Behavioral assessment of avoidance in agoraphobia

Behavioral avoidance testing is a substantial addition to self-report questionnaires in the assessment of agoraphobia. However, the tests currently in use have drawbacks and limitations. A multitask behavioral avoidance test (M-BAT) is presented, designed to meet some of these problems. The test was administered to a group of 58 patients and proved to be reliable in terms of internal consistency. Concordance with self-report measures of agoraphobia indicated a high concurrent validity. In comparison with self-report questionnaires, the tests produced a slightly more conservative picture of gains achieved in treatment. Finally, the data revealed that the multitask test was more concordant with other measures of agoraphobia than a single-task test would have been.     

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.     

Trimodal assessment in agoraphobia research: Further observations on heart rate and synchrony/ desynchrony

This paper reports new observations on heart rate and synchrony/desynchrony in the context of 22 chronic agoraphobic patients' trimodal assessment pre and post exposure treatment. The results corroborated previous reports showing weak and/or inconsistent improvement in heart rate, in contrast to significant improvement in behavioral and subjective response systems. Moreover, the results did not support recent suggestions that heartrate reactivity at pretreatment or global categories of synchrony/dysynchrony at posttreatment have important implications for treatment outcome. However, subtypes of dysynchrony based on the direction of divergence between variables had different implications for the clinical response, indicating that simply dichotomizing patients into synchronizers/desynchronizers may be misleading in addition to being uninformative.This work was supported by Grants MH34177 and MH40141 from the National Institute of Mental Health. Mary Sue Hamann, M.S., assisted in the statistical analyses.     

Cognitive factors in panic disorder, agoraphobic avoidance and agoraphobia

There remains a lack of consensus regarding the possibility that especially high levels of panic-related cognitions characterise panic disorder with agoraphobia. We administered the Anxiety Sensitivity Index, the Agoraphobic Cognitions Questionnaire and the Anxious Thoughts and Tendencies Scale as well as measures of agoraphobic avoidance to patients diagnosed with panic disorder with agoraphobia (n=75) and without agoraphobia (n=26). Patients with panic disorder with agoraphobia did not score significantly higher on any of the cognitive variables than did panic disorder patients without agoraphobia. However, most of the cognitive variables showed small to moderate-strength correlations with self-report measures of agoraphobic avoidance. Our findings suggest that anxiety sensitivity, catastrophising of the consequences of panic and a general anxiety-prone cognitive style, although to some extent associated with agoraphobic avoidance, do not discriminate panic disorder with agoraphobia from panic disorder without agoraphobia.     

Brief treatment with alprazolam and behavioral guidance in panic disorder

Abstract

Thirty-two patients with panic disorder, with or without agoraphobic limitations, were treated with alprazolam (mean dose 3.5 mg/d) plus brief behavioral guidance in an open study during eight weeks. The sample had a notorious severity in the frequency of panics and phobic avoidance but was only mildly depressed. Before starting treatment the presence of demoralized mood and extensive avoidance were significant indicators of clinical severity, whereas the presence of dizziness as a relevant somatic complaint was not related to higher severity. After eight weeks of treatment a clinical improvement equal to or exceeding 80% of change was obtained in all cases (29) who completed treatment. Ninety-two percent of the patients were panic free at the end of treatment. There were significant reductions in all the scales with comparable declines in the subgroups formed according to the presence or absence of agoraphobic avoidance and demoralization. The data suggested that moderate doses of alprazolam could be a quick and effective treatment for panic-agoraphobic patients in the short term. The behavioral guidance probably helped in reducing agoraphobic avoidance and in obtaining global good effectiveness although this awaits controlled tests. Finally, the similarity in the response to treatment regardless of the presence of extensive avoidance or demoralized mood argues in favor of not considering the different variants of panic-agoraphobic syndrome differently, at least in samples with similar severity to the present one.     

