Conceptual,methodological, and clinical issues in the assessment of anxiety disorders

Many conceptual, methodological, and clinical issues remain unresolved in the assessment of anxiety disorders. Despite the prevalence, incidence, chronicity, and severity of anxiety disorders, research efforts and funding have fallen behind with regard both to other disorders and to addressing critical issues in the field. The primary objective of this paper is to provide a scientific critique regarding a number of often ignored yet salient considerations in anxiety-disorders assessment. Critical analyses of and recommendations regarding the multidimensional nature of anxiety, comorbidity, uniformity myths, synchrony, normative comparisons, psychometric properties of measures, and treatment integrity are offered. Finally, promising areas of clinical research are presented to enhance further the current understanding of the complexities inherent in assessing anxiety disorders.Preparation of this paper was supported in part by NIMH Grant MH36299.     

Panic disorder: cognitive-behavioral treatment

The effectiveness of an integrated treatment program utilizing cognitive-behavioral therapies for Panic Disorder was examined. Treatment was comprised of Cognitive Model of Panic-derived procedures, Cognitive Therapy and Applied Relaxation Training. Subjects meeting DSM-III-R criteria for Panic Disorder received thirteen 2.5-hr sessions of outpatient therapy in small groups, over a 12-week period. Subjects were given an extensive rationale of the etiology, development and maintenance of Panic Disorder, within the framework of the Cognitive Model of Panic, and controlled behavioral experiments in panic evocation to internal panicogenic cues, cognitive reappraisal of somatic and ideational cues, breathing retraining, Applied Relaxation Training and Cognitive Therapy to identify and remediate maladaptive beliefs and dysfunctional cognitive schemas. A comprehensive assessment battery was given at pre-mid-post-treatment which included measures of tripartite functioning, global severity, panic, fear, anxiety, depression and psychiatric symptomatology. Analyses indicated statistically significant improvements across all outcome domains. All subjects were free of spontaneous (uncued) panic attacks at post-treatment, and all met operationalized criteria for high endstate functioning. These findings are discussed, with recommendations for future research.     

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.     

Behavioral assessment of imipramine effects in a depressed child

A 7-year-old boy was diagnosed as suffering from childhood depression by two independent psychiatric evaluators who employed the Research Diagnostic Criteria. Multifaceted behavioral observations were performed on target behaviors which were identified as major problematic areas of functioning related to the child's depression. The behavioral assessment strategy included daily monitoring of on-task and disruptive behavior in the classroom, enuresis, and overall hygienic, social, and compliance behaviors as a means of identifying the specific drug-induced effects of an anti-depressant, imipramine. The assimilation and application of behavioral assessment strategies within child psychiatry have been slow and tenuous. Reasons for the resistance include theoretical differences and misconceptions among psychiatric personnel, who, although open to objective evaluations, may wish to employ nonbehavioral treatments such as pharmacologic agents. The primary purpose of this study was to demonstrate the viability of behavioral assessment as an integral adjunct to pharmacologic treatment in a psychiatric setting as a means of gauging the efficacy of a psychiatric intervention. Issues regarding the role of behavioral assessment in psychiatry and, in particular, pharmacologic interventions with depressed children are examined and discussed.This study was supported, in part, by NIMH Grant MH 30915.     

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.     

Patterns of psychophysiological change in the treatment of agoraphobia

Patterns of change and synchrony were studied in a group of 26 agoraphobics under-going a 12-week treatment program. Clinical, behavioral, physiological and subjective measures were taken at pre-, 4, 8 and 12 weeks of treatment and at 1-month follow-up.Clinically and statistically significant changes were found in all response systems and our results tentatively suggest that the order of change starts with behavioral and clinical measures followed by psychophysiological measures of which psysiological responsivity has the longest lag.Although the group as a whole changed synchronously, there was evidence of individual desynchrony between physiological and subjective measures of anxiety. The most common form this look was for SUDS to decline while heart rate increased. A closer look at desynchrony in the various time sequences revealed that both the form and occurrence of desynchrony vary according to phase of treatment and that time interval between assessment points might-be of crucial importance in the determination of synchrony-desynchrony.     

How Does Homelessness Affect Parenting Behaviour? A Systematic Critical Review and Thematic Synthesis of Qualitative Research

The adverse social and physical conditions of homelessness pose significant developmental risks for children, which may be compounded or buffered by the quality of parenting behaviour they are exposed to. There is currently a limited understanding of how parents approach their care-giving role and responsibilities while adjusting to the experience of homelessness. Advancing knowledge in this area is essential for developing acceptable, appropriate and effective interventions to support highly marginalised and vulnerable homeless families. This review explored homeless parents’ perceptions of how homelessness affects their parenting behaviour and identified adaptive strategies that parents may use to mitigate the potentially negative impacts of homelessness on the quality of care-giving. A systematic search of four electronic databases (ASSIA, PsycINFO, Web of Science and MEDLINE) identified 13 published qualitative studies, all originating from the USA, which explored parenting behaviour in homeless contexts. The studies were critically appraised using the CASP qualitative assessment tool. Thematic synthesis identified the following determinants of parenting behaviour; negative self-concept in the parental role, parental mental health, material resources, challenges to autonomy and self-efficacy, daily hassles, physical environment and service context, stigma, child characteristics and lack of support. These were synthesised thematically using existing models of parenting determinants and positive parenting. Findings indicate substantive impacts of homelessness on parental mental health, parenting authority, material resources, parenting environments and social support. Parents developed a number of adaptive methods to negotiate the challenges of homeless parenting such as maintaining a positive mindset, cherishing the parental role and developing practical strategies. We conclude with recommendations that service providers should tailor parenting support to resource-constrained circumstances and that further research is required in order to better understand experiences of homeless parents in other international contexts.     

Gender,Masculinity Threat,and Support for Transgender Rights: An Experimental Study

Sex Roles - We explore how gender, attitudes about traditional gender roles, and threats to masculinity and femininity affect U.S. participants’ support for transgender rights. First, we...