Larry Michelson

Behavioral, cognitive, and pharmacological treatments of panic disorder with agoraphobia: critique and synthesis.

Theoretical, methodologic, and clinical research issues pertaining to these treatments are examined as are their strengths, limitations, and possible interactions. Attrition, outcome, and maintenance effects are compared. Composite indices of clinically significant improvement, endstate functioning, and longitudinal adjustment are presented. The article also highlights emerging models, theoretical advances, and promising interventions. Advantages and limitations of current treatments are discussed, with recommendations for future research. It is concluded that significant advances have been made in the conceptualization and treatment of panic disorder with agoraphobia.

Cognitive-behavioral treatment of agoraphobia: paradoxical intention vs self-statement training.

Abstract Twenty-six agoraphobics were randomly assigned to either Paradoxical Intention (PI) or Self-Statement Training (SST) which consisted of 12 weekly 90-min group sessions with 4–5 patients per group. Major assessments were carried out at pre-treatment, 6th week and 12th week of treatment, and at 1- and 6-month follow-ups. Measures included clinical ratings of severity of condition, phobia, anxiety and depression. Furthermore, a behavioral test was administered during which changes in subjective units of discomfort and cognitions were assessed. The results indicated statistically-significant improvement over time with both treatments. ANCOVAs performed revealed superior effects on several agoraphobia measures for the PI condition at post-treatment. However, by the 6-month follow-up assessment, the groups were equivalent due to marked improvement during the follow-up phase in the SST condition. Cognitive changes were marked by a decrease in self-defeating statements without concomitant increase in coping statements. These results and recommendations for future research are discussed.

Cognitive, behavioral, and psychophysiological treatments of agoraphobia: A comparative outcome investigation

Eighty-eight severe and chronic agoraphobics with panic attacks, diagnosed using Diagnostic and Statistical Manual of Mental Disorders (3rd ed.) criteria, were randomly assigned to one of three cognitive, behavioral or psychophysiological treatments: paradoxical intention, graduated in vivo exposure, or progressive deep muscle relaxation training. Experienced therapists, whose treatment integrity was objectively monitored, conducted 12 two-hour weekly sessions. Therapists were completely counterbalanced across treatments. All subjects received extensive programmed practice instruction and feedback, in addition to their primary treatment. A comprehensive assessment battery consisting of clinical ratings and self-report measures of severity, phobia, anxiety, panic, and depression, as well as direct measures of behavioral avoidance and in vivo phobic anxiety, was administered at pre-, mid- (6 weeks), post- (12 weeks), and at three-month follow-up. Analyses revealed statistically significant improvement across all domains and treatments, with few between-group differences. Composite measures of endstate functioning and improvement at posttreatment and three-month follow-up revealed that the treatments were equally effective, yet incomplete. The role of pretreatment clinical and historical measures was examined with regard to therapeutic outcome and maintenance. The phenomenon of tripartite concordance was investigated with regard to both treatment outcome and short-term follow-up. Theoretical and clinical issues raised by these findings are discussed with recommendations for future clinical research.

Development and psychometric properties of the Children's Assertive Behavior Scale

The purpose of this paper is to present the psychometric properties and individual items comprising the Childrens Assertive Behavior Scale (CABS). The CABS is a behaviorally designed self-report instrument for children which measures general and specific social skills and covers many socially relevant situations which are problematic for children. Acceptable psychometric properties of the 27-item test were obtained in several independent investigations across both geographical regions and grade levels. The CABS showed significant concurrent validity with peer, parent, and teacher measures of social competency. The CABS also discriminated trained versus untrained children participating in social skills versus a placebo discussion group. The instrument is presented, along with recommendations for future applications and research.

States-of-mind model: Cognitive balance in the treatment of agoraphobia.

The states-of-mind (SOM) model, an information-processing model of positive and negative cognition, was utilized to track therapeutic changes in the cognitive balance of agoraphobics. The SOM model holds that a positive dialogue is the optimal cognitive balance for coping with stress, whereas a negative dialogue is associated with moderate psychopathology. Positive and negative dialogues were denned by specific set-point ratios of positive cognitions to total cognitions. Descriptive and statistical analyses from an outcome study of graduated exposure, relaxation training, and paradoxical intention supported the model. As hypothesized, agoraphobics evinced a negative dialogue at pretreatment, a positive dialogue at midand posttreatment, and a borderline positive dialogue at 3-month follow-up. Subjects who scored higher on measures of end-state functioning and improvement and who showed concordance on measures of physiology, behavior, and affect displayed cognitive changes across assessments (cognitive trajectories) that significantly distinguished them from subjects who scored lower on those measures.

Self-directed in vivo exposure practice in behavioral and pharmacological treatments of agoraphobia.

