RESUMEN
BACKGROUND AND OBJECTIVES: The current study examined how effectiveness of exposure-based CBT was related to indices of emotional processing and inhibitory learning during exposure exercises. METHODS: Adolescents with anxiety disorder(s) (N = 72; age 11-19; 85% girls) received a group-based, intensive two-week treatment of which effectiveness was indexed by the SCARED and by ratings of anxiety and approach towards individualized goal situations. To index emotional processing, subjective units of distress (SUDs) were used to indicate both initial and final fear level, and absolute, relative, and total dose of fear reduction. To index inhibitory learning, subjective threat expectancies (STEs) were used to indicate initial and final threat expectancy, and absolute, relative, and total dose of expectancy change. RESULTS: From pre-treatment to follow-up, there was a large-sized reduction of anxiety symptoms, small-sized decrease of subjective anxiety and a large-sized increase in subjective approach towards individual treatment goals. Higher fear levels prior to exposure were related to a larger decrease of symptoms. Higher threat expectancies after exposure exercises were independently associated with less decrease of anxiety and increase of approach towards treatment goals. Total dose of experienced fear reduction and total dose of experienced expectancy change were (partly) independently related to more increase in approach towards individualized goal situations. LIMITATIONS: As patients also received other treatment elements, the results cannot be interpreted unequivocally. CONCLUSIONS: The pattern of findings seems to indicate that emotional processing (as indexed by fear reduction) and inhibitory learning (as indexed by expectancy change) are both relevant in exposure-based CBT.
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Trastornos de Ansiedad , Emociones , Femenino , Adolescente , Humanos , Niño , Adulto Joven , Adulto , Masculino , Trastornos de Ansiedad/terapia , Trastornos de Ansiedad/psicología , Miedo/psicología , Ansiedad/psicología , AprendizajeRESUMEN
INTRODUCTION: Exposure is often limited to homework assignments in routine clinical care. The current study compares minimally-guided (MGE) and parent-guided (PGE) out-session homework formats to the 'golden standard' of therapist-guided in-session exposure with minimally-guided exposure at home (TGE). METHODS: Children with specific phobia (N = 55, age 8-12, 56% girls) participated in a single-blind, randomized controlled microtrial with a four-week baseline-treatment period design. Clinical interviews, behavioral avoidance tests, and self-report measures were assessed at pre-treatment, post-treatment, and at one-month follow-up. RESULTS: TGE resulted in a larger decline of specific phobia severity from baseline to post-treatment compared to MGE but not compared to PGE. Parental anxiety was found to be a moderator of less treatment efficacy of PGE from baseline to post-treatment. Overall, there was no meaningful difference in efficacy of TGE versus MGE or PGE from baseline to follow-up. CONCLUSIONS: These findings suggest that for improving short-term treatment gains, exposure exercises can best be conducted with the help of a therapist within the therapy session before they are conducted as homework assignments outside the therapy session. However, for long-term treatment gains exposure exercises can be handled by the child itself or with help of its parents.
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Terapia Cognitivo-Conductual , Trastornos Fóbicos , Niño , Femenino , Humanos , Masculino , Terapia Cognitivo-Conductual/métodos , Padres , Trastornos Fóbicos/terapia , Método Simple Ciego , Resultado del TratamientoRESUMEN
INTRODUCTION: Exposure may be especially effective when within exercises, there is a strong violation of threat expectancies and much opportunity for fear reduction. Outcomes of exposure may therefore improve when exposure is conducted in large steps (LargeSE) relative to small steps (SmallSE). METHODS: Children and young people with a specific phobia (SP) (N = 50, age 8-17, 64 % girls) participated in a preregistered single-blind, randomized controlled microtrial comparing LargeSE and SmallSE in a four-week baseline-treatment design. Clinical interviews, behavioral avoidance tests, and self-report measures were assessed at pre-treatment, post-treatment, and at one-month follow-up. RESULTS: Within exercises, LargeSE resulted in higher initial fear levels and more within-session expectancy violation. Nevertheless, SmallSE resulted in a larger decline of SP severity from baseline to post-treatment and follow-up, and a larger decline of anxiety and avoidance towards one's individual goal from baseline to follow-up. There were no differences between LargeSE and SmallSE regarding changes in general self-efficacy or behavioral avoidance. Although session duration was standardized and similar for both conditions, participants in SmallSE received more (shorter) exercises. DISCUSSION: SmallSE might be more effective in reducing SP severity because children in SmallSE were exposed to a larger number and variety of exercises than children in LargeSE.
