The observer perspective: biased imagery in social phobia, agoraphobia, and blood/injury phobia.

Clark and Wells' (1995): 'A cognitive model of social phobia'. In Social phobia: Diagnosis, assessment, and treatment (pp. 69-93), R. G. Heimberg, M. R. Liebowitz, D. A. & F. R. Hope (eds.); cognitive model of social phobia proposes that social phobics generate a negative impression of how they appear to others. This impression often occurs in the form of an image from an "observer" perspective in which social phobics can see themselves as if from another person's vantage point. This study investigated the specificity of the observer perspective among patients with social phobia, agoraphobia, and blood/injury phobia. All participants were asked to recall and imagine a recent anxiety-provoking social situation and a non-social/non-anxiety-provoking situation, and rate their perspective for each. Consistent with predictions only patients with social-evaluative concerns (social phobics and agoraphobics) reported observer perspectives for anxiety-provoking social situations. Only social phobics showed a significant shift from an observer to a field perspective across the two conditions. The clinical implications of these findings are briefly discussed.     

Ways of acquiring phobias and outcome of behavioral treatments

The way of acquisition of phobias was studied in relation to different behavioral treatments for phobias. Ss (N = 183) were clinical patients belonging to six different phobic groups (agoraphobics, claustrophobics, social phobics, animal phobics, blood phobics and dental phobics), and the treatments were categorized as behaviorally focused (exposure in vivo and social-skills training), physiologically focused (systematic desensitization and applied relaxation) and cognitively focused (self-instruction training and fading). Results showed that both for patients with direct conditioning experiences and indirect acquisition those treated with behavioral and physiological methods improved more than those receiving cognitive methods when looking at the change-score data. Regarding the proportion of clinically improved patients there was no difference between treatments among the Ss with a background of conditioning experiences. In the group with indirect acquisition, on the other hand, the cognitive methods were more effective.     

Is agoraphobia harder to treat? A comparison of agoraphobics' and simple phobics' response to treatment

Agoraphobia is reputed to be more difficult to treat than simple phobia. In a test of this supposition, 38 agoraphobics and 19 simple phobics were each given 10 sessions of graduated in vivo exposure. They were assessed before and after therapy using a behavioral avoidance test, behavioral diaries, and self-report measures. Analysis of covariance revealed unequivocal posttest differences only on self-assessed disability level; agoraphobics had changed less in their report of global disability immediately following treatment but not at follow-up. Sixty-eight percent of the simple phobics showed clinically significant improvement on avoidance of the Main Phobia, compared with 34% of the agoraphobics. On three other outcome measures, including more precise behavioral measures of phobia, agoraphobics and simple phobics responded equivalently to treatment. Given clinicians' impression about the comparative difficulty in treating agoraphobic clients, fewer differences in treatment response were obtained than were expected. Several possible explanations for this discrepancy are discussed.     

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.     

Semi-automated desensitization : a controlled clinical trial

A clinical trial of semi-automated desensitization on phobic patients. Twelve received treatment with a therapist present and 12 received treatment from pre-recorded tapes. Therapy lasted a maximum of 16 weekly sessions. Assessment of progress was by means of self-ratings of phobic behaviour and more global fear ratings, made by the referring psychiatrist. Both treatments produced beneficial results. Both ratings agreed in finding no significant differences between the two methods of administration, thus confirming results from existing non-clinical trials of automated desensitization. Regardless of treatment group, agoraphobics and social phobics tended to improve less markedly, and less rapidly than simple phobics. Some implications of automated therapy for clinical practice are discussed.     

Perfectionism and self-consciousness in social phobia and panic disorder with agoraphobia.

Social phobics were compared to patients with panic disorder with agoraphobia and normal controls on perfectionism and self-consciousness. On concern over mistakes and doubts about action, social phobics scored higher than patients with panic disorder. Social phobics also demonstrated a higher level of public self-consciousness than patients with panic disorder and when this difference was controlled for the significant differences on perfectionism disappeared. Within each patient group, however, perfectionism was more robustly related to social anxiety than was public self-consciousness, which replicates the findings of Saboonchi and Lundh [Saboonchi, F. & Lundh, L. G. (1997). Perfectionism, self-consciousness and anxiety. Personality and Individual Differences, 22, 921-928.] from a non-clinical sample. The results are discussed in terms of public self-consciousness being a differentiating characteristic of the more severe kind of social anxiety which is typical of social phobia.     

