Is there anybody there? A psychodynamic view of panic attack

The effectiveness of cognitive-behavioural therapy is frequently cited when adopting this model as treatment of choice for panic attacks and anxiety disorders. However, Frank (1974), in discussing treatment effectiveness and patient compliance, argues that 'the more closely the conceptual framework of therapy fits that of the patient, the more readily he can accept it' (p. 370). In the following process analysis, my client's clear requirement for an exploratory approach meant that it was a psychodynamic understanding of the complex aetiology of her panic attacks that ultimately produced improved coping skills and a subjective sense of improvement for her. Process analysis has been chosen to illustrate the theoretical base, clinical impact and experiential immediacy of psychodynamic work; attention is drawn to the importance of transference and countertransference experiences in the choice of clinical interventions which tally with the client's sense of internal reality.     

Comparative analysis of a client's verbal responses in counseling sessions: quantitative case study

This study investigated how the in-session change in a client's verbal behavior might influence the effectiveness of counseling sessions. 10 sessions of counseling with a male undergraduate suffering from depressive mood were conducted by a humanistically oriented counselor. The two most effective and the two least effective sessions were identified according to the client's evaluation of the effectiveness of counseling sessions. Results indicated that over the three segments of the most effective sessions, the client gradually increased responses that indicated exploration of his own emotions, thoughts, and behaviors. By contrast, the client continued talking mainly about past events in a storytelling manner throughout the least effective sessions.     

Two models of brief group psychotherapy for herpes sufferers

The psychological consequences that often follow from contracting genital herpes fall into four general categories: sexual functioning, interpersonal relations, emotional life, and self-esteem. After detailing these, a rationale for treating genital herpes sufferers in group is offered, and then two models for the time-limited group treatment of this population are described. The first is a cognitive behavioral stress management program which has three component parts: relaxation training, rational-emotive training, and assertiveness training. The second is a dynamically oriented group in which the group focus shifts over time from the difficulties associated with the disease itself to general exploration of interpersonal styles and themes. Some comparisons between the two models are drawn.     

Dyspneic-fear and catastrophic cognitions in hyperventilatory panic attacks

The tenability of cognitive explanations of the experience of fear during panic attacks (viz. Ley's misattribution-of-symptoms hypothesis and Beck's and Clark's catastrophic-misinterpretation-of-symptoms hypotheses) is seriously questioned by findings from three independent lines of research: (a) Wolpe and Rowan's observation that catastrophic cognitions follow fear, (b) Rachman, Levitt and Lopatka's reports of panic attacks without fearful cognitions, and (c) reports of panic attacks during sleep occurring predominately during non-dreaming stages of sleep. Recognition of these findings led Ley to reject his misattribution-of-symptoms hypothesis in favor of an innate emotional-respiratory-response explanation. The revised hyperventilation theory now maintains that fear experienced during a hyperventilatory panic attack is caused by severe dyspnea in the context of little or no perceived control over the causes of the dyspnea (i.e. dyspneic-fear). Cognitions during panic attacks are discussed in terms of the cognitive deficit that results from the cerebral hypoxia produced by hyperventilation. Implications for theory and treatment are discussed.     

Response to Nadler's Commentary on Arch and Craske's (2011) “Addressing Relapse in Cognitive Behavioral Therapy for Panic Disorder: Methods for Optimizing Long-Term Treatment Outcomes”

Nadler (this issue), in his commentary of our article, “Addressing Relapse in Cognitive Behavioral Therapy for Panic Disorder: Methods for Optimizing Long-Term Treatment Outcomes” (Arch & Craske, 2011), argues that we misrepresent the role of panic attacks within learning theory and overlook cognitive treatment targets. He presents several case studies that he argues demonstrate how to target fears regarding the consequences of panic itself. We appreciate his raising these issues and creating the opportunity for discussion. We take issue, however, with two aspects of his commentary. First, his case studies beautifully illustrate a central point we make in our article regarding the importance of violating patient expectancies, and as such, exemplify our recommendations rather than illustrate what we may have overlooked. Second, Nadler's argument that we misidentify the role of panic attacks contradicts itself in ways that reveal his misunderstanding of the complexity of panic attacks from the perspective of learning theory (e.g., Bouton, Mineka, & Barlow, 2001), and disregard an important point we make in our article.     

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.     

