نقش خود کارگردان در VivoExposure در ترکیب با درمان شناختی، آموزش آرامسازی، و یا قرار گرفتن در معرض درمانگر به کمک در درمان اختلال هراس با هراس از مکانهای باز ☆

The effects of self-directed in vivo exposure in the treatment of panic disorder with agoraphobia were examined. Seventy-four chronic and severe agoraphobic subjects were randomly assigned to Cognitive Therapy plus graded exposure, Relaxation Training plus graded exposure, or therapist-assisted graded exposure alone. Treatment consisted of 16 weekly 2.5-hour sessions. All subjects received programmed practice instructions for engaging in self-directed exposure as a concomitant strategy to their primary treatment. All subjects were instructed to keep systematic behavioral diary recordings of all self-directed exposure practice. The diary data were analyzed across and within treatments and assessment phases. Statistically significant findings were obtained across all diary measure domains with powerful repeated measures effects observed across all treatments. Significant between group effects and treatment × repeated measures interactions were obtained across the diary measure domains. Multiple linear regressions of in vivo anxiety levels and, to a lesser extent, frequency of self-directed exposure practice were found to be significantly associated with global assessment of severity at posttreatment and 3-month follow-up assessments. Furthermore, depression and marital satisfaction were significantly associated with in vivo anxiety. These and other findings are discussed with regard to their conceptual and clinical implications.

In recent years a number of treatment modalities have been examined in comparative outcome studies. Specifically, cognitive, behavioral, and psychopharmacological modalities have been shown to be beneficial in treating PDA. Self-directed, graded, in vivo exposure (SDE) to phobic stimuli is a treatment strategy that has been typically combined with these interventions to facilitate improvement. In self-directed exposure (also known as programmed practice, exposure homework, or self-exposure), the client gradually enters increasingly more phobic situations to foster habituation. Several studies in the late 1970s and early 1980s demonstrated that SDE alone could effect moderate reductions in agoraphobic symptomatology and, for a small percentage of clients, could effect complete amelioration Greist et al. 1980 and Mathews et al. 1977. Later studies indicated that when combined with a single active treatment, such as behavior therapy or pharmacotherapy, SDE acts as a catalyst for effecting enhanced improvement when compared to behavior therapy or pharmacotherapy alone Mavissakalian & Michelson 1983 and Telch et al. 1985. While SDE has been shown to be an important componet in the treatment of PDA, as a singular modality, SDE appears to be an inadequate treatment for PDA. Therapeutic approaches based exclusively on the exposure principle may be incomplete by themselves because several phenomena may interfere with habituation. Elevated levels of psychophysiological arousal (Lader & Mathews, 1968), cognitive interference, such as self-defeating thoughts, perceived external locus of control (Foa & Kozak, 1986; Michelson, Mavissakalian, & Marchione, 1988), worry (Borkovec, 1985), and/or negative mood state (Foa & Kozak, 1986), can interfere with habituation processes during exposure. While SDE alone may provide presentation of phobic cues, it does not appear to reduce or stabilize some of these phenomena that interfere with habituation during exposure and may be incomplete as a unitary treatment strategy for PDA (Mavissakalian & Michelson, 1983). In a pilot study, Marchione, Michelson, Greenwald, and Dancu (1987) investigated treatment strategies that may reduce or eliminate these obstacles to exposure and habituation for PDA clients. In this preliminary work, they found that two treatment modalities, cognitive therapy combined with therapist-directed graduated exposure (CT + GE) and relaxation training combined with therapist-directed graduated exposure (RT + GE), effected reductions and stabilization in in vivo anxiety, psychophysiological arousal, cognitive interference, and negative mood state. Furthermore, it has been shown that GE improves an agoraphobic client’s ability to efficiently practice SDE by evincing increases in frequency of practice outings, total time out, total time out alone, and by significantly decreasing in vivo anxiety Marchione et al. 1987 and Michelson et al. 1986. Although the need to include SDE when planning effective treatment packages for PDA is well established Greist et al. 1980, Holden et al. 1983, Mavissakalian & Michelson 1983, Telch et al. 1985 and Michelson et al. 1986 important questions regarding the role of SDE in the treatment of PDA remain. The present study was undertaken in an effort to shed light on the relationship between theoretically and clinically salient measures and outcome across the three treatment conditions. The relationship between in vivo anxiety on frequency and duration of practice was also of interest. Theorizing that increased phobic anxiety leads to increased phobic avoidance, it was anticipated that in vivo panic would reinforce phobic anxiety. It was also predicted that frequency and duration of SDE practice would be negatively correlated with frequency of in vivo panic attacks. Negative mood state and marital satisfaction were also examined. Both depression and low marital satisfaction have been associated with diminished habituation in anxiety clients (Bland & Hallam; 1981; Foa et al., 1983; Milton & Hafner 1979 and Monteiro et al. 1985). However, neither depression nor marital satisfaction have been examined simultaneously in relation to SDE variables. The SDE variables examined include: level of reported in vivo anxiety, frequency of exposure outings, and duration of exposure outings. It was hypothesized that in vivo anxiety, Subjective Unit of Distress Scale (SUDS) would be a significant predictor of clients’ level of functioning at posttreatment and follow-up and that in vivo anxiety would be a stronger predictor of outcome than other, more behavioral SDE domains, such as duration of time spent out and/or frequency of SDE outings. These hypotheses were based on the notion that the phenomenon of phobic anxiety is central to agoraphobic avoidance and other agoraphobic symptomatology and that anxiety management is more central to symptom amelioration than the more behavioral domains. This view was supported in Michelson et al. (1986) where in vivo anxiety accounted for the majority of variance in predicting outcome for agoraphobic clients whose treatment included SDE. While there is some evidence that the frequency and duration of SDE outings may have a role in treatment outcome (Michelson et al., 1986), others have found that the more central role of SDE is found in its role in anxiety management. Edelman and Chambless (1993), for example, found that while amount of practice of SDE was associated with the reductions in fear of fear and avoidant behavior, a “no homework” group did not differ on measures of outcome. It should be noted that this was a quasi-experimental design and that in a more controlled study, Greist and colleagues (1980) found that a “no exposure” treatment group actually worsened without the inclusion of exposure. It may be that a critical threshold of exposure practice must be obtained for significant improvement to take place, but that once that threshold is obtained the amount of practice is not as essential to improvement as other qualities of the practice, such as utilization of anxiety management strategies. Lastly, it was hypothesized that enhanced SDE performance (i.e., reductions in SUDS, increases in duration of time spent out, frequency of outings and events, and distance travelled) would be evinced by the more diverse (CT and RT) treatment packages because they included additional anxiety management strategies, which the GE alone condition did not. It was proposed that these additional strategies (such as applied relaxation in the presence of phobic cues) would provide clients with an added sense of efficacy and confidence in comparison with their GE cohorts.

