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.     

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.     

Self-discrepancies in clinical depression and social phobia: cognitive structures that underlie emotional disorders?

Previous research indicates that self-discrepancies are cognitive structures that can induce emotional discomfort. The present study compared clinically depressed and social phobic subjects (plus controls) to determine whether different self-discrepancies were associated with the two disorders. In Part 1, it was shown that the depressives possessed the greatest discrepancy between their actual and ideal/own self-states, whereas the social phobics possessed the greatest discrepancy between their actual and ought/other self-states. In a later, ostensibly unrelated study, subjects responded verbally to questions about other people while their mood changes, skin conductance responses, and verbalizations were recorded. The questions included attributes from the subject's ideal and ought self-states that were mismatches with attributes from his or her actual self, as well as mismatch attributes from other subjects. Priming with self-referential mismatches induced momentary syndromes of dejection or agitation (depending on the type of mismatch). The depressives and social phobics showed the greatest increases in dejection and agitation, respectively, according to their dominant self-discrepancy. The results suggest that specific cognitive structures may underlie clinical depression and anxiety.     

Public and private heart rate feedback in social phobia: a manipulation of anxiety visibility

According to cognitive behavioural models of social phobia, bodily symptoms are the main source of information concerning social evaluation for social phobics. Experience and perception of bodily symptoms therefore play an important role in social anxiety. In this study we evaluated the effects of anxiety visibility on patients and controls using feedback of veridical heart sounds. A total of 32 social phobics and 32 controls were asked twice to sit in a chair and appear relaxed while being evaluated. Half of the participants heard their heart sounds first via headphones and then via loudspeakers which were also audible to observers. The presentation order of the heart sound was reversed for the other half of the subjects. Social phobics reported substantially more anxiety than controls. Both groups showed habituation in heart rate from the first to the second presentation, and both groups reported perception of a higher heart rate, but only social phobics reported significantly more anxiety and were more worried about their heart rates in the public than in the private condition. These effects were in excess of actual heart rate differences. In conclusion, social phobics worried about the broadcast of a bodily anxiety symptom, whereas controls did not. Information about arousal made public has a strong potential to increase anxiety levels in social phobics.     

Public and private heart rate feedback in social phobia: a manipulation of anxiety visibility

According to cognitive behavioural models of social phobia, bodily symptoms are the main source of information concerning social evaluation for social phobics. Experience and perception of bodily symptoms therefore play an important role in social anxiety. In this study we evaluated the effects of anxiety visibility on patients and controls using feedback of veridical heart sounds. A total of 32 social phobics and 32 controls were asked twice to sit in a chair and appear relaxed while being evaluated. Half of the participants heard their heart sounds first via headphones and then via loudspeakers which were also audible to observers. The presentation order of the heart sound was reversed for the other half of the subjects. Social phobics reported substantially more anxiety than controls. Both groups showed habituation in heart rate from the first to the second presentation, and both groups reported perception of a higher heart rate, but only social phobics reported significantly more anxiety and were more worried about their heart rates in the public than in the private condition. These effects were in excess of actual heart rate differences. In conclusion, social phobics worried about the broadcast of a bodily anxiety symptom, whereas controls did not. Information about arousal made public has a strong potential to increase anxiety levels in social phobics.     

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.     

Social phobia: a comparison of specific and generalized subtypes and avoidant personality disorder.

The validity of the social phobia subtype distinction was examined in a large sample of carefully diagnosed social phobics (N = 89). Generalized and specific subtypes were diagnosed reliably, and the generalized subtype showed a consistent pattern of greater symptom severity than did the specific subtype. In addition, generalized social phobics with and without avoidant personality disorder were compared, and a difference was found for only 1 of 4 parameters. The results are discussed in terms of the validity of subtyping in social phobia and the diagnostic boundary between social phobia and avoidant personality disorder.     

Acquisition of blood and injection phobia and anxiety response patterns in clinical patients.

The ways in which blood phobics (N = 81) and injection phobics (N = 56) had acquired their phobias were retrospectively investigated. The patients were required to answer a questionnaire concerning: (a) the origin of the phobia, with items relevant for conditioning experiences, vicarious experiences and experiences of negative information/instruction; (b) physiological reactions; (c) anticipatory anxiety; and (d) negative thoughts while in the phobic situation. In addition background data on marital and occupational status, family history of phobia, fainting history, and severity of the phobia were obtained. Furthermore, the patients' behavioral, physiological, and cognitive-subjective reactions during the behavioral test were assessed. The results showed that a majority (52%) of the patients attributed the onset of their phobias to conditioning experiences, while 24% recalled vicarious experiences, 7% instruction/information and 17% could not remember any specific onset circumstances. There was no significant relationship between ways of acquisition and anxiety components, nor did conditioning and indirectly acquired phobias differ in severity.     

Probability ratings in claustrophobic patients and normal controls

Forty-nine DSM-IV diagnosed claustrophobics and 49 sex- and age-matched community controls, without any current or past psychiatric disorder, were asked to estimate the probability that three types if events would occur if they were in the described situations. The events were claustrophobic, generally negative, and positive in nature. The results showed that claustrophobics significantly overestimated the probability of events they specifically feared, i.e. the claustrophobic events, while there was no difference between the groups regarding generally negative events and positive events. This finding remained when the higher scores for claustrophobics on the Claustrophobia scale and the Anxiety Sensitivity Index were covaried out. The conclusion that can be drawn is that claustrophobics' probability ratings are characterized by distortions that are specifically connected to anxiety-arousing events and not negative events in general. The hypothesis is proposed that this may be explained by an exaggerated use of simplified rules-of-thumb for probability estimations that build on availability in memory, simulation, and representativity.     

