Effect of distraction and coping style on in vivo exposure for specific phobia of spiders.

Recent studies have generated mixed findings regarding the effects of distraction on exposure-based treatments. Results have also been inconsistent regarding the effects of monitoring and blunting coping styles on outcome. The present study attempted to integrate these two areas of research. We hypothesized that the effect of distraction on treatment outcome might depend on coping style. Specifically, we predicted that for blunters (i.e.. individuals who tend to avoid threat-related information), distraction would interfere with the effects of exposure. However, we predicted that distraction might benefit monitors (i.e., individuals who tend to seek out threat-related information). Sixty individuals with a specific phobia of spiders underwent a single, two-hour session of exposure treatment. During the first hour, half of the participants were distracted by listening to an audiotape and the other half underwent exposure without distraction. In the second hour, all participants underwent focused exposure. Based on measures of heart rate, subjective fear, and behavioral testing, participants improved after one hour of treatment, and improved further during the second hour. However, neither distraction, coping style, nor their interaction had a significant effect on outcome. The present study provides support for the benefits of behavioral treatment for specific phobias. However, our hypotheses regarding distraction and coping style were not confirmed.

Psychological features of subjects with idiopathic environmental intolerance.

OBJECTIVES: Idiopathic environmental intolerance (IEI) is associated with unexplained symptoms attributed to non-noxious levels of environmental substances. Clinically, some of the symptoms of IEI overlap with those of panic disorder (PD). We have recently reported a link between IEI and panic responses to a single inhalation of 35% carbon dioxide (CO(2)), a reliable panic induction challenge. This study assessed depression, stress, anxiety, and agoraphobic symptoms among IEI subjects from our previous study versus healthy controls. METHODS: Thirty-six IEI and 37 control subjects with no preexisting psychiatric history were compared on self-report psychological questionnaires. RESULTS: IEI subjects scored significantly higher than controls on the Agoraphobic Cognitions Questionnaire (ACQ), Depression Anxiety Stress Scales (DASS), and Mobility Inventory for Agoraphobia (MI) (Student's t, P<.05). CONCLUSIONS: IEI subjects represent a group with morbidity significantly higher than a control population but less than what would be expected for a clinical psychiatric population.

Interpretations for anxiety symptoms in social phobia.

This study explored the ways in which people interpret visible physical symptoms of anxiety. A group of participants with social phobia (SP) and a nonclinical control (NCC) group completed either the Actor version or the Observer version of the Symptom Interpretation Scale (SIS), designed for the purposes of this study. The SIS asks participants to rate the extent to which each of eight interpretations is a likely explanation for a number of visible symptoms of anxiety. On the Actor version of the SIS, participants are asked to judge how their own anxiety symptoms are interpreted by others. On the Observer version of the SIS, participants are asked how they typically interpret anxiety symptoms that they notice in others. When participants were asked about anxiety symptoms that they themselves exhibit, people with social phobia were more likely than nonclinical controls to think that others interpreted these symptoms as being indicative of intense anxiety or a psychiatric condition and were less likely to think that others interpreted these symptoms as being indicative of a normal physical state. Data also suggested that people with social phobia have a more flexible cognitive style when asked to interpret anxiety symptoms exhibited by others than when asked about how others view their own anxiety symptoms. These findings are discussed in the context of recent psychological models of social anxiety and social phobia.

Treatment histories of patients with three anxiety disorders.

The current study sought to examine the extent to which empirically supported psychological and pharmacological treatments were used by individuals with panic disorder (n = 41), social phobia (n = 34), or obsessive compulsive disorder (n = 21). Participants were recruited from an anxiety disorders clinic and completed a questionnaire about previous treatment and contact with a variety of professionals. Results indicated that the types of pharmacological treatment received by patients were more often consistent with findings from the empirical literature than were the psychological treatments received by patients. Cognitive and behavioral treatments had been tried by fewer than half of participants (between 19 and 44% of participants). Results were fairly consistent across the anxiety disorders. Possible explanations for the discrepancy between the types of psychological treatments that have received empirical support and those that are typically provided to patients are provided.

Attitudes toward mental illness in medical students: does personal and professional experience with mental illness make a difference?

PURPOSE: Medical students may be susceptible to emotional difficulties because of the high levels of both academic and interpersonal stress associated with their training. This study examined attitudes toward mental illness in medical students. It was expected that people who had experience of mental illness, either in their personal lives or through their professional experience, would have more positive attitudes toward students with mental health problems than would people who had not had such experience. METHOD: Faculty and staff employed by a large American university medical centre completed a questionnaire package including several measures designed to assess specific attitudes toward medical students with emotional problems. Data were also collected on the degree to which specific mental disorders were thought to interfere with the performance of medical students. RESULTS: In general, prior experience with mental illness, either through personal or professional activities, was associated with more positive attitudes about students with mental illness. However, the pattern of findings was complex. CONCLUSION: Future research should examine the extent to which specific mental illnesses actually affect the performance of medical students.