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Trastornos Fóbicos , Adolescente , Niño , Femenino , Humanos , Masculino , Miedo , Trastornos Fóbicos/tratamiento farmacológico , Método Simple Ciego , Resultado del TratamientoRESUMEN
CBT for anxious youth usually combines anxiety management strategies (AMS) with exposure, with exposure assumed to be critical for treatment success. To limit therapy time while retaining effectiveness, one might optimize CBT by restricting treatment to necessary components. This study tested whether devoting all sessions to exposure is more effective in reducing speech anxiety in youth than devoting half to AMS including cognitive or relaxation strategies and half to exposure. After a 6-week waitlist period, adolescents with speech anxiety (Nâ¯=â¯65; age 12-15; 42 girls) were randomized to a 5-session in-school group-based CBT training consisting of either (1) exposure-only (EXP+EXP) or (2) cognitive strategies followed by exposure (COG+EXP) or (3) relaxation strategies followed by exposure (REL+EXP). Clinical interviews, speech tests, and self-report measures were assessed at pretest, posttest, and follow-up. For all conditions (a) the intervention period resulted in a stronger decline of speech anxiety than waitlist period; (b) there was a large sized reduction of speech anxiety that was maintained at six-week follow-up; (c) there was no meaningful difference in the efficacy of EXP+EXP versus COG+EXP or REL+EXP. These findings suggest that devoting all sessions to exposure is not more effective than combining exposure with AMS. AMS appeared neither necessary for CBT to be effective, nor necessary for youth to tolerate exposure. This indicates that CBT can be optimized by restricting treatment to exposure.
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Terapia Cognitivo-Conductual , Habla , Adolescente , Ansiedad/terapia , Trastornos de Ansiedad , Niño , Femenino , Humanos , Resultado del TratamientoRESUMEN
INTRODUCTION: Although there is consensus that exposure is the key ingredient in treating childhood anxiety disorders, several studies in the USA suggest exposure to be underused in clinical practice. Previous research pointed to therapists' beliefs about exposure, their age, experience, caseload, training and theoretical orientation, as well as the level of the therapists' own anxiety as important factors in the underusage of exposure in the treatment of adult anxiety disorders. This study examined what therapist characteristics may be involved in the (non-)use of exposure in treating childhood anxiety disorders. METHODS: An internet-based survey among 207 youth mental health care professionals in the Netherlands and Belgium was conducted to assess therapists' beliefs about exposure, their age, experience, caseload, training and theoretical orientation, as well as the level of the therapists' own anxiety, depression and stress. RESULTS: The current survey showed that therapists used exposure in about half of their cases of childhood anxiety and that the non-use was independently associated with the relatively strong negative beliefs about exposure, therapists' age, and non-CBT orientation. DISCUSSION: Findings point to the importance of addressing negative beliefs about exposure in therapists' training and supervision to resolve therapy drift away from exposure, and consequently improve utilization and delivery of exposure-based therapy for childhood anxiety disorders.
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Trastornos de Ansiedad/terapia , Actitud del Personal de Salud , Encuestas de Atención de la Salud , Personal de Salud/psicología , Terapia Implosiva , Salud Mental , Adulto , Anciano , Ansiedad/terapia , Femenino , Humanos , Internet , Masculino , Persona de Mediana Edad , Países Bajos , Adulto JovenRESUMEN
BACKGROUND AND OBJECTIVES: Emotional reasoning has been described as a dysfunctional tendency to use subjective responses to make erroneous inferences about threatening outcomes in objectively safe situations (e.g., "If I feel anxious/disgusted, there must be danger/risk of becoming ill"). Prior studies found evidence for anxiety-based emotional reasoning (ER) in several anxiety disorders as well as disgust-based ER in healthy individuals scoring above the clinical cut-off on a measure of contamination fear. The current study tested whether disgust- and anxiety-based ER might be involved in fear of vomiting, a phobic disorder in which both fear/anxiety and disgust are assumed to play an important role. METHODS: Non-clinical participants scoring high (>75%; n = 35) and low (<25%; n = 38) on a measure of fear of vomiting were presented with a series of scripts describing objectively safe everyday situations that systematically varied in the absence/presence of the actor's disgust/anxiety response. Following each script, participants rated their perceived danger and threat of contamination/illness. RESULTS: In line with hypotheses, specifically high vomit-fearful individuals used experienced disgust and anxiety to overestimate risk of becoming ill. Follow up analyses taking into account shared variance between both emotions revealed that more pronounced ER in the high vomit fearful group was mainly driven by the emotion of disgust. LIMITATIONS: Current study asked participants to imagine experienced emotions in scenarios instead of experimentally inducing real-life emotions. CONCLUSIONS: These findings are consistent with the view that disgust-based ER is involved in fear of vomiting.