Body checking and avoidance among behavioral weight-loss participants

The present study examined the psychological and weight-related correlates of body checking and avoidance behaviors in individuals who have lost weight through obesity treatment. Among 185 individuals in behavioral weight-control treatment, the prevalence of body checking and avoidance behavior was assessed, as well as the relationship of checking and avoidance to attitudinal disturbances, weight loss, and perception of struggling in treatment. Checking and avoidance were frequent, and they correlated significantly with higher overvaluation of shape and weight, lower self-esteem, greater body dissatisfaction, higher fear of fat, and the perception of greater struggling in weight-loss treatment. Checking was inversely correlated with the percentage weight lost in treatment and BMI lost but not related to pre-treatment or current BMI. Thus, body checking and avoidance behaviors were associated with psychological disturbances and poorer treatment outcome.     

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.     

Anticipatory anxiety and avoidance in panic disorder with agoraphobia

The present study utilized the responses of 34 patients with panic disorder with agoraphobia to investigate the occurrence and anticipation of panic attacks in relation to the avoidance of specific situations from the Fear Questionnaire [Marks & Mathews (1979) Behaviour Research and Therapy, 17, 263-267]. Results indicated that self-reports of avoidance of specific situations were often significantly correlated with the anticipation of panic but rarely with the occurrence of panic. The occurrence and anticipation of panic were also frequently associated with social phobic situations in addition to agoraphobic situations.     

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.     

Sequential evaluation of behavioral treatments and methylphenidate dosage for children with attention deficit hyperactivity disorder

We used a sequential approach to evaluate the relative and combined effects of different types of behavioral treatments, as well as dosage of methylphenidate (MPH), on the disruptive behavior of 3 students who had been diagnosed with attention deficit hyperactivity disorder. Results showed that individualized behavioral treatments produced decreases in disruptive behavior equivalent to MPH for all 3 participants and demonstrated the need to evaluate behavioral treatments and medication dosage on an individual basis.     

Myopic regret avoidance: Feedback avoidance and learning in repeated decision making

Decision makers can become trapped by myopic regret avoidance in which rejecting feedback to avoid short-term outcome regret (regret associated with counterfactual outcome comparisons) leads to reduced learning and greater long-term regret over continuing poor decisions. In a series of laboratory experiments involving repeated choices among uncertain monetary prospects, participants primed with outcome regret tended to decline feedback, learned the task slowly or not at all, and performed poorly. This pattern was reversed when decision makers were primed with self-blame regret (regret over an unjustified decision). Further, in a final experiment in which task learning was unnecessary, feedback was more often rejected in the self-blame regret condition than in the outcome regret condition. We discuss the findings in terms of a distinction between two regret components, one associated with outcome evaluation, the other with the justifiability of the decision process used in making the choice.     

Matching in concurrent variable-interval avoidance schedules

After pretraining with multiple variable-interval avoidance schedules, two rats were exposed to a series of concurrent variable-interval avoidance schedules. Responses on two levers cancelled delivery of electric shocks arranged according to two independent variable-interval schedules. The ratio of responses and time spent on the two levers approximately matched the ratio of shocks avoided on each. Matching to the number of shocks received was not obtained. Concurrent variable-interval avoidance can therefore be added to the group of positive and negative reinforcement schedules that can be expressed in the quantitative framework of the matching law.     

On the use of fluency training in the behavioral treatment of autism: a commentary

The substantial demand for behavior-analytic treatment of early childhood autism has been associated with rapid dissemination of treatment procedures to practitioners and caregivers. This level of demand could plausibly induce premature dissemination of treatments that do not yet have sufficient empirical support. We argue that this might have happened with the use of fluency training for learners with autism and identify four areas of research that are necessary to ensure that dissemination efforts are better matched to the available empirical support for this instructional strategy.     

Utilization and predicted trends of behavioral inventories

Published articles (N=1703) during the period 1975 to 1982 in three behavioral journals (Behavior Therapy, Journal of Behavior Therapy and Experimental Psychiatry, andJournal of Applied Behavior Analysis) were reviewed for the utilization of preintervention and categories of behavioral inventories. Results revealed that (a) the three forms of the Fear Survey Schedule (FSS) and the Social Avoidance and Distress Scale (SADS) were the most utilized traditional behavioral measures, (b) new self-developed inventories were reported with significantly (p<.05) different frequencies across the three journals, (c) numerous published inventories beyond the traditional FSS and SADS were reported, and (d) an expanded use of IQ measures in preintervention behavioral assessment was also found. Trends regarding the nature of behavioral inventories among the three journals and a discussion on advances in behavioral assessments are presented.     