Clinical applications of analogue behavioral observation: dimensions of psychometric evaluation

Clinical assessment applications of analogue behavioral observation are discussed in the context of psychometric principles. Analogue behavioral observation involves the measurement of a client's overt behavior in a contrived situation that is analogous to situations that the client is likely to encounter in his or her natural environment. The goal of analogue behavioral observation is to derive valid estimates of the client's behavior in a current or future natural environment. Analogue behavioral observation instruments are often developed with insufficient attention to their psychometric properties, particularly content validity. Psychometric evaluative dimensions vary in their importance, as a function of the goals of the assessment. Although analogue behavioral observation instruments can be sensitive to change, their validity can erode over time and is affected by numerous sources of variance. Analogue behavioral observation assessment may be especially useful in detecting important functional relations in clinical assessment.     

Cognitive-Behavioral Treatment of Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD) can be treated effectively with cognitive-behavioral therapy. When working with clients who have GAD, therapy can focus on four central areas that help to promote therapeutic change. The initial focus of therapy is on developing a sound therapeutic alliance and educating the client about anxiety symptoms. Skills training focuses on relaxation training and cognitive changes that can help clients confront their worries in a constructive manner. Then, exposure to internal and external aspects of the anxiety can help clients test and refine their coping skills. Finally, because of the chronic nature of GAD, relapse prevention strategies can be used to help maintain treatment gains over time. These strategies allow a broad but flexible treatment plan that can be adapted to the unique needs of each individual client.     

The role of hyperventilation in panic disorder: a response to Ley (1991)

Ley (Behaviour Research and Therapy, 29, 301–304, 1991) provided a reinterpretation of experimental findings on the efficacy of breathing retraining plus cognitive restructuring in reducing the symptomatology of patients with panic disorder with agoraphobia which were presented in a 1989 article in this journal. On the basis of his reinterpretation, they concluded that our findings supported the central role of hyperventilation in panic attacks. Ley's arguments are discussed and we conclude that his reinterpretation provides new arguments against a hyperventilation theory of panic. Furthermore, recent evidence from empirical studies does not support a central role for hyperventilation in panic attacks.     

Cognitive-Behavioral Treatment of Social Phobia

Social phobia can be a chronic disorder, capable of restricting a client's social and occupational functioning. Cognitive-behavioral therapy can help many clients learn to overcome their social inhibitions, and make lasting changes in their interpersonal style. Cognitive-behavioral therapy for social phobia includes four general components for helping clients learn to manage their social anxiety. First, therapy begins with the establishment of a sound therapeutic alliance, a focus on assessment, diagnostic interviewing, and education regarding anxiety symptoms and their treatment. Second, the therapist helps clients to develop competence in social skills, relaxation training, and cognitive restructuring. Third, therapy uses exposure to social situations in order to help clients confront their fears and refine their coping skills. Fourth, relapse prevention strategies are used to help clients learn to tolerate feelings of discomfort and confront challenging social interactions. This treatment framework can be adapted to the specific needs of different clients.     

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.     

Mastery goal orientation and cognitive ability effects on performance in learner‐guided training

To conserve resources, organizations are increasingly turning to learner‐guided training methods in which workers are given control over when, how, and what they cover in the learning process. However, the impact of individual differences such as goal orientation and cognitive ability has not been adequately addressed in learner‐guided training. This study seeks to advance our knowledge of how these differences affect performance through previously unexplored pathways. Specifically, we examined the indirect effects of mastery goal orientation and cognitive ability on post‐training performance in a learner‐directed training context. Findings indicate that off‐task thoughts mediate the positive effect of mastery goal orientation on post‐training performance, while declarative knowledge mediates the positive effect of cognitive ability on post‐training performance.     

Psychophysiological outcome of cognitive, behavioral and psychophysiologically-based treatments of agoraphobia

Psychophysiological process and outcome phenomena were analyzed to examine differential temporal patterns within and across cognitive, behavioral and physiologically-based treatments of agoraphobia. Eighty-eight severe and chronic agoraphobics with panic attacks (DSM-III) were randomly assigned to one of three treatments: Paradoxical Intention, Graduated Exposure or Progressive Deep Muscle Relaxation Training. Protocol therapists, whose treatment integrity was objectively monitored, conducted 12 two-hour weekly sessions. All subjects received programmed practice instructions concurrent with their primary treatment. Analyses revealed numerous significant reductions on in vivo psychophysiological measures for the relaxation condition, a few improvements for the exposure treatment and no effects for the paradoxical intention modality. The mediating role of pretreatment physiological reactivity in treatment outcome and follow-up status was examined and revealed no significant associations. Synchrony-desynchrony patterns were found to vary widely according to both treatment phase and the time interval between assessments. No between-group differences were observed on the proportion of synchronizers. However, synchronizers exhibited superior outcome and follow-up compared to desynchronizers on all domains except the physiological measures. Conceptual, methodological and clinical implications of these findings are discussed with recommendations for future research.     