This study investigated the role of self-directed in vivo prolonged exposure (practice) in 49 agoraphobics treated with either combined imipramine-flooding, imipramine, flooding, or a control condition consisting of rationale, instructions, and reinforcment for practice, which were common to all treatment conditions. None of the behavioral diary variables such as number of outings, number of alone-outings, number of practices, and time spent in these actities, differentited treatment groups or discriminated between postteatment “low” versus “high” functioning patients. Lower level of anxiety (SUDS) during outings, in general, and practice, in particular, was the only measure to differentiate both effective treatments and highly improved patients. The discrepancy between behavioral and subjective diary measures coupled with the significantly greater improvement obtained in the imipramine, flooding, and combined conditions, suggest that imipramine and therapist-assisted flooding enhance the therapeutic benefit derived from an equivalent amount of practice. The possible mechanisms underlying this potentiation and recommendations for the use of diaries in future clinical reseerch are briefly discussed.

Treatment consonance and response profiles in agoraphobia: The role of individual differences in cognitive, behavioral and physiological treatments

Abstract The mediating role of individual differences, response profiles and treatment consonance in the outcome of agoraphobics undergoing cognitive, behavioral and physiological treatments was investigated. Severe and chronic agoraphobics (DSM-III) received either Paradoxical Intention, Graduated Exposure or Progressive Deep Muscle Relaxation Training consisting of 12 2-hr weekly sessions. An assessment battery was utilized consisting of ratings of severity, phobia, anxiety, depression and avoidance as well as direct measures of behavioral, cognitive and psychophysiological response systems which were evaluated at pre, mid, post and 3-month follow-up phases. Comparisons of Ss who were consonantly vs non-consonantly treated were conducted, based upon their initial response profiles. Significant differential treatment outcome and treatment × response profile interaction effects were observed. Hypotheses were confirmed regarding the predicted effects of consonant vs non-consonant Ss × treatment interactions. The short- and long-term implications of individual differences and treatment consonance in agoraphobia and anxiety disorders are discussed. Conceptual, methodological and clinical issues are highlighted with regard to both clinical intervention and future research.

A comparative outcome study of behavioral social-skills training, interpersonal-problem-solving and non-directive control treatments with child psychiatric outpatients

Abstract The purpose of the present study was to compare the short- and long-term efficacy of behavioral social-skills training and interpersonal-problem-solving with a control condition (non-directive treatment) with a clinical population of 61 socially-maladjusted outpatient boys. Treatment consisted of 12 weekly 1-hr sessions, with follow-up conducted at 12 months. A comprehensive assessment strategy was employed which included direct behavioral observations, parent, teacher, peer, self-report and academic performance measures. The results of this social-skills comparative outcome study indicated that the behavioral and interpersonal treatments resulted in changes on parent, teacher, self-report and peer sociometric ratings at post-treatment. At the 1-yr follow-up, the behavioral treatment maintained its gains and continued to show modest improvement. Conversely, the interpersonal treatment manifested significant declines, as did the control group. These findings and implications for future research are discussed.

Cognitive behavioral treatment of agoraphobia

Abstract Severe and chronic agoraphobics with panic attacks (DSM-III) were randomly assigned to one of three cognitive behavioral treatments: Cognitive Therapy plus Graduated Exposure, Progressive Deep Muscle Relaxation Training plus Graduated Exposure vs Graduated Exposure alone. Treatment consisted of 16 sessions conducted by experienced protocol therapists. All subjects received 90 min of graduated in vivo exposure each session and an extensive rationale, emphasizing self-directed exposure and programmed practice in addition to their primary treatment. Subjects also received cognitive therapy, relaxation training or programmed practice. An assessment battery consisting of clinical ratings of severity, phobia, anxiety, depression, panic and tripartite monitoring of behavioral, cognitive and psychophysiological response systems was administered at pre-, mid- and post-treatment. Analyses revealed statistically significant differences across treatments, tripartite response systems and assessment phases. The multi-modal treatments exhibited enhanced performance on self-report, phobic anxiety/avoidance, physiological, cognitive, and behavioral measures as compared to exposure alone. Conceptual and applied issues of these findings are discussed with regard to both future research and integration of cognitive behavioral strategies in the treatment of agoraphobia and related anxiety disorders.

Problem-solving skills and attributional styles of agoraphobics

Recent formulations of agoraphobia have emphasized the potential role of misattributional processes and dysfunctional problem solving in the development and maintenance of phobic anxiety and avoidance. The present study examined problem-solving skills and attributional styles as a function of experimentally induced success and failure experiences. Twenty-three female agoraphobics and 20 normals solved three sets of anagrams that differed in task difficulty. Subjects also completed an assessment battery that included measures of psychiatric symptomatology, interpersonal problem solving, and general attributional style. Analyses revealed that agoraphobics did not differ statistically from normals on cognitive problem-solving measures of anagram performance. Interpersonal problem-solving deficits were, however, exhibited for generating effective alternative solutions and selecting effective behavioral preferred responses. Moreover, agoraphobics differed from normals for globality attributions, perceived significance, anticipated future outcomes, and performance appraisals toward experimentally induced failure experiences. Conceptual, clinical, and research implications of these findings are discussed.