Carbon dioxide inhalation challenges in idiopathic environmental intolerance.

BACKGROUND: Idiopathic environmental intolerance (IEI) is associated with unexplained physical symptoms, which overlap considerably with those of panic disorder (PD). OBJECTIVE: This study tested the hypothesis that patients with symptoms to suggest IEI exhibit features of PD in response to nonnoxious environmental stimuli. METHODS: A single-blind, case-control 35% carbon dioxide inhalation challenge was conducted at a university-based occupational health unit with the use of standardized psychologic questionnaires involving 36 patients with IEI and 37 healthy control subjects. The main outcome measures included panic attack symptoms and scores on the Anxiety Sensitivity Index, a measure of panic-related anxiety. RESULTS: Patients with IEI scored significantly higher on the Anxiety Sensitivity Index than control subjects did (P <.05). Significantly more patients with IEI (71%) than control subjects (26%) fulfilled panic attack criteria after carbon dioxide (P <.001). Physiologic responses to the challenge were not significantly different between groups. CONCLUSIONS: Results suggest that, similar to patients with PD, patients with IEI display high anxiety sensitivity and in response to carbon dioxide inhalation tend to experience heightened anxiety and panic attacks.

Heartbeat perception in panic disorder: a reanalysis.

This article describes a reanalysis of seven studies on heart beat perception (HBP) in panic disorder. The pooled sample had 709 participants from eight diagnostic categories. Accurate HBP was uncommon, but more prevalent among panic disorder patients than among healthy controls, depressed patients, patients with palpitations and individuals with infrequent panic attacks. No differences were found between panic disorder patients and patients with other anxiety disorders. Accurate perceivers had higher anxiety sensitivity scores than inaccurate perceivers. The data remain inconclusive as to whether perceived heart rate is correlated with anxiety in inaccurate perceivers. Physical exercise, distraction, variations in instructions and treatment each influenced HBP. However, the influence was different than previously thought. Finally, it is suggested that HBP may be understood in terms of schema-guided information processing.

Negative priming for obsessive-compulsive checkers and noncheckers.

Negative priming--the slowing of a response to an item that was recently ignored--was investigated in three groups: obsessive-compulsive disorder (OCD) checkers, OCD noncheckers, and nonclinical control participants. All groups performed both a standard negative priming task, selecting targets based on a perceptual feature (i.e., color), and a modified negative priming task, selecting targets based on a semantic feature (i.e., referent size). All three groups demonstrated significant negative priming in both tasks, although the negative priming was much larger in the novel, semantic task than in the common, perceptual one. The findings suggest that patients with OCD do not demonstrate impairments in negative priming, contrary to earlier claims (Enright & Beech, 1990, 1993a, 1993b; Enright, Beech, & Claridge, 1995).

Symptom structure in obsessive-compulsive disorder: a confirmatory factor-analytic study.

Although obsessive-compulsive disorder (OCD) has long been a unitary diagnosis, there is much recent interest in its potential heterogeneity, as manifested by symptom subgroups. This study evaluated existing models of symptom structure in a sample of 203 individuals with OCD. Using confirmatory factor analysis, we examined the ability of each model to account for two levels of data: a priori symptom groupings (second-order) and individual symptoms, identified by the Yale-Brown Obsessive Compulsive Scale symptom checklist. Four models were examined: a single-factor, a two-factor (i.e., obsessions and compulsions), and two multidimensional models, comprising three and four factors. Adequate fit was found solely for the four-factor model--specifying obsessions/checking, symmetry/ordering, contamination/cleaning, and hoarding--but only at the second-order level; it did not account for relationships among discrete symptoms. Parameter estimates showed within-factor heterogeneity, as well as overlap between factors, most notably the two representing checking and contamination-related symptoms. The implications of these findings are discussed. Results provide evidence for the multidimensionality of OCD symptoms, but suggest that a comprehensive model has yet to be identified. They also point to the inadequacy of groupings based solely upon overt behavioural similarities (e.g., 'checking'). Recommendations are made for future research.

Psychometric properties of the frost multidimensional perfectionism scale in a clinical anxiety disorders sample.