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Ansiedad/fisiopatología , Emociones/fisiología , Trastornos Fóbicos/fisiopatología , Pensamiento/fisiología , Vómitos/psicología , Adulto , Femenino , Humanos , Masculino , Adulto JovenRESUMEN
BACKGROUND: Existing literature on panic disorder (PD) yields no data regarding the differential rates of improvement during Cognitive Behavioral Therapy (CBT), Selective Serotonin Reuptake Inhibitor (SSRI) or both combined (CBT+SSRI). METHOD: Patients were randomized to CBT, SSRI or CBT+SSRI which each lasted one year including three months of medication taper. Participating patients kept record of the frequency of panic attacks throughout the full year of treatment. Rate of improvement on panic frequency and the relationship between rate of improvement and baseline agoraphobia (AG) were examined. RESULTS: A significant decline in frequency of panic attacks was observed for each treatment modality. SSRI and CBT+SSRI were associated with a significant faster rate of improvement as compared to CBT. Gains were maintained after tapering medication. For patients with moderate or severe AG, CBT+SSRI was associated with a more rapid improvement on panic frequency as compared to patients receiving either mono-treatment. LIMITATIONS: Frequency of panic attacks was not assessed beyond the full year of treatment. Second, only one process variable was used. CONCLUSIONS: Patients with PD respond well to each treatment as indicated by a significant decline in panic attacks. CBT is associated with a slower rate of improvement as compared to SSRI and CBT+SSRI. Discontinuation of SSRI treatment does not result in a revival of frequency of panic attacks. Our data suggest that for patients without or with only mild AG, SSRI-only will suffice. For patients with moderate or severe AG, the combined CBT+SSRI treatment is recommended.
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Agorafobia/terapia , Terapia Cognitivo-Conductual , Trastorno de Pánico/terapia , Inhibidores Selectivos de la Recaptación de Serotonina/uso terapéutico , Adulto , Anciano , Agorafobia/complicaciones , Agorafobia/psicología , Terapia Combinada , Femenino , Humanos , Masculino , Persona de Mediana Edad , Trastorno de Pánico/complicaciones , Trastorno de Pánico/psicología , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Adulto JovenRESUMEN
Patients suffering from anxiety disorders have been shown to infer danger on the basis of their anxiety responses "if I feel anxious, there must be danger." This tendency logically hampers the identification of false alarms and may thus act in a way to confirm the a priori threat value of the feared stimuli/situations. Since disgust is assumed to play a critical role in the persistence of contamination fears in OCD, the question rises whether individuals suffering from fear of contamination perhaps similarly infer danger on the basis of their disgust response: "If I feel disgusted, it must be contagious." Therefore, this study tested whether indeed disgust-based reasoning might be involved in fear of contamination. On the basis of the contamination fear subscale of the Padua Inventory (PI), we selected a group of participants scoring higher than the established clinical range (n=31, PI>13) and a group of participants low (n=27, PI<5) in contamination fear. Each participant was presented with a series of 2 times 4 types of scripts that systematically varied in the absence/presence of objective threat of contamination and the absence/presence of the actor's disgust response. Following each script, participants rated their perceived threat of contamination/illness. In line with the hypothesis that disgust-based reasoning might be involved in fear of contamination, specifically high contamination fearful individuals inferred risk of becoming ill on the basis of experienced disgust (in addition to objective threat), as was evidenced by a significant Group (high vs. low)×Threat (yes vs. no)×Disgust response (yes vs. no) interaction. This finding might not only help to explain the persistence of contamination fears, but also provides some fresh clues to improve currently available treatment options.
