توجه متمرکز در مقابل حواس پرتی در طول مواجهه در هراس دندانپزشکی

A survey of the discrepant findings regarding the effects of attention focusing and distraction on exposure suggested that subjective measures of anxiety and avoidance respond better to the latter condition, and heart rate (HR) reaction responds to the former. To test this hypothesis, 63 dental phobics were recruited who had not visited a dentist for a mean of 6.6 (1.5–25) years. Participants received a 1-h exposure session with either attention focusing or distraction. Subjective anxiety and HR to phobia-related pictures were assessed before and after the treatment session and again after 1 week. Avoidance was recorded in terms of adherence to the dental treatment schedule in the following 6 months. Contrary to expectation, state anxiety showed a greater decrease in the attention focusing than the distraction condition after 1 week. Both treatment conditions were similarly effective with regard to HR and avoidance. HR habituated in both groups after exposure and 73% of followed-up patients adhered to the dental treatment schedule. Comparison of the present with previous results suggests that the differences between attentional conditions tend to be more pronounced during shorter exposure sessions than were employed in the present study.

Specific phobias are strong, irrational fear responses to situations or objects, and phobics typically react with flight or avoidance when confronted with the phobic stimulus. Prolonged exposure to the phobic stimulus has long been found to be the most effective treatment method of this disorder, but some questions remain as to the mode of exposure. Among the problems still to be resolved is that of the attentional focus during exposure treatment: Need phobics attend the phobia-related material or is its presence just as efficacious in reducing anxiety if phobics are distracted? In the original model of emotional processing by Foa and Kozak (1986), attention focusing is essential for fear reduction. According to this model, exposure activates the prototype of the fear reaction, which consists of a neuronal network that contains all aspects of stimulus properties, and emotional, physiological and behavioural fear responses including cognitive appraisal. This fear structure is stored in memory and recalled on exposure to any of its elements. Exposure introduces corrective, incompatible information leading to an uncoupling of the elements. According to this model, attention focusing, which promotes sensory encoding of the presented phobic stimuli, is necessary for the full activation of the fear structure. In contrast, distraction strategies prevent encoding of the relevant stimulus elements and inhibit activation of the fear structure and thereby also emotional processing. Incomplete emotional processing is thought to result in partial relapse, also termed return of fear (e.g. Sartory, Rachman, & Grey, 1982). Alternatively, Bandura's model (1983) of fear reduction stresses the importance of self-efficacy, i.e., the individual's conviction to be able to cope with a situation. Accordingly, it is the perceived lack of self-efficacy that induces fear during potentially aversive situations (Bandura, 1988). Behavioural mastery of fear-inducing situations is considered to enhance perceived self-efficacy. Coping strategies aimed at mastery have been found to be highly effective in combination with exposure and to improve self-efficacy (Jones & Menzies, 2000). According to this model, fear reduction results from enhancement of self-efficacy. Distraction from phobic stimuli would be considered a coping strategy as it allows the phobic individual to master the situation with less anxiety than would otherwise have been the case. The experience of being relatively free from anxiety in the presence of the phobic stimulus improves perceived self-efficacy and contributes to fear reduction. As shown in Table 1, results of the condition of attention focusing and distraction during exposure treatment are inconsistent. In a first such study in obsessive-compulsive patients (Grayson, Foa, & Steketee, 1982), one group was asked to attend to the anxiety-inducing material and the other group was also asked to pick it up while playing a video game with the therapist during the treatment session. Both groups showed a similar extent of reduction in subjective discomfort at the end of the session but the attention group evidenced a more marked reduction in heart rate (HR). The distraction group experienced return of fear at the following session, whereas the attention group's fear reduction remained stable across sessions. In a subsequent study, Grayson, Foa, and Steketee (1986) failed to replicate the follow-up result but confirmed the greater HR decrease in the attention condition. In contrast, the distraction condition led to more improvement with regard to subjective units of discomfort (SUD). Subsequent studies showed discrepant results. Measures of SUD appear to favour distraction (Craske, Street, Jayaraman, & Barlow, 1991; Johnstone & Page, 2004; Penfold & Page, 1999), although there are also exceptions (Mohlman & Zinbarg, 2000; Oliver & Page, 2003). HR, on the other hand, appears to respond better to an attention-focusing condition (Grayson, Foa, & Steketee (1982) and Grayson, Foa, & Steketee (1986); Johnstone & Page, 2004). There are, however, also a number of studies showing no effect on HR by either condition (Craske et al., 1991; Kamphuis & Telch, 2000; Mohlman & Zinbarg, 2000). The elusiveness of the effect on HR may be due to differences in the way assessments were carried out. In some studies, HR was recorded during exposure, in others during the behavioural avoidance test. Even so, results suggest a pattern whereby distraction appears to have a superior effect on SUDs and approach as well as on cognitive factors such as self-efficacy and internal locus of control, whereas attention focusing appears to lead to greater improvement in physiological reactions to phobia-related stimuli. Various components of the phobic reaction may underlie different processing modes and therefore also respond to different treatment conditions. Table 1. Comparisons between attention focusing (A) and distraction (D) during exposure Authors (year) Participants (st. —student sample) Design, procedure Measures Results Grayson et al. (1982) OCD A, D; 90 min, FU SUD, HR HR: A>D FU: SUD: A>D Grayson et al (1986) OCD A, D; 90 min, FU SUD, HR SUD: D>A HR: A>D Craske, Street, and Barlow (1989) PD with agoraphobia A, D; 11 S, FU SUD, BAT No diff. Craske et al. (1991) Animal phobics (st.) Ex., A, D; 6 min SUD, HR, SUD: D>A Rodriguez and Craske (1995) Animal phobics (st.) D, no D×hi/ lo intens. ex.; 15 min SUD, HR, BAT SUD: hi ex: no D>D Penfold and Page (1999) Blood injury phobics (st.) A, D; ex.; 10 min SUD, BAT SUD: D>A, ex. Kamphuis and Telch (2000) Claustrophobics (st.) A, D, AD, ex.; 6×5 min SUD, HR, BAT SUD: A>D Mohlman and Zinbarg (2000) Animal phobics A, D; 7×3 min SUD, HR, BAT SUD: A>D Antony, McCabe, Leeuw, Sano, and Swinson (2001) Animal phobics D, ex.; 30 min SUD, HR, BAT No diff. Oliver and Page (2003) Blood injury phobics (st.) A, D, ex.; 3×10 min weekly, FU SUD D>A, ex. FU: D>A, ex. Johnstone and Page (2004) Animal phobics (st.) A, D; 3×10 min weekly, FU SUD, HR, BAT SUD+BAT: D>A HR: A>D Abbreviations: OCD: obsessional compulsive patients; S: sessions; SUD: subjective units of discomfort; HR: heart rate; PD: panic disorder; ex.: exposure alone; hi/lo intens.: high/low intensity; BAT: behavioural avoidance test. Table options The present study aimed at investigating the course of phobic response components during attention focusing and distraction in dental phobics who were in need of dental treatment. Patients received one exposure session with either attention focusing or distraction. HR and SUDs were assessed before and after and at follow-up after 1 week. The follow-up assessment was included in order to monitor return of fear in any of the measures. Patients completed questionnaires measuring phobic severity and dysfunctional cognitions initially and at follow-up. Additionally, attendance of dental treatment was recorded in the weeks after the experiment. SUDs, dysfunctional cognitions and avoidance behaviour were expected to benefit more from distraction than attention focusing with the reverse being the case for HR. Additionally, the distraction condition was expected to lead to greater return of fear than attention focusing at the follow-up measurement after 1 week.