Motivation and treatment credibility predict alliance in cognitive behavioral treatment for youth with anxiety disorders in community clinics.

OBJECTIVE: We examined whether motivation and treatment credibility predicted alliance in a 10-session cognitive behavioral treatment delivered in community clinics for youth anxiety disorders. METHOD: Ninety-one clinic-referred youths (meanage  = 11.4 years, standard deviation = 2.1, range 8-15 years, 49.5% boys) with anxiety disorders-rated treatment motivation at pretreatment and perceived treatment credibility after session 1. Youths and therapists (YT) rated alliance after session 3 (early) and session 7 (late). Hierarchical linear models were applied to examine whether motivation and treatment credibility predicted YT early alliance, YT alliance change, and YT alliance agreement. RESULTS: Motivation predicted high early YT alliance, but not YT alliance change or alliance agreement. Youth-rated treatment credibility predicted high early youth alliance and high YT positive alliance change, but not early therapist alliance or alliance agreement. CONCLUSION: Conclusion Efforts to enhance youth motivation and treatment credibility early in treatment could facilitate the formation of a strong YT alliance.

Season of birth and electrodermal unresponsiveness in male schizophrenics.

The present study was designed to examine differences in the electrodermal activity of schizophrenics born in the season of excessive risk (January-April), and those born in the season of nonexcessive risk (May-December). Thirty-two male schizophrenics were presented with a series of orienting tones (1000 Hz, 80dB, 2 sec duration) while electrodermal activity was monitored. They were subdivided according to season of birth and compared in three electrodermal variables, and also in some background and clinical parameters. We found that schizophrenics born in the season of excessive risk were characterized by significantly lower electrodermal activity and more negative symptoms than those born in the season of nonexcessive risk.

One-Session treatment of specific phobias in youths: a randomized clinical trial.

Sixty children, ages 7-17 years, who fulfilled Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnosis for various specific phobias were randomized to (a) 1-session exposure treatment alone, (b) 1-session treatment with a parent present, or (c) wait-list control group for 4 weeks. After the waiting period, the wait-list patients were rerandomized to the active treatments. The patients' phobias were assessed with behavioral approach tests (approach behavior, experienced anxiety, and physiological reactions), whereas general anxiety, depression, phobic tendencies, and anxiety sensitivity were assessed with self-report inventories. Assessments were done pre-, post-, and 1-year following treatment. Results showed that both treatment conditions did significantly better than the control condition, whereas the treatment groups did equally well on most measures, and the effects were maintained at follow-up. The implications of these results are discussed.

Misinterpretation of body sensations in panic disorder.

Cognitive accounts of panic predict that panic disorder patients will be particularly prone to misinterpret autonomic sensations. Several studies have produced results consistent with this prediction, but each is open to alternative interpretation. To clarify matters, 2 studies administered the Body Sensations Interpretation Questionnaire (BSIQ) to panic patients and controls. Panic patients were more likely to interpret ambiguous autonomic sensations as signs of immediately impending physical or mental disaster and were more likely than other anxiety disorder patients and nonpatients to believe these interpretations. In a 3rd study, a brief version of the BSIQ was shown to have satisfactory test-retest reliability, to change with treatment, and to discriminate treatments that varied in their effects on panic.

Blood and injection phobia: background and cognitive, physiological, and behavioral variables.

Blood-phobic (n = 81) and injection-phobic (n = 59) patients fulfilling the DSM-III-R criteria for simple phobia were compared on a number of variables. There were no differences between the samples in age at onset, age at treatment, marital and occupational status, history of fainting in the phobic situation, and impairment. Higher proportions of blood-phobic subjects than of injection-phobic subjects reported having first-degree relatives with the same phobia (61% vs. 29%) and reported fearing that they were going to faint in the phobic situation (77% vs. 48%). In both samples, these proportions were higher in the subgroup with a history of fainting. Injection-phobic subjects rated 2 of 11 physiological items higher than did blood-phobics subjects, but the groups did not differ on behavioral variables. Overall, the similarities were more marked than the differences, and it is suggested that these two specific phobias should be regarded as one diagnostic entity.

Preattentive bias for emotional information in panic disorder with agoraphobia.

A combined emotional Stroop and implicit memory (tachistoscopic identification) task with 3 types of words (panic-related, interpersonal threat, and neutral words) and 2 exposure conditions (subliminal, supraliminal) was administered to 35 patients with panic disorder and 35 age- and sex-matched controls. The patients showed Stroop interference for panic-related words both sub- and supraliminally and a similar but not equally robust effect on interpersonal threat words. On the tachistoscopic identification task, the patients identified more panic-related words than the controls did but showed no implicit memory bias effect. The patients' subliminal Stroop interference for panic-related words was found to correlate with trait anxiety and depression, although not with anxiety sensitivity.

Electrodermal nonresponding, premorbid adjustment, and symptomatology as predictors of long-term social functioning in schizophrenics.