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.     

Treatment of adolescent agoraphobics: Effects on parent-adolescent relations

Three adolescent agoraphobics, accompanied by their mothers, were treated in a small group. Treatment consisted of self-initiated exposure, panic management and cognitive restructuring, with the parent acting as co-therapist. Measures of adolescent-parent relationships were administered as well as measures of agoraphobia. As with adult agoraphobics treated with their spouse, results indicated a parallel relationship between phobia and family relations; that is, as phobia improved, the relationship improved. Unlike adult agoraphobics, adolescents were unable to comprehend that agoraphobic fears concerning health or dying were unrealistic. This interfered with motivation and underscored the need of the parent as a co-therapist.     

Thought suppression: specificity in agoraphobia versus broad impairment in social phobia?

The paradoxical effects of intended thought suppression have been linked to psychological disorders, specifically anxiety disorders. So far, the evidence for thought suppression playing a major role in the disorder is mixed. One important issue is whether thought suppression is impaired only for thoughts related to the disorder, or if the ability for mental control is generally impaired in anxiety patients. This study compared groups of agoraphobics and social phobics with a healthy control group. All subjects were asked to suppress two topics related to the respective central fear of the two disorders and one nonspecific topic. We found a rather specific deficit in thought suppression for the agoraphobics; that is, when compared with the control group, we found the biggest differences for the agoraphobic fear. The social phobics seem to be characterized by a general impairment of mental control, affecting specific and nonspecific stimuli. In addition, among several psychopathological variables, social anxiety proved to be the strongest predictor for problems with thought suppression. Taken together, there are several indicators that generally impaired thought suppression may be an important feature of social phobia.     

Psychological states and traits in female agoraphobics: A controlled study

Recent surveys on the psychology of agoraphobia point to the paucity of sound empirical studies addressing personality and symptomatology factors related to the disorder. In the present study, a sample of female agoraphobics was compared with control groups of nonphobic psychiatric and of nonpatient normal female Ss on a relatively large number of psychological state and trait measures. Besides scoring clearly higher than both groups of controls on agoraphobic symptoms, agoraphobics, as a group, scored significantly higher in terms of (a) anxiety, (b) certain components of depression, (c) interpersonal difficulties, (d) general psychological malaise, and (e) fears of bodily injury, illness, and death as well. Further, compared to both groups of controls, agoraphobics could be characterized by higher levels of (a) neuroticism, (b) seclusion (low on extraversion and sociability and showing greater tendencies toward isolating themselves from social contacts), (c) situational dependency (higher scores on a restrictive style of living), (d) passivity (greater hypoactivity), and (e) intropunitiveness (scores in more intropunitive than extrapunitive direction). The claim, frequently made in the clinical literature, that agoraphobics have dependent personalities was not confirmed.     

Virtual reality treatment versus exposure in vivo: a comparative evaluation in acrophobia

The aim of the present study was to evaluate the effectiveness of low-budget virtual reality (VR) exposure versus exposure in vivo in a between-group design in 33 patients suffering from acrophobia. The virtual environments used in treatment were exactly copied from the real environments used in the exposure in vivo program. VR exposure was found to be as effective as exposure in vivo on anxiety and avoidance as measured with the Acrophobia Questionnaire (AQ), the Attitude Towards Heights Questionnaire (ATHQ) and the Behavioral Avoidance Test (BAT). Results were maintained up to six months follow-up. The present study shows that VR exposure can be effective with relatively cheap hardware and software on stand-alone computers currently on the market. Further studies into the effectiveness of VR exposure are recommended in other clinical groups as agoraphobics and social phobics and studies in which VR exposure is compared with more emerging virtual worlds as presented in CAVE-type systems.     

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.     

Accuracy of fear inventories and self-efficacy scales in predicting agoraphobic behavior

Self-rating fear inventories are widely used as primary dependent measures of therapeutic change in agoraphobia, but objective behavioral evidence of their validity has been largely unavailable. In contrast, self-efficacy scales are rarely used in agoraphobia research despite evidence that they correlate highly with agoraphobic behavior. In the present study, 37 agoraphobics completed the Marks and Mathews Fear Questionnaire, the Mobility Inventory for Agoraphobia, a set of agoraphobia-related self-efficacy scales, and a set of agoraphobia-related behavioral avoidance tests in the natural community environment. The Fear Questionnaire and Mobility Inventory items proved to be only modestly predictive of agoraphobic dysfunction, whereas the self-efficacy scales were highly predictive of agoraphobic dys-function. Although self-efficacy scales are not intended to be substitute measures of behavior, the findings indicate that they estimate agoraphobia much more accurately than do the standard fear inventories.     