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Emociones , Trastornos Fóbicos/psicología , Adulto , Miedo/psicología , Femenino , Humanos , Masculino , Riesgo , Encuestas y Cuestionarios , Adulto JovenRESUMEN
UNLABELLED: Specific phobia of vomiting (also known as emetophobia) is a relatively understudied phobia with respect to its aetiology, clinical features and treatment. In this stage, research is mostly based on people with self-reported fear of vomiting. This paper presents a survey on the clinical features of fear of vomiting of individuals. Self-reported vomit-fearful subjects from the Dutch community and from an Internet support group are included. Both vomit-fearful groups were characterized by high reports of fear, the presence of panic symptoms, and by extensive avoidance and safety behaviours. They also reported other psychiatric complaints, which were measured with a structured screening instrument. Vomiting complaints started mostly in late puberty. A significant proportion of the vomit-fearful participants had a treatment history. The prevalence rate of fear of vomiting in the community sample was established at 8.8% (female : male ratio = 4:1). Overall, results show that fear of vomiting is a common phenomenon, which can seriously impair daily functioning. Finally, clinical questions to be addressed in future research are formulated. KEY PRACTITIONER MESSAGE: Specific phobia of vomiting (also known as emetophobia) is among the least studied phobias. Most clinical data come from research with self-described fear of vomiting. This paper presents data on the clinical features, prevalence and additional psychiatric complaints of fear of vomiting in two vomit-fearful samples and one control sample with no fear of vomiting. Estimates of prevalence of fear of vomiting in a Dutch community sample were established at 1.8% for men and 7% for women. Evidence suggests that fear of vomiting is a chronic and disabling condition that may cause significant impairment in daily functioning.
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Trastornos Fóbicos/epidemiología , Vómitos , Edad de Inicio , Comorbilidad , Estudios Transversales , Femenino , Estado de Salud , Humanos , Masculino , Trastornos Mentales/epidemiología , Persona de Mediana Edad , Países Bajos/epidemiología , Trastornos Fóbicos/psicología , PrevalenciaRESUMEN
OBJECTIVE: To establish the long-term effectiveness of 3 treatments for DSM-IV panic disorder with or without agoraphobia: cognitive-behavioral therapy (CBT), pharmacotherapy using a selective serotonin reuptake inhibitor (SSRI), or the combination of both (CBT + SSRI). As a secondary objective, the relationship between treatment outcome and 7 predictor variables was investigated. METHOD: Patients were enrolled between April 2001 and September 2003 and were randomly assigned to treatment. Academic and nonacademic clinical sites participated. Each treatment modality lasted 1 year. Pharmacotherapists were free to choose between 5 SSRIs currently marketed in The Netherlands. Outcome was assessed after 9 months of treatment (posttest 1), after discontinuation of treatment (posttest 2), and 6 and 12 months after treatment discontinuation (follow-up 1 and follow-up 2). RESULTS: In the sample (N = 150), 48% did not suffer from agoraphobia or suffered from only mild agoraphobia, while 52% suffered from moderate or severe agoraphobia. Patients in each treatment group improved significantly from pretest to posttest 1 on the primary outcome measures of level of anxiety (P < .001), degree of coping (P < .001), and remitter status (P < .001), as well as on the secondary outcome measures of depressive symptomatology (P < .001), and from pretest to posttest 2 for health-related quality of life (P < .001). Gains were preserved from posttest 2 throughout the follow-up period. Some superiority of CBT + SSRI and SSRI as compared with CBT was observed at posttest 1. However, at both follow-ups, differences between treatment modalities proved nonsignificant. Client satisfaction appeared to be high at treatment endpoint, while patients receiving CBT + SSRI appeared slightly (P < .05) more satisfied than those receiving CBT only. CONCLUSIONS: No fall-off in gains was observed for either treatment modality after treatment discontinuation. SSRIs were associated with adverse events. Gains produced by CBT were slower to emerge than those produced by CBT + SSRI and SSRI, but CBT ended sooner. TRIAL REGISTRATION: Netherlands Trial Register (www.trialregister.nl) Identifier: ISRCTN8156869.
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Agorafobia/terapia , Terapia Cognitivo-Conductual , Trastorno de Pánico/terapia , Inhibidores Selectivos de la Recaptación de Serotonina/uso terapéutico , Adulto , Agorafobia/complicaciones , Agorafobia/tratamiento farmacológico , Terapia Combinada , Femenino , Humanos , Masculino , Trastorno de Pánico/complicaciones , Trastorno de Pánico/tratamiento farmacológico , Valor Predictivo de las Pruebas , Escalas de Valoración Psiquiátrica , Calidad de Vida , Factores de Tiempo , Resultado del TratamientoRESUMEN
The present paper discusses theoretical and methodological issues involved in the processes of change in cognitive-behavioural treatment (CBT) of obsessive-compulsive disorder (OCD). Treatment outcome studies showed that CBT is effective in reducing obsessive-compulsive symptoms. However, why and how CBT works cannot be corroborated by comparing pre- and post-assessment. Recently, there has been a resurgence of interest in theory driven process studies. By showing patterns of change over time, process studies can contribute to our insight into the actual mechanisms of change during treatment. We review process research in the field of OCD and discuss methodological issues involved in process studies for this particular disorder. It is concluded that studying the processes of change harbours promising possibilities for bridging the gap between theory and clinical practice.
