Wiljo J. P. J. van Hout

Psychophysiological and subjective reactions of social phobics and normals to facial stimuli.

Nine social phobics and 9 normal control subjects were exposed to slides of angry faces, happy faces, and neutral objects (i.e. flowers or mushrooms). Skin conductance responses (SCRs) to the stimuli and eyeblink rate (EBR) during stimulus exposure were recorded. In addition, subjects were asked to rate the stimuli in terms of pleasantness. While angry face stimuli elicited greater SCRs, stronger inhibition of EBR, and were evaluated more negatively than the other stimuli, there were no differences between social phobics and normals in these respects. Thus, the findings lend no support to the idea that social phobics are particularly sensitive to facial cues in general or to negative facial cues in particular.

A randomized trial of cognitive-behavioral therapy or selective serotonin reuptake inhibitor or both combined for panic disorder with or without agoraphobia : Treatment results through 1-year follow-up

OBJECTIVE To establish the long-term effectiveness of 3 treatments for DSM-IV panic disorder with or without agoraphobia: cognitive-behavioral therapy (CBT), pharmacotherapy using a selective serotonin reuptake inhibitor (SSRI), or the combination of both (CBT + SSRI). As a secondary objective, the relationship between treatment outcome and 7 predictor variables was investigated. METHOD Patients were enrolled between April 2001 and September 2003 and were randomly assigned to treatment. Academic and nonacademic clinical sites participated. Each treatment modality lasted 1 year. Pharmacotherapists were free to choose between 5 SSRIs currently marketed in The Netherlands. Outcome was assessed after 9 months of treatment (posttest 1), after discontinuation of treatment (posttest 2), and 6 and 12 months after treatment discontinuation (follow-up 1 and follow-up 2). RESULTS In the sample (N = 150), 48% did not suffer from agoraphobia or suffered from only mild agoraphobia, while 52% suffered from moderate or severe agoraphobia. Patients in each treatment group improved significantly from pretest to posttest 1 on the primary outcome measures of level of anxiety (P < .001), degree of coping (P < .001), and remitter status (P < .001), as well as on the secondary outcome measures of depressive symptomatology (P < .001), and from pretest to posttest 2 for health-related quality of life (P < .001). Gains were preserved from posttest 2 throughout the follow-up period. Some superiority of CBT + SSRI and SSRI as compared with CBT was observed at posttest 1. However, at both follow-ups, differences between treatment modalities proved nonsignificant. Client satisfaction appeared to be high at treatment endpoint, while patients receiving CBT + SSRI appeared slightly (P < .05) more satisfied than those receiving CBT only. CONCLUSIONS No fall-off in gains was observed for either treatment modality after treatment discontinuation. SSRIs were associated with adverse events. Gains produced by CBT were slower to emerge than those produced by CBT + SSRI and SSRI, but CBT ended sooner. TRIAL REGISTRATION Netherlands Trial Register (www.trialregister.nl) Identifier: ISRCTN8156869.

Clinical Features, Prevalence and Psychiatric Complaints in Subjects with Fear of Vomiting

UNLABELLED Specific phobia of vomiting (also known as emetophobia) is a relatively understudied phobia with respect to its aetiology, clinical features and treatment. In this stage, research is mostly based on people with self-reported fear of vomiting. This paper presents a survey on the clinical features of fear of vomiting of individuals. Self-reported vomit-fearful subjects from the Dutch community and from an Internet support group are included. Both vomit-fearful groups were characterized by high reports of fear, the presence of panic symptoms, and by extensive avoidance and safety behaviours. They also reported other psychiatric complaints, which were measured with a structured screening instrument. Vomiting complaints started mostly in late puberty. A significant proportion of the vomit-fearful participants had a treatment history. The prevalence rate of fear of vomiting in the community sample was established at 8.8% (female : male ratio = 4:1). Overall, results show that fear of vomiting is a common phenomenon, which can seriously impair daily functioning. Finally, clinical questions to be addressed in future research are formulated. KEY PRACTITIONER MESSAGE Specific phobia of vomiting (also known as emetophobia) is among the least studied phobias. Most clinical data come from research with self-described fear of vomiting. This paper presents data on the clinical features, prevalence and additional psychiatric complaints of fear of vomiting in two vomit-fearful samples and one control sample with no fear of vomiting. Estimates of prevalence of fear of vomiting in a Dutch community sample were established at 1.8% for men and 7% for women. Evidence suggests that fear of vomiting is a chronic and disabling condition that may cause significant impairment in daily functioning.

Processes of Change in Cognitive-Behavioural Treatment of Obsessive-Compulsive Disorder: Current Status and Some Future Directions

The present paper discusses theoretical and methodological issues involved in the processes of change in cognitive-behavioural treatment (CBT) of obsessive-compulsive disorder (OCD). Treatment outcome studies showed that CBT is effective in reducing obsessive-compulsive symptoms. However, why and how CBT works cannot be corroborated by comparing pre- and post-assessment. Recently, there has been a resurgence of interest in theory driven process studies. By showing patterns of change over time, process studies can contribute to our insight into the actual mechanisms of change during treatment. We review process research in the field of OCD and discuss methodological issues involved in process studies for this particular disorder. It is concluded that studying the processes of change harbours promising possibilities for bridging the gap between theory and clinical practice.