The purpose of this study was to examine the factor structure of the Frost Multidimensional Perfectionism Scale (MPS-F; Frost, Marten, Laharte, & Rosenblate, 1990). Although perfectionism is thought to contribute to the development of psychopathology and the MPS-F is gaining popularity for use in assessing perfectionism in clinical samples, to date the factor structure has not been examined in a clinical sample. Three hundred and twenty-two individuals diagnosed with an anxiety disorder using the SCID for DSM-IV and 49 nonclinical controls completed the MPS-F as well as a measure of perfectionism (MPS-H) developed by Hewitt and Flett ( 1991 ). Analyses suggested that the MPS-F has similar psychometric properties in clinical samples to those in nonclinical samples, and factors very similar to those observed by Frost et al. (1990) could be extracted. A 3-factor solution appeared more appropriate for statistical reasons, and the 3 scales based on these factors distinguished among diagnostic groups in a manner similar to scales based on the 6-factor solution in past research. Results were discussed in terms of the potential utility of a 3-factor solution and in terms of the general construct of perfectionism and the distinction between nonpathological high performance standards and neurotic perfectionism.

Cognitive features of social phobia.

New cognitive models of social phobia have been developed based, in part, on a growing number of studies suggesting that people with social phobia process information related to social threat differently than people who are not socially anxious and, in some cases, differently than individuals with other anxiety disorders. In addition to providing an overview of recent models of social phobia, this paper reviews the research literature to date on the following aspects of cognition in social phobia: attention, memory, attributions and appraisals, imagery and perspective, and perfectionism.

Dimensions of perfectionism across the anxiety disorders.

To explore the role of perfectionism across anxiety disorders, 175 patients with either panic disorder (PD), obsessive compulsive disorder (OCD), social phobia, or specific phobia, as well as 49 nonclinical volunteers, completed two measures [Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R., (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14, 449-468; Hewitt, P. L., & Flett, G. L., (1991). Perfectionism in the self and social contexts: Conceptualization, assessment and association with psychopathology. Journal of Personality and Social Psychology, 60, 456-470.] that assess a total of nine different dimensions of perfectionism. Relative to the other groups, social phobia was associated with greater concern about mistakes (CM), doubts about actions (DA), and parental criticism (PC) on one measure and more socially prescribed perfectionism (SP) on the other measure. OCD was associated with elevated DA scores relative to the other groups. PD was associated with moderate elevations on the CM and DA subscales. The remaining dimensions of perfectionism failed to differentiate among groups. The clinical implications of these findings are discussed.

The State-Trait Anxiety Inventory, Trait version: structure and content re-examined.

Although the State-Trait Anxiety Inventory (STAI) is a popular measure of anxiety, some previous research suggests that the trait scale may assess depression, as well as anxiety. The factor structure of the trait items was initially examined using factor analytic procedures. Confirmatory factor analytic methods suggested that a hierarchical solution best fit the data, with one overall factor and two lower order factors. The lower order subscales created from this factor solution were examined in a sample of individuals diagnosed with an anxiety disorder. Overall, the results offered good support for the notion that the trait scale of the STAI assesses depression, as well as anxiety. One set of items appeared to assess anxiety and worry, whereas the other assessed sadness and self-deprecation. The two subscales correlated differentially with other measures of anxiety and depression in a manner that was consistent with their content. Finally, diagnostic groups and controls could be meaningfully distinguished on these subscales. Implications for the use of this measure are discussed.

Illness intrusiveness in individuals with panic disorder, obsessive-compulsive disorder, or social phobia.

To measure the extent to which anxiety disorders interfere with various domains of functioning, the Illness Intrusiveness Ratings Scale (IIRS) was completed by individuals with a DSM-IV principal diagnosis of panic disorder (PD; N = 35), obsessive-compulsive disorder (OCD; N = 51), or social phobia (SP; N = 49). Although the three groups did not differ on total IIRS scores, group differences did emerge for particular domains of functioning. Patients with OCD reported significantly more interference with respect to passive recreation (e.g., reading) than did SP patients and with respect to religious expression compared with both PD and SP patients. Patients with SP reported more impairment with respect to social relationships and self-expression/self-improvement compared with the other two groups. When compared with populations with a variety of other chronic illnesses, patients in the present study reported much higher levels of illness intrusiveness. The implications of these findings and future directions for research are discussed.

What is binge eating? A comparison of binge eater, peer, and professional judgments of eating episodes.

Binge eating is a central diagnostic feature of bulimia nervosa (BN) and binge-eating disorder (BED), yet the phenomenon of bingeing has not been adequately defined, and there is considerable variability in how individuals label eating episodes as binges. We examined the agreement among binge-eating individuals, non-eating-disordered peers, and professional dietitians over whether particular eating episodes were binges. Twenty-nine females with BED, fifteen nonclinical binge eaters (NCB), three peer judges, and three dietitians rated a sample of eating episodes of the binge-eating individuals as either binges or nonbinges based on the types and amounts of food eaten as well as the duration of each eating episode. BED participants labeled a significantly higher proportion of their intakes as binges relative to NCB participants. Peer judges were more likely than were dietitians to label participants' eating episodes as binges. Agreement within dietitian and peer groups was poor to fair, whereas agreement between these groups was fair. Finally, agreement between participants and the external judges (i.e., peers, dietitians) was poor. Possible explanations for these findings as well as implications for the diagnosis of BN and BED are discussed.