Pragmatic causal distortion in counselling

A person's actions are caused by the interaction between external environmental forces and internal personal forces. Attributing actions to one or the other set of forces is an arbitrary distortion. In therapy, attributing actions to external forces - particularly past events - relieves the client of guilt and helps him to make sense out of his actions. Attributing actions to internal sources provides a means by which the client can change his actions by changing his ideas, interpretation of events, and attitudes. Using both of these distortions of cause, a method of therapy is presented which emphasises the client's responsibility for his actions, and is aimed at developing the client as an active causal agent in his own life.     

The Education-Contingent Association Between Religiosity and Health: The Differential Effects of Self-Esteem and the Sense of Mastery

Using data from a representative sample of adults in Toronto, Canada, I examine the education-contingent association between religiosity (subjective religiosity and religious attendance) and four health-related outcomes: depression, anxiety, alcohol use, and self-rated health. I also test the extent that two personal resources—the sense of mastery and self-esteem—contribute to those associations. Findings indicate that subjective religiosity and attendance are generally associated with lower levels of depression, anxiety, alcohol use, and poor health. Moreover, although not entirely uniform, subjective religiosity and attendance tend to be associated more negatively with these outcomes among individuals with fewer years of education. While the sense of mastery suppresses the education-contingent influence of religiosity on distress outcomes, self-esteem generally contributes to those patterns. On balance, the suppression effects of mastery are offset by the explanatory effects of self-esteem. These findings elaborate on the well-established association between religiosity and health by illustrating education-contingent effects and potential counterbalancing roles of personal resources in these processes.     

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.     

儿童早期自尊的行为观察研究

以自尊情感模型为理论起点,采用行为事件取样法,对58名1.5-4岁婴幼儿的掌控感和归属感事件进行系统观察。结果表明：早期掌控感源于以动作为基础的掌控行为,包括掌控自我、掌控外物和掌控他人。而归属感一方面源于儿童以不同的行为方式寻求归属,即主动归属感;另一方面源于不同情境下成人的行为使儿童获得了归属,即被动归属感。掌控感和归属感事件均随年龄增长而逐渐减少,反映了个体自尊的早期形态。     

Gender differences in loss of psychological resources following experimentally-induced vicarious stress

Abstract

The present research focuses on gender differences in resource loss, perceived threat, and negative affective reactions induced by experimental manipulation of vicarious stress. Israeli students (54.7% women) were randomly allocated to one of two conditions: (1) Threat Condition (n=98), in which participants were exposed to a video film depicting terror attacks and (2) Control Condition (n=30), in which participants viewed a video film depicting a series of non-emotive news broadcasts. Participants also completed measures of mastery, optimism, and self-esteem. The data indicated that whereas under the Threat Condition women scored lower on psychological resources and higher on perceived threat than men, no significant gender differences were observed under the Control Condition. A path analysis revealed that gender was directly related to perceived threat and resource loss, which, in turn, were related to negative affect. In addition, a greater sense of mastery was related to lower resource loss. Overall, these experimental findings suggest that gender and mastery bear prominent effects on cognitive and emotional reactions to vicarious life threat.     

Gender differences in loss of psychological resources following experimentally-induced vicarious stress

The present research focuses on gender differences in resource loss, perceived threat, and negative affective reactions induced by experimental manipulation of vicarious stress. Israeli students (54.7% women) were randomly allocated to one of two conditions: (1) Threat Condition (n=98), in which participants were exposed to a video film depicting terror attacks and (2) Control Condition (n=30), in which participants viewed a video film depicting a series of non-emotive news broadcasts. Participants also completed measures of mastery, optimism, and self-esteem. The data indicated that whereas under the Threat Condition women scored lower on psychological resources and higher on perceived threat than men, no significant gender differences were observed under the Control Condition. A path analysis revealed that gender was directly related to perceived threat and resource loss, which, in turn, were related to negative affect. In addition, a greater sense of mastery was related to lower resource loss. Overall, these experimental findings suggest that gender and mastery bear prominent effects on cognitive and emotional reactions to vicarious life threat.