Rate of improvement during and across three treatments for panic disorder with or without agoraphobia : Cognitive behavioral therapy, selective serotonin reuptake inhibitor or both combined

BACKGROUND Existing literature on panic disorder (PD) yields no data regarding the differential rates of improvement during Cognitive Behavioral Therapy (CBT), Selective Serotonin Reuptake Inhibitor (SSRI) or both combined (CBT+SSRI). METHOD Patients were randomized to CBT, SSRI or CBT+SSRI which each lasted one year including three months of medication taper. Participating patients kept record of the frequency of panic attacks throughout the full year of treatment. Rate of improvement on panic frequency and the relationship between rate of improvement and baseline agoraphobia (AG) were examined. RESULTS A significant decline in frequency of panic attacks was observed for each treatment modality. SSRI and CBT+SSRI were associated with a significant faster rate of improvement as compared to CBT. Gains were maintained after tapering medication. For patients with moderate or severe AG, CBT+SSRI was associated with a more rapid improvement on panic frequency as compared to patients receiving either mono-treatment. LIMITATIONS Frequency of panic attacks was not assessed beyond the full year of treatment. Second, only one process variable was used. CONCLUSIONS Patients with PD respond well to each treatment as indicated by a significant decline in panic attacks. CBT is associated with a slower rate of improvement as compared to SSRI and CBT+SSRI. Discontinuation of SSRI treatment does not result in a revival of frequency of panic attacks. Our data suggest that for patients without or with only mild AG, SSRI-only will suffice. For patients with moderate or severe AG, the combined CBT+SSRI treatment is recommended.

Classical conditioning and attentional bias

The present study was designed to test whether an attentional bias can arise from aversive classical conditioning. Using a differential conditioning paradigm in which slides of angry faces served as conditioned stimuli (CS+/CS-) and electric shock served as unconditioned stimulus (UCS), skin conductance responses (SCRs) of normal subjects (N = 20) were recorded. The effectiveness of the conditioning procedure was proved by differential SCRs to CS+ and CS- slides during the later acquisition trials. During a subsequent extinction phase, sets of three numbers were superimposed on CS+ and CS- slides. subjects were asked to add up these numbers as quickly as possible and to vocalize the results. Vocalization latencies as indexed by chin EMG activity were significantly longer with CS+ than with CS- trials. This result is explained in terms of the attention attracting properties that the CS+ acquires as a result of its pairing with the UCS. It is argued that these properties compete with the attentional resources that are needed for an ongoing task (i.e., addition task). The data suggest that a learning approach to the origins of attentional biases in anxious subjects might be fruitful.

Covariation bias for social events and signs of (dis)approval in high and low socially anxious individuals

In two covariation bias experiments, we investigated whether socially anxious women overestimate the contingency between social events and signs of rejection and/or to underestimate the contingency between social events and approval. Participants were exposed to descriptions of ambiguous or negative social events, situations involving animals, and nature scenes that were randomly paired with disgusting, happy, and neutral faces. Socially anxious participants reported enhanced belongingness between ambiguous events and signs of rejection, together with reduced belongingness between negative events and approval. This contributes to previous findings suggesting that socially anxious individuals suffer from fear-confirming interpretive biases. There was no evidence for enhanced negative or reduced positive covariation bias in socially anxious individuals.

The efficacy of the personality diagnostic questionnaire-revised as a diagnostic screening instrument in an anxiety disorder group

The efficacy of the Personality Diagnostic Questionnaire - Revised (PDQ-R) as a screening instrument was examined in a sample of 137 anxious outpatients. The SCID-II was used as the criterion. The PDQ-R cut-offs were adjusted until the maximum kappa agreement for each scale was reached. The results showed that increasing the cut-offs decreased the number of false-positive diagnoses and only slightly increased the number of false-negative diagnoses. Inclusion of the PDQ-R as a screening instrument, followed by the SCID-II to verify the false-positive diagnoses appears to be a promising method for the categorical assessment of personality disorders. However, more studies are needed, using DSM-IV instruments to determine the optimal cutoffs. The following aspects should be considered as well: (1) the differences in prevalence rates of PDs, (2) the ability of the PDQ-R to differentiate between state and trait phenomena, (3) the consequences of the false-negative diagnoses and (4) the limited validity of the personality disorder definitions. Copyright (C) 1999 John Wiley Rr Sons, Ltd.

Assessment of self-statements in agoraphobic situations

The study describes the development and psychometric evaluation of a self-report questionnaire for use in both treatment-outcome research and process studies: the Agoraphobic Self-Statements Questionnaire (ASQ). The ASQ comprises two subscales: a positive self-statements subscale and a negative self-statements subscale. Confirmatory factor analysis showed that, with the exception of one item, the proposed bidimensional structure of the ASQ reappeared in a second agoraphobic patient sample. Internal consistency of both subscales was satisfactory. Both subscales appeared to be sensitive to change in treatment and discriminated between agoraphobic patients and normal controls. Construct validity of the negative subscale was satisfactory, whilst additional validation of the positive subscale is required. Findings also revealed that positive thinking may serve as a coping device and that the occurrence of negative self-statements might be considered a sine qua non for the occurrence of positive self-statements. It is concluded that the ASQ can contribute to the understanding of cognitive processes during treatment of agoraphobia.