Assessment and treatment of social phobia.

Social phobia is an anxiety disorder characterized by heightened fear and avoidance of one or more social or performance situations, including public speaking, meeting new people, eating or writing in front of others, and attending social gatherings. People with social phobia are typically anxious about the possibility that others will evaluate them negatively and/or notice symptoms of their anxiety. Social phobia affects up to 13% of individuals at some time in their lives and is usually associated with at least moderate functional impairment. Research on the nature and treatment of social phobia has increased dramatically over the past decade. As with many of the anxiety disorders, sensitive assessment instruments and effective treatments now exist for people suffering from heightened social anxiety. Typical assessment strategies include clinical interviews, behavioural assessments, monitoring diaries, and self-report questionnaires. Treatments with demonstrated efficacy for social phobia include pharmacotherapy (for example, phenelzine, moclobemide, selective serotonin reuptake inhibitor [SSRI] medications) and cognitive behaviour therapy (CBT) (for example, cognitive restructuring, in vivo exposure, social skills training). Although preliminary comparative studies suggest that both approaches are about equally effective in the short term, each approach has advantages and disadvantages over the other. Trials examining combined psychological and pharmacological treatments are now under way, although no published data on the relative efficacy of combined treatments are currently available.

Response to hyperventilation and 5.5% CO2 inhalation of subjects with types of specific phobia, panic disorder, or no mental disorder.

OBJECTIVE: This study tested the hypothesis that compared to other DSM-IV specific phobia types, situational specific phobias have more in common with panic disorder and agoraphobia. METHOD: Responses to hyperventilation and CO2 inhalation were compared across groups of patients with the four main DSM-IV specific phobia types, a group with panic disorder, and a group of comparison subjects with no anxiety disorder (N = 15 per group). RESULTS: Although these challenges have been shown previously to distinguish patients with panic disorder from other groups, no groups differed significantly in their responses to hyperventilation. In addition, whereas the patients with panic disorder responded more to the CO2 challenge than did the normal subjects, the specific phobia groups did not differ from one another or from the other groups on most measures. For the few CO2 measures on which specific phobia groups differed, patients with situational and natural environment phobias showed the greatest response. CONCLUSIONS: Overall, these findings provided only limited support for the hypothesis that situational specific phobias are related to panic disorder.

Memory and confidence in memory judgements among individuals with obsessive compulsive disorder and non-clinical controls.

The present study investigated episodic memory functioning in: (1) obsessive compulsive disorder (OCD) patients with primarily checking symptoms (i.e. checkers); (2) OCD patients without checking symptoms (i.e. non-checkers); and (3) non-clinical control participants. On a measure of recall, all groups were statistically equivalent with respect to the proportion of words correctly recalled. Using a recognition measure, checkers were unimpaired in episodic memory, as compared to non-checkers and non-clinical controls. However, relative to the other groups, patients with checking symptoms showed decreased confidence in their correct and incorrect recognition memory judgements, according to their item-by-item self-report confidence ratings. When checkers correctly identified previously seen words, they were also slower to respond than were the other groups, supporting the view that they were less confident in their memory judgments relative to the other groups, which did not differ on this measure. The results of the present study suggest that OCD checking is not related to memory impairments per se but rather that checking in OCD is a symptom of decreased confidence in memory.

Heterogeneity among specific phobia types in DSM-IV.

Recently, it has been suggested that situational specific phobias (e.g., phobias of driving, flying, enclosed places) are more closely related to agoraphobia than are other specific phobia types. The present study investigated this hypothesis by examining heterogeneity among the four main DSM-IV specific phobia types, particularly with respect to variables believed to be associated with agoraphobia. Using interviews and behavioral testing, 60 patients with specific phobias of animals, heights, blood/injections, or driving were compared with respect to etiology, age of onset, physiological response, predictability of panic attacks, and focus of apprehension. Fifteen patients suffering from panic disorder with agoraphobia served as a comparison group for some measures. Relative to the other specific phobias, driving phobias were most strongly associated with a later age of onset, similar to that of individuals with agoraphobia. Height phobias were also associated with a late age of onset as well as a more internal focus of apprehension, relative to other groups. Finally, individuals in the blood/injection phobia group reported a more internal focus of apprehension than those in other groups and were the only group to report a history of fainting in the phobic situation. Overall, the results did not support the hypothesis that situational phobias are a variant of agoraphobia. In fact, on several of the variables for which groups did differ, individuals with height phobias (a phobia from the natural environment type) showed a pattern most similar to individuals with agoraphobia. The implications of these results for the classification of specific phobias are discussed.