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Terapia Cognitivo-Conductual/métodos , Trastorno Obsesivo Compulsivo/terapia , Terapia Combinada , Humanos , Trastorno Obsesivo Compulsivo/diagnóstico , Trastorno Obsesivo Compulsivo/tratamiento farmacológico , Inhibidores Selectivos de la Recaptación de Serotonina/uso terapéuticoRESUMEN
Perceived Criticism (PC) evolved in the context of Expressed Emotion (EE) research and, like EE, predicts the course of various psychiatric disorders. However, little is known about PC's validity. We examined (in Study 1) to what extent PC reflects the perceiver's current depressive and marital complaints, whether PC measures reciprocal criticism that characterizes dyads rather than individuals, and (in Study 2) whether PC reflects actual interactive behaviour. Both studies compared a single-item with a multi-item measure of PC. In Study 1, general community couples completed self-reports of PC, depressed mood, and marital dissatisfaction, and expressed their feelings in a brief EE interview (Five Minute Speech Samples). Multilevel analyses suggested that PC was associated with both partners' expressions of criticism, and the perceiver's depressive and marital complaints. In Study 2, general community couples completed self-reports of PC and participated in a videotaped problem solving interaction. Interactions were coded with the Kategorien system für partnerschaftliche Interaktion (KPI). PC was related to the partner's verbal and nonverbal expression of criticism and the perceiver's expression of nonverbal negative behaviour. Overall, the pattern of findings fits in well with theoretical formulations regarding EE, and supports the usefulness of PC measures as practical alternatives for the assessment of EE.
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Asociación , Depresión/psicología , Emoción Expresada , Relaciones Interpersonales , Matrimonio/psicología , Percepción Social , Adulto , Depresión/diagnóstico , Femenino , Humanos , Masculino , Modelos Estadísticos , Análisis Multivariante , Características de la Residencia , Autoimagen , Adulto JovenRESUMEN
In two covariation bias experiments, we investigated whether socially anxious women overestimate the contingency between social events and signs of rejection and/or to underestimate the contingency between social events and approval. Participants were exposed to descriptions of ambiguous or negative social events, situations involving animals, and nature scenes that were randomly paired with disgusting, happy, and neutral faces. Socially anxious participants reported enhanced belongingness between ambiguous events and signs of rejection, together with reduced belongingness between negative events and approval. This contributes to previous findings suggesting that socially anxious individuals suffer from fear-confirming interpretive biases. There was no evidence for enhanced negative or reduced positive covariation bias in socially anxious individuals.
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Ansiedad/psicología , Trastornos Fóbicos/psicología , Medio Social , Adolescente , Señales (Psicología) , Interpretación Estadística de Datos , Emoción Expresada/fisiología , Expresión Facial , Miedo/psicología , Femenino , Humanos , Masculino , Escalas de Valoración PsiquiátricaRESUMEN
In the etiology of disgust-relevant psychopathology, such as emetophobia (fear of vomiting), two factors may be important: disgust propensity, i.e., how quickly the individual experiences disgust, and disgust sensitivity, i.e., how negatively does the individual evaluate this disgust experience [van Overveld, W. J. M., de Jong, P. J., Peters, M. L., Cavanagh, K., & Davey, G. C. L. (2006). Disgust propensity and disgust sensitivity: separate constructs that are differentially related to specific fears. Personality and Individual Differences, 41, 1241-1252]. Hence, the current study examines whether emetophobic participants display elevated levels of disgust propensity and sensitivity, and whether these factors are differentially related to emetophobia. A group of emetophobic members of a Dutch website on emetophobia (n=172), and a control group (n=39) completed an internet survey containing the Emetophobia Questionnaire, Disgust Propensity and Sensitivity Scale-Revised, Disgust Scale, and Disgust Questionnaire. Results showed that the emetophobic group displayed significantly elevated levels of both disgust propensity and disgust sensitivity compared to the control group. Most importantly, disgust sensitivity consistently was the best predictor of emetophobic complaints.