of a significant interaction for the BAT in favour of the OST. At post-treatment, 61.5% of the Internet group and 84.6% of the OST group achieved a clinically significant improvement on the BAT. At follow-up, the corresponding figures were 90% for the Internet group and 100% for the OST group (completer sample). Within-group effect sizes for the Snake Phobia Questionnaire were large (d = 1.63 and d = 2.31 for the Internet and OST groups, respectively, at post-treatment). It is concluded that guided Internet-delivered exposure treatment is a potential treatment option in the treatment of snake phobia, but that OST probably is better.     

One vs five sessions of exposure and five sessions of cognitive therapy in the treatment of claustrophobia

Forty-six patients fulfilling the DSM-IV criteria for claustrophobia were assessed with behavioral, physiological, and self-report measures. They were randomly assigned to four conditions: (1) one-session (E1); or (2) five-sessions of exposure (E5); (3) five-sessions of cognitive therapy (C5); and (4) Wait-list for 5 weeks. The first condition consisted of a single 3 h session of massed exposure, and condition 2 and 3 of 5 h of gradual treatment, which was done individually by very experienced therapists. The results showed that treatment was significantly better than the wait-list condition, and the three treatments did equally well with no differences between them. At post-treatment 79% of treatment patients vs 18% of the wait-list controls had improved to a clinically significant extent. When the three treatments were compared 80% in the E1-group, 81% in the E5-group, and 79% in the C5-group were clinically improved. At the 1 year follow-up the corresponding figures were 100%, 81%, and 93%, respectively. The implications of these results are discussed.     

Effect of distraction and coping style on in vivo exposure for specific phobia of spiders

Recent studies have generated mixed findings regarding the effects of distraction on exposure-based treatments. Results have also been inconsistent regarding the effects of monitoring and blunting coping styles on outcome. The present study attempted to integrate these two areas of research. We hypothesized that the effect of distraction on treatment outcome might depend on coping style. Specifically, we predicted that for blunters (i.e.. individuals who tend to avoid threat-related information), distraction would interfere with the effects of exposure. However, we predicted that distraction might benefit monitors (i.e., individuals who tend to seek out threat-related information). Sixty individuals with a specific phobia of spiders underwent a single, two-hour session of exposure treatment. During the first hour, half of the participants were distracted by listening to an audiotape and the other half underwent exposure without distraction. In the second hour, all participants underwent focused exposure. Based on measures of heart rate, subjective fear, and behavioral testing, participants improved after one hour of treatment, and improved further during the second hour. However, neither distraction, coping style, nor their interaction had a significant effect on outcome. The present study provides support for the benefits of behavioral treatment for specific phobias. However, our hypotheses regarding distraction and coping style were not confirmed.     

Acquisition of phobias and anxiety response patterns in clinical patients

The ways in which phobic patients (N = 106; animal-, social- and claustrophobics) acquired their phobias were investigated in the present study. The results showed that a large majority (58%) of the patients attributed their phobias to conditioning experiences, while 17% recalled vicarious experiences, 10% instructions/information and 15% could not recall any specific onset circumstances. There was no clearcut relationship between the ways of acquisition and anxiety components (subjective, behavioral, physiological), nor did the conditioning and indirectly acquired phobias differ in severity. However, some interesting trends emerged in the data, showing that animal phobics who recalled conditioning experiences to a larger extent also responded physiologically. For patients with indirect onset experiences (for all three types of phobias) the reverse was true, i.e. they responded to a larger extent in a cognitive-subjective way, rather than with increased physiological arousal.     

Influence of expressed emotion and perceived criticism on cognitive-behavioral therapy for social phobia

This study examined significant others' expressed emotion (EE) and a closely related construct, perceived criticism, as predictors of cognitive-behavioral therapy outcome in a sample of 40 patients with social phobia (social anxiety disorder). Patients enrolled in group therapy for social phobia completed pre- and post-treatment questionnaire measures of perceived criticism and anxious and depressive symptoms. Designated significant others were assessed for the components of high EE (criticism, hostility and emotional overinvolvement) using the Camberwell Family Interview. It was hypothesized that these high-EE components and patients' perceived criticism would be associated with poorer treatment outcome, and results ran counter to these expectations. Controlling for initial social phobia severity, lower levels of perceived criticism predicted treatment dropout. There was also a nonsignificant trend for participants with a significant other rated as high in emotional overinvolvement to show less change on a composite symptom measure. Findings from this study suggest that close relationships impact the outcome of cognitive-behavioral interventions for social phobia.