The hypothesis that electrodermal nonresponsiveness to orienting stimuli delineates a core group of "Kraepelinian" type schizophrenics was tested by following up social functioning outcome over a 2-year period in 37 schizophrenics. Good social functioning outcome required both some self-supporting ability in the job market and a minimal social life. The prior assessments included monitoring of electrodermal responses to a series of moderately intense tones, ratings of reported and observed symptoms during an interview, and ratings of premorbid adjustment on the basis of an interview with a close relative. Electrodermal nonresponding, poor premorbid adjustment, and negative symptomatology predicted poor social functioning during the second follow-up year, but the relationship to nonresponding pertained exclusively to a group of 15 first-episode patients. Discriminant analysis showed that electrodermal nonresponding and symptoms were the only independent predictors of outcome.

Electrodermal activity and social network as predictors of outcome of episodes in schizophrenia.

The predictive value of electrodermal activity and social network was examined among 48 consecutively admitted schizophrenic patients. The patients were followed from an initial admission, through hospital stay, discharge, follow-up (M = 31 months), and possible relapse. Outcome variables were the length of stay in the hospital at the key episode and time to relapse, defined as a marked exacerbation or return of schizophrenic symptoms requiring inpatient or expansion of outpatient treatment. Multivariate analyses showed that a psychosocial variable, the availability of attachment, was the only independent predictor of length of stay in the hospital. Age at admission was a strong predictor of time to relapse. Age interacted with both outcome and electrodermal activity, and young electrodermal nonresponders were found to have the shortest time to relapse. At the 1-year follow-up, a main relapse effect was found for patients with a low skin conductance level.

Electrodermal orienting response, maternal age, and season of birth in schizophrenia.

Consistent with earlier research, male schizophrenic patients born during the season of excess risk for schizophrenia (January-April) showed significantly lower electrodermal responsivity than controls born during the season of excess risk, and patients and controls born during the season not associated with increased risk (May-December). No support for maternal age as an explanation for the season-of-birth effect was found.

A maintenance program for behavioral treatment of anxiety disorders.

A maintenance program for behavioral treatments of anxiety disorders is presented in some detail, together with preliminary results of its application as part of three treatment trials. Compared to previous studies reporting long-term effects of behavioral treatments, the present program yielded a larger percentage of improvement during the follow-up period, a lower proportion of patients needing further treatment, and fewer relapses.

One-session treatment for specific phobias.

A rapid and effective treatment for specific phobias, in which the treatment is done in one single session, is described in detail. The treatment method consists of a combination of exposure in vivo and modeling. The short- and long-term outcome for a consecutive series of 20 patients are reported. Mean treatment time was 2.1 h and at follow-up after an average of 4 yr 90% were much improved or completely recovered.

The Agoraphobia Scale: an evaluation of its reliability and validity.

This article presents the Agoraphobia Scale (AS), and evidence for its reliability, validity, and sensitivity to change after treatment. The scale consists of 20 items depicting various typical agoraphobic situations, which are rated for anxiety/discomfort (0-4) and avoidance (0-2). The results show that AS has high internal consistency. Regarding concurrent validity it correlated significantly with other self-reported measures of agoraphobia (Mobility Inventory and Fear Questionnaire). The scale's predictive validity was shown as it correlated with avoidance behavior and self-rated anxiety during both an individualized and a standardized behavioral test of agoraphobia. The AS also discriminated between an agoraphobic sample and a normal sample, and a sample of simple phobia patients. Finally, it was sensitive to changes after behavioral treatment. The AS is useful both as a state, and as an outcome self-report measure of agoraphobia.

One-session group treatment of spider phobia.

Forty-two patients with spider phobia, fulfilling the DSM-III-R criteria for simple phobia, were assessed with behavioral, physiological and self-report measures. They were randomly assigned to two group treatment conditions: (1) small groups of three to four patients, and (2) large groups of seven to eight patients. They received one 3-hr session consisting of exposure and modeling. The results showed that both conditions yielded significant improvements on almost all measures, and these were maintained or furthered at the 1-yr follow-up. With one exception, there was no difference between the conditions, but on most measures there was a trend for the small group condition to yield better effects. The proportions of clinically significantly improved patients at post-treatment were 82% in the small group and 70% in the large group. At follow-up the corresponding figures were 95% and 75%, respectively. The conclusion that can be drawn is that one-session group treatment is a feasible alternative to individual treatment, yielding almost as good effects.

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.

Explicit and implicit memory bias in social phobia. The role of subdiagnostic type.