Social phobia: individual response patterns and the effects of behavioral and cognitive interventions

In the present study, the role of individual response patterns in the treatment of social phobic patients was investigated. Seventy-four patients were diagnosed as social phobics. On the basis of extreme scores on a behavioral test (the Simulated Social Interaction Test) and on a cognitive measure (the Rational Behavior Inventory), the response patterns of 39 patients were analyzed, and the patients themselves were classified as either 'behavioral reactors' or 'cognitive reactors'. Half of the patients with each response pattern received a behavioral focused treatment, i.e. social skills training (SST), while the other half received a cognitive oriented treatment, i.e. rational emotive therapy (RET). Patients received group therapy in eight weekly sessions. Within-group differences showed a considerable improvement in all treatment groups. Between-group differences failed to lend support to the hypothesis that treatment that fits a response pattern (i.e. SST for behavioral reactors and RET for cognitive reactors) will result in a greater improvement than one that does not.     

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.     

Covariation detection in treated and untreated spider phobics.

Twenty treated and 18 untreated spider phobics were exposed to a series of 72 slides. Three different categories of slides were used: phobia-relevant slides (spiders), alternative fear-relevant slides (weapons), and neutral slides (flowers). Slides were randomly paired with either a shock, a tone, or nothing at all. Despite the absence of a systematic correlation between slides and outcomes, untreated phobics strongly overestimated the covariation between spider slides and shock. Treated phobics did not show a covariation bias, suggesting that such bias can be modulated by behavioral treatment. In addition, untreated subjects were more confident about their contingency estimates than were treated subjects. The present results fit with earlier studies.     

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.     

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.     

Event-related potentials to schematic faces in social phobia

Social phobia has been associated with an attentional bias for angry faces. This study aimed at further characterising this attentional bias by investigating reaction times, heart rates, and ERPs while social phobics, spider phobics, and controls identified either the colour or the emotional quality of angry, happy, or neutral schematic faces. The emotional expression of angry faces did not interfere with the processing of their colour in social phobics, and heart rate, N170 amplitude and parietal late positive potentials (LPPs) of these subjects were also no different from those of non-phobic subjects. However, social phobics showed generally larger P1 amplitudes than non-phobic controls with spider phobic subjects in between. No general threat advantage for angry faces was found. All groups identified neutral schematic faces faster and showed larger late positive amplitudes to neutral than to emotional faces. Furthermore, in all groups the N170 was modulated by the emotional quality of faces. This effect was most pronounced in the emotion identification task.     

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.     

The Impact of Anxiety on Memory for Details in Spider Phobics

According to the attentional narrowing account of emotional memory, physiological arousal results in attention being directed towards central rather than peripheral characteristics of the situation. Consequently, memory for central details would be relatively good, whereas memory for peripheral information would be impaired. The present experiment sought to test this attentional narrowing hypothesis under highly stressful conditions. Spider phobics and low-fear controls were confronted with a large live spider, eliciting high levels of emotion in the phobic group. Afterwards, subjects' memory for the experimental situation was tested. On a cued recall test, phobics displayed a poor memory for peripheral detail information relative to control subjects. There were no differences between phobics and controls with respect to central detail information. Thus, the present data provide partial support for the attentional narrowing account of emotional memory. © 1997 by John Wiley & Sons, Ltd.     

Covariation bias,classical conditioning,and phobic fear

The present study investigated whether phobics show an illusory correlation (IC) between phobia-relevant stimuli and aversive events. Nineteen treated and 19 untreated spider phobics were exposed to a series of 72 slides. Three different categories were used: Phobia-relevant slides (spiders), alternative fear-relevant slides (weapons), and neutral slides (flowers). Slides were randomly paired with either a shock, a siren, or nothing at all. All slide/outcome combinations occurred equally frequently. A posteriori recorded contingency estimates indicated that untreated phobics dramatically overestimate the covariation of spiders and shock. On-line recorded outcome expectancies revealed that the bias to overestimate the spider-shock contingency is highly resistant to extinction. The covariation bias was accompanied by differentially heightened electrodermal first interval responses (FIR) and unconditioned electrodermal responses (third interval responses: TIR) on phobia-relevant trials. Treated phobics did not show a covariation bias, indicating that such bias can be modulated by behavioral treatment. The present findings sustain the hypothesis that phobic subjects process information in a fear-confirming way.     

The Social Phobia and Anxiety Inventory: concurrent validity with a clinic sample

The Social Phobia and Anxiety Inventory (SPAI) is an empirically derived self-report inventory developed as a specific measure of social phobia. The current investigation included two studies. The first examined the correlation of the SPAI with daily social behavior of a clinic sample of social phobics. The results indicated that the SPAI provides a reasonable indication of the distress experienced during daily social encounters in three dimensions: behavior, cognitions, and overall distress. The second study examined the validity of the SPAI with reference to the somatic response and avoidance behavior of social phobics. The results indicated that the somatic items of the SPAI are related to the somatic response of social phobics and that performance on the SPAI is associated with avoidance behavior in an anxiety-producing task.     

Psychophysiological and subjective reactions of social phobics and normals to facial stimuli

Nine social phobics and 9 normal control subjects were exposed to slides of angry faces, happy faces, and neutral objects (i.e. flowers or mushrooms). Skin conductance responses (SCRs) to the stimuli and eyeblink rate (EBR) during stimulus exposure were recorded. In addition, subjects were asked to rate the stimuli in terms of pleasantness. While angry face stimuli elicited greater SCRs, stronger inhibition of EBR, and were evaluated more negatively than the other stimuli, there were no differences between social phobics and normals in these respects. Thus, the findings lend no support to the idea that social phobics are particularly sensitive to facial cues in general or to negative facial cues in particular.