When viewed overall, these results point to the importance of SDE in the treatment of PDA. The value of SDE as a component of any plan for the treatment of PDA has been highlighted both by both current and previous research (Mavissakalian & Michelson 1983, Holden et al. 1983, Greist et al. 1980, Telch et al. 1985 and Michelson et al. 1986; Al-Kubaisy et al., 1992) and by the finding that performance on in vivo anxiety on SDE measures was a significant predictor of clients’ level of functioning at posttreatment and follow-up (on GAS). It has been reported that SDE alone does not appear to be highly efficacious in reducing PDA symptomatology (Mavissakalian & Michelson, 1983), but should be combined with an active treatment component, such as cognitive therapy to enhance therapeutic outcomes. However, consistent with the emotional processing model (Foa & Kozak, 1986; Rachman, 1980), SDE appears to be a highly beneficial for facilitating activation of fear memories and structures and for the presentation and higher order integration of more adaptive information regarding feared stimuli and the development of new, coping responses. Thus, the present findings point to SDE as an important ingredient in the multimodal treatment of PDA. By continuing to utilize SDE as a component in treatment packages for PDA, future research could accomplish a number of important goals. First, and foremost at this time, research should continue to develop more effective treatments for PDA. Furthermore, as highlighted by Al-Kubaisy et al. (1992), future research should examine the efficacy of PDA treatment programs without therapist-assisted exposure in an effort to enhance efficiency of treatment and to examine the differential effects of SDE versus therapist-assisted exposure. Studies that included groups receiving no SDE (e.g., Edelman & Chambless, 1993; Greist et al., 1980) point out the importance of controlling the SDE variable in outcome research. Inclusion of “no exposure” groups in future research may be helpful in teasing out the roles of behavioral practice and in vivo anxiety management in treatment outcome. Most importantly, however, future research should examine the underlying mechanisms of SDE and in vivo anxiety as powerful predictors of treatment outcome for PDA. Not only would it be highly beneficial to the conceptualization of the processes of fear activation and habituation, but increased understanding of in vivo anxiety in the SDE process would allow for further refinement of exposure homework techniques, which may in turn lead to improved outcomes and longitudinal adjustment. Furthermore, therapeutic shifts in information processing, emotional processing, and core beliefs should be examined regarding their role (cause, correlate, and consequence) in SDE endeavors, as well as in their relation to psychotherapy outcome.