A longitudinal analysis of self-regulation and well-being: avoidance personal goals, avoidance coping, stress generation, and subjective well-being

We conducted 2 longitudinal meditational studies to test an integrative model of goals, stress and coping, and well-being. Study 1 documented avoidance personal goals as an antecedent of life stressors and life stressors as a partial mediator of the relation between avoidance goals and longitudinal change in subjective well-being (SWB). Study 2 fully replicated Study 1 and likewise validated avoidance goals as an antecedent of avoidance coping and avoidance coping as a partial mediator of the relation between avoidance goals and longitudinal change in SWB. It also showed that avoidance coping partially mediates the link between avoidance goals and life stressors and validated a sequential meditational model involving both avoidance coping and life stressors. The aforementioned results held when controlling for social desirability, basic traits, and general motivational dispositions. The findings are discussed with regard to the integration of various strands of research on self-regulation.     

Antidepressant discontinuation in the context of cognitive behavioral treatment for panic disorder.

Cognitive behavioral treatment (CBT) has been shown to reduce risk for adverse reactions (e.g., rebound panic) following benzodiazepine taper for patients with panic disorder (PD). This study evaluated the effects of antidepressant discontinuation for patients with PD in the context of CBT. Patients with PD (n=21) on a stable dose of antidepressants completed a 12-week group CBT treatment and were randomly assigned to discontinue antidepressants during week 8 of the treatment. There were no statistically significant differences between groups at posttreatment or 6-month follow-up. Data indicate no apparent immediate or long-term adverse effects for antidepressant discontinuation for patients with PD receiving CBT.     

The evolutionary significance of habituation and sensitization across phylogeny: A behavioral homeostasis model

The phenomenon of habituation may be interpreted as a process that has evolved for filtering out iterative stimuli of little present relevance. That habituation is seen in aneural as well as neural organisms throughout phylogeny with remarkably similar characteristics suggests that its role is an important one in animal survival. If habituation is to be viewed as a process to filter out iterative stimuli that have no significant consequences, then how is sensitization to be viewed? One way of viewing these two behavioral changes, i.e. habituation and sensitization, is that they are homeostatic processes which optimize an organism’s likelihood of detecting and assessing the significance of a stimulus in a new iterative series or a change in it. If one views the level of initial responsiveness to a new stimulus as a function of an organism’s threshold just prior to stimulus occurrence, then “high responders” (i.e. those who initially react more strongly) are assumed to have a lower threshold for detecting and assessing the significance of this stimulus than are the “low responders” (i.e. those who initially react more weakly). Thus, high-responders would initially receive more sensory input and progressively decrease their responsiveness to a non-threatening stimulus (habituation). Likewise, initial low-responders would receive less sensory input followed by a decreased threshold and an increased response to the next stimulus occurrence (sensitization). The level of responsiveness achieved in both habituaters and sensitizers, as an asymptote is approached, is a balance between being too sensitive to an unimportant stimulus (and possibly missing other significant stimuli) and being too insensitive, and missing a change in the relevance of the present stimulus. These response changes can be taken as indices of the organism’s mechanisms for achieving an appropriate threshold level to an iterative stimulus in order to accurately assess its present significance and then eventually to asymptote at an optimal stable response level. This approach toward an asymptote is a behavioral homeostatic process that reflects the accumulated significance of the iterative stimulus at each occurrence. The purpose of adding “behavioral” to the term “homeostasis” is to extend the usual meaning of the concept from primarily internal processes to also include (a) iterative external stimulation, (b) the organism’s initial threshold to the initial stimulus as well as (c) the behavior which results from it. Since we are discussing organisms that range from intact, single-celled protozoa to intact mammals, as well as surgically simplified preparations, the termsstimulus, response andbehavior will be used broadly. While other investigators have focused on specific cellular mechanisms underlying habituation and sensitization in a given organism, this paper focuses on the adaptive significance of these two behavioral processes viewed across phylogeny.