Fourty-five patients with social phobia and 45 normal controls were compared on explicit memory (cued recall) and implicit memory (word stem completion) for positive, neutral, social threat, and physical threat words. Although there were no significant differences between the social phobics and the normal controls, the subgroup of patients with non-generalized social phobia showed an implicit memory bias for social threat words. The results are discussed in terms of a critical analysis of the concept of implicit memory bias, which is operationalized as the difference between a bias on primed and unprimed words, and where the latter represents a "baseline bias". In the present study, this baseline word completion bias for social threat words showed a strong negative correlation (r = -0.72) with the implicit memory bias for social threat words, and showed positive correlations with several psychopathology-related measures among the social phobics. It is suggested that future research should consider results on both implicit memory bias and its corresponding baseline bias. The possibility is discussed that implicit memory bias and baseline bias may serve as indexes of externally and internally generated priming effects, and that the relative contributions of external and internal priming may differ in different subtypes of social phobia.

Long-term follow-up of migraine treatment: do the effects remain up to six years?

Fifty migraine subjects (constituting 79% of the originally treated sample) participated in a follow-up study to 6 yr after the end of treatment. Subjects had been treated with different forms of biofeedback methods (skin temperature, BVP of the temporal artery) and applied relaxation training. The assessment included 4 weeks of continuous self-monitoring of headache activity and medication usage, as well as a retrospective self-rating scale. The main results indicated that, on a group basis, headache reductions achieved at the end of treatment persisted for up to 6 yr, and were indeed enhanced during the follow-up period.

One-session therapist directed exposure vs two forms of manual directed self-exposure in the treatment of spider phobia.

Fifty-two patients with spider phobia, fulfilling the DSM-III-R criteria for simple phobia, were assessed with behavioral, physiological and self-report measures. They were randomly assigned to five different treatment conditions: (1) one session therapist-directed exposure (maximum 3 hours), (2) specific manual-based treatment in the home, (3) specific manual-based treatment at the clinic, (4) general manual-based treatment in the home and (5) general manual-based treatment at the clinic. The results show that therapist-directed one-session treatment was significantly more effective than three of the manual-based treatments, both at the post-treatment and follow-up stages. Specific manual-based treatment at the clinic was significantly more successful than the other manual-based treatments, but only at follow-up. The proportion of clinically significant improved patients at follow-up was 80% in the therapist-directed group compared to 63% for the specific manual-based treatment at the clinic, 10% for specific manual-based treatment in the home, 9% for general manual-based treatment in the home, and 10% for general manual-based treatment at the clinic. The conclusion that can be drawn is that one-session therapist-directed treatment is the treatment of choice for spider phobia but manual-based treatment is a good alternative in some cases.

Cognitive bias in panic disorder patients and changes after cognitive-behavioral treatments.

The aim of this study was to investigate cognitive biases in panic disorder patients via a questionnaire originally developed by Clark and co-workers [Clark, Salkovskis, Gelder, Koehler, Martin, Anastasiades, Hackman, Middleton & Jeavons, (1988). In Hand, I. & Wittchen, H.-U. (Eds) Panic and Phobias 2] to assess interpretations of ambiguous internal (bodily sensations) and external events. The results showed that, compared to normal controls, panic disorder patients interpreted bodily sensations in a more threatening fashion, while there was no difference concerning external events. Cognitive-behavioral treatments normalized this bias, and Cognitive Behavior Therapy and Applied Relaxation were equally effective in this respect. Moreover, compared to panicking patients, panic-free patients had reduced their cognitive threat bias at post-treatment and follow-up to a significantly larger extent. The results support the cognitive theory of panic disorder.

Prediction of outcome in the treatment of specific phobia. A cross validation study.

The purpose of this study was to investigate possible predictors of treatment outcome in specific phobia at 1 week after treatment, and at I year follow-up. The subjects (n = 138) came from four studies (two on spider phobia, one on blood phobia and one on injection phobia), and all had been diagnosed with simple phobia according to DSM-III-R. The dependent variable was clinically significant improvement in three different factors; avoidance behavior in a behavior test, self-rated anxiety during the test, assessor rating of phobic severity or fainting behavior. Fourteen variables covering self-report, demographic and physiological variables, and data from the behavior test were used as prognostic variables. Multiple regression analyses were used in a cross validation procedure. The results showed that diastolic blood pressure at pretest was a predictor at post-treatment for one sample and credibility was found as a predictor for the other sample both at post-treatment and at 1 year follow-up. Analyses were made for the diagnoses and the treatments but the results were inconclusive. Despite the large sample size and the cross validation procedure no stable predictors were found for short- and long-term outcome. The few significant predictors should be considered as chance findings.

Recognition bias for critical faces in social phobics.

Social phobics were compared with normal controls on a task of face recognition. The subjects were presented with 20 photos, and were required to judge whether the persons on the photos were critical or accepting; five minutes later they were unexpectedly presented with a recognition task. The social phobics recognized more of the critical than the accepting faces, whereas the controls tended to recognize more accepting than critical faces. The results are discussed in terms of a possible recognition bias or response bias, and in terms of differences in the encoding activities of the subjects. It is also argued that research on memory in emotional disorders should make more use of concrete non-verbal stimuli (like faces) in the future, since subjects' encoding activities are more amenable to experimental control with such stimuli than with verbal stimuli.