Personality differences within a diagnostic entity: Types of phobia in men and women

Often, psychodiagnostic entities, like phobias, have been assumed implicitly to be homogeneous with respect to important personality variables. Three types of phobic women, agoraphobics, social phobics and simple phobics (n = 15 per type) were compared among themselves and with non-phobics on a variety of personality characteristics. The same was done with phobic men (respectively, n = 12, n = 11, n = 8). The results showed that types of phobia differ with regard to several personality characteristics; for women differently than for men. Implications for theory building, diagnosis, and therapy are discussed. On the whole, a personality-oriented approach to psychopathology is advocated.     

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.     

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.     

Irrational beliefs and the anxiety disorders

This study investigated the levels of irrationality reported by a clinical sample of anxiety disorder patients, including simple and social phobics, panic disorder patients, agoraphobics, and obssessive compulsive patients. The levels of irrationality were compared between these groups and a group of normal control subjects, using the Rational Behavior Inventory (RBI). Agoraphobic patients were significantly less rational than control subjects on six of the RBI's subfactors and the total score of the Inventory. Patients in all diagnostic categories except simple phobia were significantly different from control subjects on the projected misfortune subfactor, and patients in all categories except simple phobia and panic disorder were significantly different from controls on the total RBI score. There were only four instances where patients in anxiety disorder categories significantly differed from each other in levels of irrationality. The implications of these findings, methodological limitations, and directions for future research are discussed.Joseph A. Himle, ACSW is a Clinical Social Worker at the Anxiety Disorders Program, Department of Psychiatry, University of Michigan. David P. Himle, Ph.D. is an Associate Professor of Social Work at the University of Michigan. Bruce A. Thyer, Ph.D. is an Associate Professor of Social Work, University of Georgia and Faculty Fellow at the University Affiliated Program. He is also an Associate Clinical Professor at the Department of Psychiatry and Health Behavior, Medical College of Georgia.     

Panic onset and major events in the lives of agoraphobics: a test of contiguity

Major life events were reported in greater numbers and by a higher percentage of 50 index agoraphobics during a time period around panic onset than during either a within-subjects or a between-subjects control period. These differences were found for analyses of life events in general, events that preceded panic, and foreseeable events that occurred shortly after panic onset. Though many events involved separation or interpersonal conflict, other types of events were frequently reported. Results provide more convincing evidence than prior studies of a contiguous relationship between life events and onset of panic attacks associated with agoraphobia.     

Cognitive bias in symptomatic and recovered agoraphobics

Symptomatic agoraphobics, recovered agoraphobics, and normal control subjects completed a series of sentence stems that had either ambiguous or unambiguous meanings, and had either a potentially threatening or a nonthreatening connotation. The written completions made by subjects to these stems were classified as indicating either a biased (i.e. threat-related) or unbiased interpretation of the meaning of the stem, and if a biased interpretation was made, whether the subject indicated efforts at adaptive coping with the perceived threat. Results indicated that symptomatic agoraphobics exhibited strong biases for interpreting information as threatening, relative to normal control subjects. Moreover, recovered agoraphobics resembled symptomatic agoraphobics more than normal control subjects, thus indicating that cognitive biases may persist following cessation of panic attacks and reductions in avoidance behavior. However, recovered agoraphobics also exhibited tendencies to cope adaptively with perceived threats whereas symptomatic agoraphobics did not.     

Avoidant personality disorder and the generalized subtype of social phobia.

Social phobia and avoidant personality disorder (APD) may be given as comorbid diagnoses. However, it is not known if the labels provide independent, useful diagnostic information. We classified social phobics by social phobia subtype and presence of APD. Generalized social phobics with and without APD (ns = 10 and 10) and nongeneralized social phobics without APD (n = 10) were distinguished on measures of phobic severity. The generalized groups also showed earlier age at onset and higher scores on measures of depression, fear of negative evaluation, and social anxiety and avoidance than did the nongeneralized group. APD criteria of general timidity and risk aversion were more frequently endorsed by social phobics with APD. The data suggest that both the generalized subtype of social phobia and the presence of APD do provide useful diagnostic information but the additional diagnosis of APD may simply identify a severe subgroup of social phobics.