Michael Gelder

New Oxford textbook of psychiatry

PART 1 - THE SUBJECT MATTER OF AND APPROACH TO PSYCHIATRY PART 2 - THE SCIENTIFIC BASIS OF PSYCHIATRIC AETIOLOGY PART 3 - PSYCHODYNAMIC CONTRIBUTIONS TO PSYCHIATRY PART 4 - CLINICAL SYNDROMES OF ADULT PSYCHIATRY PART 5 - PSYCHIATRY AND MEDICINE PART 6 - TREATMENT METHODS IN PSYCHIATRY PART 7 - SOCIAL PSYCHIATRY AND SERVICE PROVISION PART 8 - THE PSYCHIATRY OF OLD AGE PART 9 - CHILD AND ADOLESCENT PSYCHIATRY PART 10 - INTELLECTUAL DISABILITY PART 11 - FORENSIC PSYCHIATRY

Social phobia: The role of in-situation safety behaviors in maintaining anxiety and negative beliefs

One of the puzzles surrounding social phobia is that patients with this problem are often exposed to phobic situations without showing a marked reduction in their fears. It is possible that individuals with social phobia engage in behaviors in the feared situation that are intended to avert feared catastrophes but that also prevent disconfirmation of their fears. This hypothesis was tested in a single case series of eight socially phobic patients. All patients received one session of exposure alone and one session of exposure plus decrease in “safety” behaviors in a counterbalanced within-subject design. Exposure plus decreased safety behaviors was significantly better than exposure alone in reducing within-situation anxiety and belief in the feared catastrophe. Other factors that may moderate exposure effects are also discussed.

Comparison of behavior therapy and cognitive behavior therapy in the treatment of generalized anxiety disorder

In a controlled clinical trial, 57 Ss meeting DSM-III-R criteria for generalized anxiety disorder, and fulfilling an additional severity criterion, were randomly allocated to cognitive behavior therapy (CBT), behavior therapy (BT), or a waiting-list control group. Individual treatment lasted 4-12 sessions; independent assessments were made before treatment, after treatment, and 6 months later, and additional follow-up data were collected after an interval of approximately 18 months. Results show a clear advantage for CBT over BT. A consistent pattern of change favoring CBT was evident in measures of anxiety, depression, and cognition. Ss were lost from the BT group, but there was no attrition from the CBT group. Treatment integrity was double-checked in England and in Holland, and special efforts were made to reduce error variance. Possible explanations for the superiority of CBT are discussed.

An experimental investigation of the role of safety-seeking behaviours in the maintenance of panic disorder with agoraphobia.

This study evaluates the hypothesis that safety-seeking behaviours play an important role in maintaining anxiety because they prevent patients from benefiting from disconfirmatory experience. Patients suffering from panic disorder with agoraphobia carried out a behaviour test, closely followed by an experimental session, which included a brief (15 min) period of exposure during which participants either stopped or maintained within-situation safety-seeking behaviours. When the behaviour test was repeated within two days, patients who had stopped their safety-seeking behaviours during the experimental session showed a significantly greater decrease in catastrophic beliefs and anxiety than those who had maintained safety-seeking behaviour. This difference was also reflected in questionnaires measuring clinical anxiety. These results are consistent with the cognitive hypothesis.

Cognition-behaviour links in the persistence of panic.

The cognitive theory of panic disorder proposes that panic attacks occur as a result of an enduring tendency to misinterpret bodily sensations as a sign of imminent catastrophe such as a heart attack. The persistence of such catastrophic cognitions is in part due to the tendency of patients to avoid and/or escape situations where panic occurs. It is proposed that within-situation safety seeking behaviours also have the effect of maintaining catastrophic cognitions in the face of repeated panics during which the feared catastrophe does not occur. The association between catastrophic cognitions and within-situation safety behaviours matched the pattern predicted from the cognitive theory in 147 panic disorder patients. The implications of these findings for the way in which therapy is conducted are discussed.

A home-based treatment program for agoraphobia: Replication and controlled evaluation*

Twenty-eight agoraphobic women were randomly allocated to one of two treatments: programmed practice in entering feared situations or a treatment aimed at anxiety reduction by resolving life problems. Each treatment was conducted by one of two therapists and both were carried out at the patients home, involved the spouse, and used the same structured format of delivery. Behavioral changes were assessed by the patient, spouse, and an independent psychiatrist. Assessments were made before and after treatment and 3 and 6 months later. Results replicated the findings of a previous study and showed the superiority of programmed practice over the problem solving treatment. However, changes in the latter were unexpectedly large, and one therapist obtained results comparable to these which both therapists obtained with programmed practice. This finding does not support the hypothesis that systematic practice in entering the feared situations is essential for the treatment of agoraphobia.

A self-help treatment program for anxiety state patients †

The effects of anxiety management training in reducing generalized anxiety using a self-help format were examined. Twenty-seven anxiety state patients were randomly allocated to one of three groups which differed only in the length of time patients waited for treatment. Self-ratings of anxiety and depression were made at the start of the wait period, before and after treatment, and 1 and 3 months later. Assessments were also made by an independent assessor. There was a significant reduction in anxiety level at the end of treatment, and improvement was maintained during the follow-up period. Comparison between anxiety training and the no-treatment condition showed that the changes during treatment were mainly due to the effects of the treatment rather than other factors such as self-monitoring. The results are discussed in terms of the effectiveness of selfhelp methods in reducing anxiety and in comparison with the results of previous studies.

Anxiety management: Developing effective strategies

Abstract This paper focuses on three aspects of generalised anxiety; anxious cognitions, avoidance behaviour and the efforts made to cope with symptoms. It presents information from structured interviews and informal observations which were collected during a clinical trial of anxiety management for generalised anxiety disorder. The findings are discussed in terms of their implications for future modifications of anxiety management.

Problem solving: Not a treatment for agoraphobia

This replication study was designed to follow up the suggestion (Jannoun, Munby, Catalan, & Gelder, 1980) that problem solving without exposure may provide an effective treatment for agoraphobia. A consecutive series of 14 agoraphobic women was treated with problem solving by two therapists. Results suggest that problem solving is not as effective as the exposure-based treatment, planned practice. The good results obtained by one therapist with problem solving in the earlier trial were not replicated. Reasons for the previous anomalous finding are considered.

Behaviour Therapy for Neurotic Disorders

This article reviews evidence about the value of behaviour therapy for the treatment of patients who present with phobic disorders anxiety states, obsessional neuroses, and hysteria. Although progress has been made in developing effective behaviour therapy for the major neurotic syndromes, much remains to be done. Only in the phobic disorders is there a sufficient body of knowledge to give clear guidance to the clinician about the best methods of treatment. However, this work on phobias already has pointed to several lines of enquiry which are likely to be fruitful with the other syndromes in which the contribution of behavioural methods is promising, though less certainly established. In particular, more attention needs to be given to ways of ensuring that patient treatment by behavioural measures will be continued.